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Takeaway Food:
In recent decades there has been an increase in the growth of the ‘informal eating out sector'; nationally one in six meals are now eaten out of the home with men deriving a quarter of their energy and women a fifth from these foods1. Restaurants, cafes, work canteens and other food outlets on average capture 27% of consumer expenditure2. More than £10 billion each year is spent on sandwiches, chips, burgers, curries and similar food from small independent outlets3. In 2005 children reported spending £1.01 on the way to school and 74p on the way home equating to £549 million per annum alone4.
Takeaway foods offer an alternative to the routine of shopping, food preparation and cooking and an over abundance of outlets can distort what is available. Recent evidence in the UK suggests a rise in the consumption of fast foods as individuals downgrade from more expensive restaurant meals due to the economic downturn5. With the great demand for food eaten outside the home, effective measures to improve food quality need to be in place sooner rather than later.
This briefing paper aims to provide the evidence and justification on why the growth of the informal eating out sector poses significant public health challenges as well as the opportunities that could lead to action locally to improve the eating out environment and support for small businesses.
Some Eating Out Facts:
• We spend over £30 billion a year on eating out (excluding alcoholic drinks)6. • Only 6% of us never eat out or buy a takeaway7. • We spend more than £10 billion a year on sandwiches, chips, burgers, takeaways etc.
which is five times more than the government spends on providing food for public institutions such as schools, hospitals and prisons8.
• Nearly a third of children under three eat a takeaway meal at least once a week9.
• Major consumers of takeaway meals are reported to include staff at fire and police stations, doctors surgeries and hospitals2.
• A recent survey found 40% of Liverpool residents eat from takeaway outlets or fast food outlets at least once or twice per week10.
Data from the Health Survey for England 2009 indicates that from 1993 to 2009 obesity in men has increased from 13% to 22% and in women from 16% to 24%. This upward trend does appear to be slowing however, in children. Data from 1995 to 2001 shows that mean BMI increased among both boys and girls aged 2-15 years yet between 2001 to 2009 there was no significant change for either boys or girls. However amongst boys aged 11-15 years the proportion that was obese in 2009 was 20% which is amongst the highest levels recorded11.
The current culture and environment of the UK has been described as ‘obesogenic'. For example, in environments where there is a proliferation of fast food outlets, options are skewed towards unhealthy choice, making it difficult for healthier choices to be the easier choice. It will take major changes in lifestyle and environment to slow or reverse the current trend of increasing levels of obesity and overweight. Consumption of foods prepared outside the home (such as takeaway foods) has been associated with increasing overweight12. Where there are a large number of fast food outlets in an area there is an association with increase in BMI in children, this may be a reflection of an obesogenic environment13. Obesity prevalence also shows strong links with deprivation, as deprivation rises so does obesity. This correlates over recent decades with an increase in away-from-home and fast food consumption in the UK14. Whilst there has been a rise in the informal eating out market there has also been a change in trends, with a decline in more traditional outlets. See Table 1 below.
Changes in the type and number of eating out premises in Coventry from 1978 -2008.
Cafes/sandwich shops Fish and Chip Shops Source McDonalds and Allegra strategies, 2009.14



Meals and snacks eaten outside the home tend to be higher in fat (with about 40% of calories coming from fat)15. A report by Consumer Focus (previously the National Consumer Council) found that food from takeaway outlets was often high in fat, salt and sugar and making healthy choices was hard, even for those looking to purchase a healthier version16. When researchers looked in detail at what was on offer in some high street takeaways they found that some meals contained nearly the guideline maximum intake for an entire day. For example a KFC meal of a tower burger, regular BBQ beans, yoghurt and cola provided 97% of the guideline maximum daily amount of salt and 69% of sugar. There were healthier options available, however consumers reported that nutritional information or information on healthy choices was hard to find and difficult to understand. The high energy density of fast food and the associated impact on the burden of chronic disease has been emphasised in the Foresight Report ‘Tackling Obesities'17. High levels of salt in the diet are linked to high blood pressure and in turn can lead to stroke and coronary heart disease. Excessive dietary saturated fats elevate serum cholesterol and are a powerful risk factor for cardiovascular disease. Average population intakes of both salt and saturated fats are far higher than recommended in both adults and children. Industrially produced trans fatty acids (IPTFAs) are also a major public health concern, evidence suggests that an increase of 2% of food energy derived from trans fatty acids(TFAs) is associated with a 23% increase in the incidence of coronary heart disease18. The 2009 review of IPTFAs by WHO19 classes IPTFAs as ‘industrial additives' which have no known health benefits and therefore emphasised the need "to significantly reduce or virtually eliminate industrially produced TFA from the food supply chain".
