Helen Cooke, Nutrition lead, Portland Centre for Integrative Medicine

Elizabeth Thompson, CEO, Portland Centre for Integrative Medicine

Published in JHH13.2 – Nutrition and Lifestyle

I’m a nutritional therapist (BSc) with a nursing and complementary health background, running two busy nutritional therapy clinics alongside my work at the Portland Centre for Integrative Medicine (PCIM). I’ve had the pleasure of working in a variety of whole-person healthcare settings (including several years at Penny Brohn Cancer Care) which includes nutrition as part of its recommendations. I was also national lead of the College of Medicine’s Innovations Network (2012– 15). I’m delighted to be project managing Kitchen on Prescription (co-ordinated by PCIM) as it’s making a dream of mine a reality – making food part of mainstream healthcare.

Helen Cooke

I am a holistic doctor living and working in Bristol at the new Portland Centre for Integrative Medicine, a community interest company set up to support and inspire a broad range of holistic services within mainstream healthcare. I was strategic lead for the Bristol Green Capital Kitchen on Prescription project and the feasibility research and am Honorary Senior Lecturer in the Department of Social and Community Medicine in Bristol University.

Elizabeth Thompson

Background

It now looks like a healthy diet can play a key role in the prevention and treatment of chronic illness. However, a variety of factors including the growing reliance on processed food is preventing people of all social back[1]grounds from following the healthy eating advice available to them. One such challenge is weak cooking skills and the need for greater practical knowledge about how to eat healthily on a budget.

The NHS faces serious challenges as people live longer and as chronic health conditions such as diabetes and obesity increase. In England 15 million have one or more long-term conditions, predicted to rise to 20 million by 2020. The pressure this is having on the health system is immense – people with long-term conditions take up 50% of all GP appointments and 70% of inpatient bed days, and account for 70% of the primary and acute care budget in England.

In light of these figures, we need to rethink how these long-term conditions are treated. One approach being advocated is a focus on self-care or self-management approaches that aim to empower patients to improve their health through their own actions.

In response to this challenge, a group of medical, nutritional and culinary professionals across Bristol are working together to bring cookery education into mainstream healthcare. The initiative is called Kitchen on Prescription (KOP). KOP is a ‘socially prescribed’ healthcare intervention that enables healthcare professionals to refer people with a long-term condition to a motivational healthy eating cooking course. It can also be used as a preventative intervention for people who want to stay well and those at risk of developing a health condition.

The KOP model has been developed and delivered over several years in several centres across Bristol, with similar initiatives being delivered in particular in Wellspring Health Centre in Barton Hill, Hartcliffe Health & Environment Action Group (HHEAG) in Hartcliffe and Knowle West Health Association.

Throughout 2015, funded by a Bristol European Green Capital Grant, the Portland Centre for Integrative Medicine has been collaborating with a variety of community food and other professionals/organisations with the ultimate aim to deliver KOP across Bristol as part of a social prescribing model. Bringing in psychological as well as nutritional expertise has been a key innovation as has developing a KOP curriculum which could be delivered across a broad range of communities. This project has involved a wide variety of activities including the development of an academic feasibility study in collaboration with the University of Bristol.

KOP aims

Courses have a strong focus on achieving long-lasting behavioural change. They last between six and ten weeks and contain three key elements of nutritional, culinary and psychological input.

Content includes:

• practical experience in cooking affordable, quick/easy to prepare nutritious food from scratch (the group usually eats together at the end of each session)
• discussions around healthy eating (input from either a nutritionist or experienced community food educator), meal planning, portion size/food label advice
• discussions around healthy eating (input from either a nutritionist or experienced community food educator), meal planning, portion size/food label advice
• psychological support (with input from a psychologist or experienced community food educator) with the aim of helping participants to overcome obstacles and promote long-term behaviour change.

Bristol Kitchen on Prescription Alliance

One of the key successes of the last 12 months has been collaborating with other community food initiatives across Bristol. In early 2016 we created the Bristol Kitchen on Prescription Alliance (BKOPA) [members listed on page 24*] with the aim of developing a pan-Bristol (pun intended!) KOP offer within a social prescribing framework underpinned by quality best practice standards (currently in development).

Our purpose is to:

• work towards a shared vision of making food part of a mainstream healthcare offer
• co-create KOP best practice guidelines (to ensure KOP courses are a ‘recognisable’ intervention and adhere to a quality standard)
• share learning/resources/protocols
• jointly create monitoring and evaluation tools and to jointly pool data
• jointly raise the profile of individual providers/ organisations in the health care arena
• ease referral to KOP courses for healthcare professionals (including mapping of providers.)

Social prescribing

A review of the evidence base for social prescription suggests that it increases people’s confidence, provides opportunities to build social networks and increases self[1]efficacy, and that it can increase people’s engagement with weight loss and exercise programmes. GPs recognise the social prescribing mechanism as a valuable part of their practice, particularly the emphasis on the strengths of patients to tackle their own problems themselves.