Industrially Produced Trans Fatty Acids and Fast Food: IPTFAs are found in many varieties
of food from fast food outlets and takeaways; some may be found in the ingredients but some may occur as a result of the food being fried in hydrogenated vegetable oil. The repeated reheating and cooling of frying oils result in chemical changes within the oil increasing the levels of IPTFAs. Changes in the composition are also affected by factors such as; how well frying is managed, how long the oil is being used for and the type of oil being used. It is estimated that 0.2 – 1% of total fat content are converted into trans fatty acids through the deep frying process over longer periods with initially IPTFA-free vegetable oils20. Frying practices in small takeaway businesses often indicate exposure to wider fluctuations in temperature and much longer turnaround than that found in the frying practices of large conglomerates. There is little data available on the levels of IPTFAs in takeaway food in the UK. International evidence indicates that analysis of fast food in Austria showed IPTFA levels in French fries and burgers can range between 0.1 and 8.93% of overall fat content21.
Health Inequalities: The current UK recommendations on trans fats intake recommend
a maximum limit of 2% of food energy. In the UK average trans fats intakes for adults have been estimated at 0.8% of food energy by the rolling National Diet and Nutrition Survey (NDNS) 2008/200922. However the authors urge caution in interpreting the results; the survey sample was smaller than expected and engagement was low. Furthermore the foods analysed for the survey potentially miss 20% of food eaten and it is likely the missed food is snack food and fast food eaten outside of the home. The Low Income Diet and Nutrition Survey data shows that in lower income adults, an estimated 12% are eating more than the maximum recommended amounts of TFAs.
Unpublished research carried out in Tower Hamlets in London showed that eating out three times a week (from takeaway/fast food outlets) meant some individuals could be consuming between 6-12% of dietary energy from TFAs depending on where they bought their food and how often they ate out23. Eating out invariably means losing some control over your food. The variation in consumption levels among different social groups contributes to health inequalities. High exposure to TFAs appears very likely in deprived communities throughout the UK – a situation which should be investigated urgently24. A high density of takeaways in a geographical area and limited choice of alternative shops or supermarkets represents a form of food poverty. This is also a significant factor that contributes to the obesogenic environment. A study carried out in Preston, Lancashire showed that Preston had more fast food outlets (186 – not including restaurants who operate takeaways) than general grocery outlets (165)25, 26. Furthermore, for those engaged in part time and piece-meal work, taking time off to eat means they lose pay. Eating from fast food outlets is cheap and does not involve time in shopping and preparation. Also for migrant groups, eating out is a representation of social Children and Young People: The School Food Trust research carried out in 2008 produced a
measure of the ratio of fast food outlets (including confectionery shops) to secondary schools; the national average was 23 outlets per secondary school, with an urban average of 25 outlets per school27. Despite the introduction of nutrient based standards for food served in secondary schools in 2009, recent annual results from the School Food Trust indicates the national average for uptake of school lunches in secondary schools is 35.8%. A study in two large, mixed comprehensive schools, one in a leafy, affluent suburb, and the other in a more deprived city was carried out by the Nutrition Policy Unit at London Metropolitan University. The study found that secondary school pupils get more food from ‘fringe' shops than from the school canteen, 80% buy from local shops and 41% never go to the school canteen. Food bought by school children in ‘fringe' shops provided at least 23% of their daily energy requirement, and was often high in fat or sugar. Three out of ten fringe purchases were made in takeaways and were generally hot food such as chips, chicken and chips or pizza. The fat content of purchases from takeaways was high (an average of 42g of fat per purchase). The average fat content of a £1.00 portion of chicken and chips was 53.2g, well over half the amount of fat a child of this age should be eating in a whole day28.
Policy Context; Promoting Healthier Food Choices: Policies which take into account
upstream factors lead to changes in the health of the whole population. By changing the food environment it is possible to make the healthy choice the easier choice29.The previous government's strategy for England ‘Healthy Weight, Healthy Lives' produced in 2008, mentions the use of planning regulations and states that action is required to allow local authorities to manage proliferations of fast food outlets. NICE public health guidance (2010) on ‘prevention of cardiovascular disease at population level' recommends a specific policy goal to ‘empower local authorities to influence planning permission for food retail outlets in relation to preventing and reducing CVD'30. The recent public health white paper, Healthy Lives, Healthy People also states that ‘Local Government and communities will have new resources, rights and powers to shape their local areas…. Health considerations are an important part of planning policy and the Department for Communities and Local Government will consider how to take this forward in the new National Planning Policy Framework'31.