We have been working with the Bristol public health team and Richard Kimberlee (Senior Research Fellow at the University of the West of England) and KOP is now recognised as a social prescribing intervention by the Bristol public health team.

Activities: pilots/evaluation and research

Throughout 2015 and early 2016 we have been busy running and evaluating four pilot projects.

Two standard KOP courses open to anyone (Portland Centre for Integrative Medicine/Southmead Development Trust and Hartcliffe Health and Environment Action Group) and two with a specific focus – childhood obesity (Square Food Foundation/All About Food) and mental health (Knowle West Health Association).

Details of the pilots including a snapshot of evaluation and research are included below.

Portland Centre for Integrative Medicine/Southmead Development Trust pilot

The pilot Kitchen on Prescription course ran between May and July 2015 at the Greenway Community Centre in Southmead, and was marketed for people suffering from diabetes or other long-term conditions. A pop-up kitchen was used in the design of this course as there were existing kitchen facilities extended by funding a range of cooking stations and utensils. We could therefore test out the functionality of a pop-up kitchen and whether this could be rolled out in other sites across Bristol if the KOP initiative was to be funded within a social prescribing model. The course ran for 6 weeks with 13 participants.

The majority of participants were referred by health[1]care practitioners and all participants (except one) stated they had a long-term condition (eg cancer, polycystic ovary syndrome, diabetes, back pain).

We evaluated the course using both an in-house evaluation form and Measure Yourself Concerns and Wellbeing (MYCaW) a validated patient-centred outcome measure. The data and feedback from this course suggests a positive reaction to the course and that it supported a change in cooking and eating habits. A good MYCaW result was obtained suggesting a positive shift in concerns and wellbeing in a relatively short amount of time.

The main things participants felt they had got out of course included:

• fun cooking with others: 7/9 (top rated comment)
• learnt about nutrition and what a healthy diet means for me: 5/9
• learnt how to cook good food on a budget: 4/9
• improved my cooking skills: 4/9
• improved my sense of wellbeing: 4/9
• feel more confident about cooking from scratch: 3/9.

Areas to improve included:

• Be in a more contained space (as you know!). Sometimes felt as though we were in a zoo!!’ [The course was conducted in an open plan café using ‘pop-up’ kitchen equipment].
• Felt rushed at times, would have liked more time to ask questions during demos. More 1:1 to discuss own health issues.’

Hartcliffe Health and Environment Action Group (HHEAG pilot)

A further KOP 10-week pilot course ran in May 2016 with seven participants.

Changes that occurred from the evaluation forms (one person did not complete the evaluation) included:

• four out of six said their cooking skills improved
• one showed an improvement in terms of perceived support, four remained the same, and one felt they had less support.
• all six said they had met their goals for the course
• five showed improvements in their food choices and one remained the same.

The social element was very important for this course as well as for the Southmead pilot. One woman reported that she had not left the house alone for four years until attending this course.

Quotes from the benefits section of the evaluation form included:

• ‘very good for socialising’
• ‘meeting new people and making friends’
• ‘it has got me out of the house more often and introduced me to the walking group’

Community food educator Alex Burr who led the course says

‘I found having a nutritionist and a clinical psychologist in the room very useful. Between us, the scope for developing conversation around food and physical/ mental health was greater.

‘From my experience with other groups, there was much to be learnt from this pilot. The resources the psychologist provided were an excellent framework to start consistently referencing goals; I will start to implement this in sessions along with mindful eating.’

Feasibility study at the Square Food Foundation

In April 2016 we ran a feasibility study to evaluate a new KOP programme, ‘Nourish’, to help families with an obese child learn how to cook healthy food from scratch, based at the Square Food Foundation. The course was led by Barny Haughton and Francine Russell (community food educator from All About Food). It aimed to help families to learn cooking skills and to overcome any barriers they face to healthy eating and was intended to be ‘prescribed’ by GPs.

Childhood obesity poses a serious health challenge in the UK, and multi-component behavioural family lifestyle interventions are recommended. It’s clear that cooking skills interventions can improve dietary habits and weight, but evidence is limited.

The study was funded by an Awards for All lottery grant and the National Institute for Health Research (NIHR) Bristol Nutrition Biomedical Research Unit based at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. Four focus groups were conducted with 23 primary care practitioners to explore their views on child[1]hood obesity and their role in obesity and healthy eating, as well as obtaining feedback on the proposed intervention. Focus groups and interviews were held with six families to explore their eating, cooking and shopping habits, and their thoughts on the proposed intervention. Three of the families took part in a pilot ‘Nourish’ cooking-from-scratch course, which lasted six weeks (with a follow-up session) and was group-based, practical and involved the whole family. It had three key strands: culinary, nutritional and psychological support. Data was collected using online food diaries, photos of meals, and a self-efficacy questionnaire, to test the acceptability and feasibility of the outcome measures. Interviews with the families after the course explored their experience of taking part in the course and the research study.