Waltham Forest is an example of a borough in London where successful development of supplementary planning guidance and the use of local development frameworks has facilitated exclusion zones for fast food outlets around schools where there are a large number of outlets within a geographical area32, 33. This has also happened in Tower Hamlets and Barking and Dagenham. In addition to reducing the number of takeaways, the NICE guidance also makes recommendations to support owners and managers of takeaways and other food outlets to improve the nutritional quality of the food they provide. A report produced by the New Economics Foundation (NEF) in July 2010 identified that for small businesses within the casual food industry, many operate on narrow margins, serving large numbers of people who cannot afford (and do not expect) to spend too much on lunch. The study goes on to present how cheap food comes with hidden costs not only to the people who produce it, sell it and eat it but also to the environment and to future generations. There is an argument that small independent businesses should be recognised within local economies and supported to be diverse, independent, support local supply chains and provide food that is healthier, sustainable and affordable. However this requires supportive policies and raised awareness within communities3. In 2008, under the previous government, the Food Standards Agency (FSA) launched its Saturated Fat and Energy Intake Programme outlining the actions needed to help consumers reduce saturated fat intakes and balance the amount of calories they consume with their needs. The Agency has been working with food businesses (including retailers, manufacturers and caterers) and their trade associations to support and encourage reductions in the levels of saturated fat and added sugar in the foods they produce. More than 40 major UK caterers have been working with the agency to provide healthier choices, promote healthier options and to provide consumers with more information. The companies involved include many well known restaurants, pubs, coffee shops and sandwich chains34. This has been in addition to work with the catering sector to support voluntary reduction of salt in processed foods, as part of the Agency's salt reduction programme launched in 2006, working initially with the UK's biggest contract caterers and A programme of work to develop a voluntary calorie labelling scheme for the catering industry has also been piloted. The Agency has developed principles to encourage continued and increased voluntary adoption of calorie labelling at point of choice across the catering industry, and to ensure a consistent approach that will help consumers make healthier choices35. There has been some evidence for support for this scheme from the current Secretary of State for Health.
It is unclear to the extent to which this will be implemented; for example in New York, only chains with 15 or more outlets have to provide such information. To date the majority of the action piloted by the Food Standards Agency has been voluntary and the responsibility for this work has now been transferred to the Department for Health and is being taken forward under the government's Responsibility Deal with businesses. Those businesses signed up will pledge to provide calorie information for food and non alcoholic drink for customers in out of home settings from 1 September 2011 in accordance with the principles for calorie labelling agreed by the Responsibility Deal36. The FSA has also piloted work to develop fact sheets for small businesses on providing healthier options. The FSA has worked with the National Federation of Fish Friers (NFFF) to produce two leaflets to help share best practice on cooking chips and a range of simple, practical steps that will help make chips crispier and reduce the amount of saturated fat and salt in a portion37. Further fact sheets have been planned to cover other sectors of the eating out sector. The ‘Talking Food: Taking Action' campaign coordinated across the Northwest of England by Our Life is helping to create a mass discussion around what kind of food system people want to see - linking the problems people have with food and diet to the wider food supply chain to identify the issues that cause the most concern.
Evidence from communities taking part in the campaign has shown that the proliferation of takeaways within local communities is causing concern38. From the information and evidence available there appears to be a case for considering both regulatory action in controlling the proliferation of outlets in particular areas as well as supporting smaller independent businesses to make changes to their food provision. To do this locally there needs to be evidence and support for local policy.
Summary of the Broad Strategies and Policies that May Improve Provision of Healthy Food
The public health white paper suggests that ‘protecting the population from health threats should be led by central government, with a strong system to the front line. But beyond that local leadership and wide responsibility across society is the way to improve everyone's health and wellbeing, and tackle the wider factors that influence it, most effectively'31. This should include approaches such as personal responsibility, positively promoting healthy behaviours and lifestyles and adapting the environment to make healthy choices easier. A range of broad strategies that include these approaches through ‘providing consumers with information', ‘enabling choice and guiding choice' and regulation are detailed below. Some of these strategies may be achieved through effective local policy and with the transfer of public health to Local Authorities and jointly appointed Directors of Public Health there is greater opportunity to develop such policies.