Recruitment of families was extremely challenging; the most successful method was recruiting participants from a previous similar weight management course. Facebook showed some promise. Pre-course, families were generally confident at cooking from scratch and ate meals together as a family. The main barriers to cooking from scratch were time and fussy children. The course addressed both these barriers to some extent. Other barriers included cost and family illness, which were not fully addressed by the course. Families did enjoy, value and adhere to the course and felt that children were very well involved in the cooking, although staff observed a lack of parental engagement during the course. Suggested changes to the course were a wider range of dishes, listening to children’s wishes, addressing cost, and removing any reference to obesity/weight.

Comments from course participants (mothers)

‘They [kids] loved it, they really did enjoy it.’

‘M wouldn’t let me [not go], she’s like, “are we going this week mummy? We have to go”. Yeah, she loved it.’

‘I wonder if it would be better, you know, as more promoted as just something fun rather than educational, nutritional, psychologists involved, you know, everyone can learn to cook with your kids, come and have a taster session first and get them in … and then throw all the stuff at them [about weight].’

Primary care practitioners recognised the local prevalence of obesity and factors associated with this. However, many felt that GPs were not responsible for obesity/healthy eating, which was seen as a public health issue. GPs felt unable to discuss obesity with families due to patients’ denial and their perceived criticism, and the emotional nature of the subject. A major barrier to dealing with child[1]hood obesity was that children do not present in primary care, particularly not with obesity. Practitioners suggested that rather than accessing the course via the GP it should be advertised in schools, waiting rooms, and via parents who are obese.

Comments from primary care practitioners

There may be a good percentage of people who might take it up and it might change their life, so please don’t stop trying.

‘I think there’s a huge need for something, because generally diets and lifestyles are terrible.’

Sometimes obesity or poor eating can occur in the context of personal chaos, and then I think it’s understanding how you help a family for whom eating may be one of the least of their problems. It may just be symptomatic of what one would call poor lifestyle hygiene, you know, families that don’t really eat together, don’t have any routine, household chaos, all that kind of stuff.’

In terms of feasibility of the research study, the food diaries and photo methods of data collection do not appear to be feasible, due to issues with email and internet access, lack of time or forgetting, and involving the whole or extended family (with children who live in different households during the week). More useful alternatives may be a written food diary or a mobile phone app. For the photos more instructions and reminders are needed, perhaps just before families’ mealtimes. The self-efficacy questionnaire was acceptable and feasible.

The main implications for the intervention are that social prescribing by GPs may not be feasible, and the focus on obesity and being overweight should be removed. The design and content of the course was appropriate and appeared to impact dietary habits (although our data is very limited). More emphasis on eating healthily cheaply is needed, as well as incorporating children’s preferences, and with a longer course it was felt that changes could be more easily embedded into everyday life. There is clearly a need for further feasibility work before a trial is carried out, in particular to explore recruitment, referral, data collection methods and involving the child’s wider family.

Knowle West Health Association Food and Mood KOP

The last pilot course we ran this year was a six-week ‘Food and Mood’ course. Seven people enrolled (five with mental health issues, one with irritable bowel syndrome). Six attended regularly and reported significant benefits from attending.

Comments from participants on their hopes for the course and whether achieved included:

• improve my cooking skills: 6/6 [fully achieved: 4/6, partly achieved: 2/6 ]
• increase my self-esteem: 3/6 [fully achieved: 3/3]
• meet new people: 4/4 [fully achieved: 4/4]
• improve my own health 5/6 [fully achieved: 4/5, partly achieved: 1/5]
• improve the health of my family: 5/6 [fully achieved: 2/5 partly achieved: 2/5 not achieved: 1/5].

The data and feedback from this course suggests a positive reaction to the course, including encouraging Measure Yourself Concerns and Wellbeing questionnaire responses.

Future activities

We have had a very informative year and learnt a lot from the pilots. The challenge is to explore whether we can deliver enough courses through the network to provide KOP as a mainstream health offer across Bristol. The Bristol KOP Alliance is seeking funding with the aim of rolling KOP out across Bristol, evaluating the social and health impact of the intervention and if possible looking at pilots outside the Bristol area with a view to KOP becoming a UK-wide initiative. It’s not clear how soon or if social prescribing such as KOP will be funded by clinical commissioning groups, but judging by the results of these initial pilots there appears to be a clear need. If you are working in a similar field and would like to discuss piloting a KOP course at your project, please get in touch, helen.cooke@portlandcentrehealthcare.co.uk

• *BKOPA members: All about Food, Co-exist Kitchen, Food Inside Out, Hartcliffe Health & Environment Action Group, Knowle West Health Association, Lawrence Weston City Farm, Penny Brohn Cancer Care, Portland Centre for Integrative Medicine, Southmead Development Trust, Square Food Foundation and Wellspring Healthy Living Centre.