• Limit the proliferation of fast food outlets through zoning and control of outlets by imposing limits on concentrations.
• Use of supplementary planning guidance to support public health. With public health moving to Local Authorities this presents further opportunity to link the two agendas.
• Encourage or require healthier food offers to be served in takeaway outlets. How realistic is this for small businesses? How aware are business owners and will people purchase healthier options? • Encourage or require healthier food preparation practices e.g. change cooking oils, reduce certain ingredients such as trans fats, sat fat, salt and sugar.
• Support informed choice through improved provision of consistent nutrition information • Reformulation of food at source, this may focus on the supply chain (upstream choice • Encourage ‘new' businesses to enter the market.
• Create public demand for alternative (healthier) affordable, takeaway food. • Restrict marketing and promotion of food and drink high in fat, salt or sugar to children.


The Local Perspective:
Cheshire and Merseyside: Over 25% of deaths within the Heart of Mersey area are due
to cardiovascular disease39. The mortality rate for CVD in the most deprived area of Heart of Mersey is three times higher than in least deprived areas. Poor diet is responsible for over half of cardiovascular disease cases and around one third of cancers. These are the biggest killers in the UK accounting for 66% of all deaths40.
Analyses of takeaway foods sold in Liverpool and Wirral have demonstrated very high levels of total fat, saturated fat, salt and energy in many dishes. It has been reported 40% of Liverpool residents eat from takeaway outlets or fast food outlets at least once or twice Gaps in the Evidence Base:
• There have been no detailed assessments in this area focusing on takeaway food consumption patterns and how takeaway food consumption might relate to other food consumption patterns (who uses them, who makes the food choices when buying for families etc). This might also usefully consider socioeconomic and ethnic patterns of • Limited detailed analysis of trans fats in takeaway food (and consumption patterns among sub groups of the population) other than analysis carried out from takeaway meals in Wirral.
• Mapping of takeaway outlets within communities and their proximity to schools. • Mapping of takeaway outlets, other food retail premises, types of food available and indices of multiple deprivation (food poverty – to include fresh fruit and vegetable provision) in Merseyside and Cheshire, considering the impact on health inequalities.
• An understanding of the barriers to small businesses to change their provision.
• An understanding of consumer demand, awareness and concerns about takeaway food and the proliferation within local communities.
Supporting Partners in Developing Local Policy: There is some good practice and work
being piloted within the region in response to concerns about takeaway food. In 2006 Heart of Mersey commissioned Liverpool John Moores University (LJMU) to investigate deep frying practices in a sample of Merseyside fast food outlets and made a number of applications for funding, to generate evidence to develop local policy, so far unsuccessfully. Other initiatives Eatright Liverpool: A collaborative piece of work with Liverpool City Council Trading
Standards and Liverpool John Moores University and funded by Liverpool PCT. Working with takeaway proprietors, the initiative promotes healthy dishes and improves the nutritional quality of takeaway meals. Training is provided in food hygiene and nutrition. Future developments include recipe development and food labelling.
Knowsley: There are approximately 61 hot food takeaway outlets in Knowsley; a joint proposal
has been prepared by Knowsley MBC and NHS Knowsley with support from Heart of Mersey which has now successfully received funding from Knowsley at Heart. Proposals include analysis of the nutritional content of takeaway food in order to influence local policy and the development of further projects to investigate promotion of healthier alternatives. Sampling will provide a breakdown of trans fats content as well as other nutritional criteria such as salt and saturated fat. Sefton: A pilot initiative to learn more about the use of oil in the frying industry. Sampling of
frying oils at the point of change will try and develop bespoke guidance for fryers in Sefton.
The aim is to better inform fryers how to get the best from their oil and the best time to change it to improve the overall nutritional quality of the food served.
St Helens MBC has approximately 161 hot food takeaways and is in the process of developing
a draft supplementary planning document to support the council's approach to hot food takeaway development in the borough. The document addresses the health impact of new applications in close proximity to schools as well as maximum permissible percentage of shop frontage within in a particular area that can be utilised as a premise for hot food takeaways. The document has been led by the development control team within St Helens Council and is part of a broader strategy to tackle health issues reflected in the Local Development Framework. Following a formal consultation process it is anticipated the council will then proceed to adopt. Wirral Trading Standards: There are approximately 270 takeaways in Wirral, 150 were
identified to take part in a sampling programme to establish an evidence base of nutritional content of meals. Officers are working with the takeaway industry to identify recipes that minimise risk and publicise healthier alternatives including information for businesses to supplement the FSA Safer Food, Better Business packs. Research Applications: Heart of Mersey with support from colleagues within NHS Knowsley,
Wirral Trading Standards and Liverpool John Moores University have been seeking to secure funding to develop the evidence base within the sub-region; including opportunities to explore the perceived barriers to improving the nutritional composition of food served as identified by proprietors of independent takeaway outlets.


Future Developments: On the basis of the available evidence strong proactive policies are
needed both nationally and locally. In reviewing the existing evidence base and work demonstrated in this area there are a number of potential actions outlined below in which Heart of Mersey could support local partners in taking this policy goal forward: (1) Further data and research is required in developing the issues and evidence base both in support of local action and considering regulatory and legislative change nationally.
(2) A collective approach within Cheshire and Merseyside should be considered to share good practice and develop local action.
(3) Develop an understanding of what can be done locally, exploring powers of local authorities and opportunities presented by the new approach to ‘localism'; via both the Localism Bill and new structures accountable for public health including Health and Wellbeing Boards. The Bill may further support development of supplementary planning documents and will also: • devolve greater powers to councils and neighbourhoods and give local communities more control over housing and planning • provide for neighbourhood plans, which would be approved if they received 50% of the votes cast in a referendum Local Statutory Health and Wellbeing Boards will support collaboration across the NHS and local authorities to assess the needs of their communities and meet their needs as effectively as


Prepared by:
Nicola Evans, Food and Nutrition Programme Manager, Heart of Mersey With thanks to contributors:
Professor Simon Capewell, Professor of Clinical Epidemiology, University of Liverpool.
Professor Martin Caraher, Reader in Food Policy, Centre for Food Policy, Robin Ireland, Chief Executive, Heart of Mersey Jane Landon, Deputy Chief Executive, National Heart Forum Ffion Lloyd-Williams, Heart of Mersey Research Programme Manager/ Research Fellow University of Liverpool John Malone, Trading Standards Manager, Wirral MBC Jane Rawlings, Senior Trading Standards Officer, Wirral MBC Dr Leo Stevenson, Reader in Food Sciences, Liverpool John Moores University Food Standards Agency Website. 2010. Available at:
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Heart of Mersey, Burlington House, Crosby Road North, Liverpool L22 OQB Tel: +44 (0) 151 928 7820 Fax: + 44 (0) 151 949 0799 Charity No: 1110067 Company No: 5382971 Publication date: April 2011

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2nd PHARMACOECONOMICS AND OUTCOME RESEARCH CONFERENCE 2014 "PHARMACOECONOMICS IN HEALTHCARE TRANSFORMATION: TOWARDS UNIVERSAL COVERAGE" Conference Advisor : Prof. Dato' Dr. Syed Mohamed Aljunid Organising Chairperson : Dr. Soraya Azmi : Lee Sit Wai and Nurul Azwani Nadia Mansor THE HONOURABLE MINISTER OF HEALTH,

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The Asian Conference on Psychology & the Behavioral Sciences 2013 Official Conference Proceedings Cognitive-Behavioral Therapy of Bipolar Depressive Disorder (Manic-depressive): A Case Study Mohammad Khodayarifard University of Tehran, Iran The Asian Conference on Psychology & the Behavioral Sciences 2013 Official Conference Proceedings 2013 Introduction: The usual treatments of the bipolar depressive disorder, such as medication and electroconvulsive therapy (ECT) have negative side effects on memory and cognition and the likelihood of recurrence. Researchers and clinical experts have been trying to design alternative psychotherapeutic methods for treating this disorder. For example, cognitive behavior therapy (CBT) has been shown to be an efficient treatment. Objective: the purpose of the present case study is to examine the efficiency of CBT combined with medication in the treatment of bipolar depression. Method: Two participants with bipolar disorder were treated using CBT and medication. In this method, techniques such as self-monitoring, positivism, relaxation, cognitive re-construction, training problem solving and social skills were applied. Result: The results showed that the combination of CBT and medication can be effective in treating bipolar depression. Conclusion: The findings, which are congruent with those of previous investigations, indicating that unhealthy beliefs, attitudes and cognitive constructs may play an important role in the formation and continuation of this disorder, and therefore a proper way of treating it would be to work with those unhealthy cognitive constructs. Key words: Mood disorders, bipolar disorder, manic depression, cognitive behavior therapy