1. Food, health and homelessness
Alison McKay

2. Homelessness in Hampshire
Climate of increasing homelessness across UK and in Hampshire.
Lacking accurate definitions and counts
statutory vs single homeless/rough sleepers/hidden homeless
Vulnerable and marginalised group
Statutory homelessness has been on the increase; since 2009 numbers of individuals accepted by local authorities have increased by around a third across the UK (1). These figures represent only those recognised to be in priority need according to statutory homeless definitions. There are many times more who could be homeless, but there are no accurate methods of defining or counting these, particularly those who don’t approach homelessness services. Locally in Winchester and in Southampton the numbers approaching homeless services has increased significantly even over the past year.
What we do know is that the homeless are a vulnerable group, marginalised in society and with no voice; As the graffiti artist Banksy has illustrated – we are not all in it together as David Cameron would lead us to believe - some are more in it than others.

3. Maslow’s Hierarchy of Needs
This model of human development, designed in the 1940’s by the psychologist Abraham Maslow, describes levels of human needs and motivation (2). Homeless people often struggle to satisfy even basic needs for food, water, warmth, rest as well as safety. Without satisfying these needs it nearly impossible to move up and achieve psychological and self-fulfilment needs. Homeless services help to target basic needs and help give people a hand up to help better fulfil their potential.

4. What is Public Health Nutrition (PHN)
The promotion of good health through the primary prevention of diet-related illness in the population
    What people eat
    Nutritional needs through the lifespan
    Dietary recommendations
    Nutritional surveillance
    Achieving change
    Food supply, food safety and policy

5. Is PHN relevant for the homeless?
Homeless people are a subject to complex and often multiple needs, which may include problems with housing, health, addictions, relationships, lack of money, work and low self esteem.
Good nutrition is currently not considered a priority need, however to have the best chance of escaping homelessness, good physical and mental health are important: a good quality diet is an important way to help achieve this.

6. Food related homeless services
Types:
Day centres, hostels and supported accommodation
Churches and voluntary groups
Food provision:
Food or cooking facilities
Resources are limited – financial, human
Often depend on donations of food and/or money
Examples of good practice;
Edinburgh Cyrenian’s
St Mungo’s
In the absence of guidance and funding to support the nutrition related health of homeless people, homeless service providers, churches and voluntary organisations have taken on the responsibility to provide food-related services. This may be by providing food or facilities to cook food. These services are limited by resources in particular money, people and infrastructure.
At Winchester Churches Night Shelter guests a provided with a 2 course evening meal and breakfast; this is dependant on donations of food and money and on the services of volunteers. Without these the shelter would not be able to provide the service which it does.
Also in Winchester the day centre provides hot meals during week days, a breakfast on Saturday morning, and the Salvation army and church groups provide food on specific days during the week.
Else where within the homeless sector some examples of good practice are:
Edinburgh Cyrenians – ‘Good food in tackling homelessness’ programme has had an important impact on quality of food served, and also cooking skills, nutritional awareness, growing and food distribution projects.
St Mungos - The ‘Can Cook Will Cook’ course is run in partnership with catering company which teaches skills which are transferable to employment.

7. Why is food important for homeless people?
A nutritious and healthy diet is important:
In restoring and safeguarding health
In improving quality of life
In helping people make a
sustainable recovery from
homelessness.
There plenty of research evidence to indicate that what we eat influences or health and wellbeing.

8. The quality of peoples diets is very important for health
The quality of peoples diets is very important for health. The Government’s healthy eating guidelines are outlined by the ‘Eatwell Plate’ (3): recommendations are that one 1/3 of diet should be starchy foods, another 1/3 fruit, veg and salads, with smaller proportions of protein based foods and dairy foods and limited sugary and fatty foods.
My research of a sample of Southampton’s homeless found that diets were generally low in fruit, vegetables and salad and high in sugary and fatty foods food. This may reflect the food on offer which often includes fried foods, cakes and biscuits. It may also reflect the craving for sweet food which has been associated with drug use (4) - (59% of the Southampton study population reported using one more illegal drug).

9. Short term consequences of a poor diet
Low energy, tiredness
Irritability and lack of concentration
Increased susceptibility to infection
Low energy and tiredness can be a result of lack of energy intake or low blood sugar (hypoglycaemia). Anaemia (symptoms include tiredness and apathy) through lack of iron and vitamin C and an increased risk or susceptibility to infection can result through general inadequacy of energy, protein, vitamins and minerals.

10. Poor diet and longer term health
Often a tri-morbidity of:
physical illness,
mental health problems
substance abuse
Common health problems:
Dental caries and gum disease
Liver disease
Exacerbation of pre-existing health conditions
Increased risk of premature mortality
Role of diet and lifestyle ???
A tri-morbidity of physical illness, mental health problems and substance abuse is common amongst homeless people (5). Research published by St Mungos - ‘Homelessness it makes you sick’’ (6) found 49% of their hostel residents had mental health problems (including depression, schizophrenia, emotional or psychological disorders); 43% of all residents reported a physical illness. The Homeless Link health needs audit recently competed in Hampshire found 725 of respondents reported one or more physical health need, and 82% reported one or more mental health need. This was in line with the national findings (7).
The average age of mortality of an chronically homeless person is 47 years (for the general pubic this is 77 years); health needs of single homeless people cost the NHS 8 x more than the general public (8).
Common health problems are associated with lifestyle factors which include smoking, drinking and drug use, and with diets high in fat and sugar, and low in nutrients and fibre.
In my survey of Southampton homeless 85% smoked cigarettes, 72% men and nearly as many women were hazardous drinkers, and 59% took one or more illegal drug – heroin 23%, crack cocaine 23%. Research indicates strong links in these behaviours to mental and physical health outcomes.
Commonly reported health problems included dental caries and gum disease – often associated with smoking and high sugar/low fibre diets. Liver disease associated with alcohol consumption
Poor diet can exacerbation existing health conditions, for example diabetes, skin problems, HIV AID’s, hepatitis. It is also associated with premature mortality –ie cancer CVD.

11. Food and health project
Aim:
To understand the eating habits and food acquisition practices of the users of Southampton's homeless services
Key activities:
Interviews with service providers
Service users’ survey
4 homeless services in Southampton:
1 Day centre
1 Hostel with full board
1 Hostel with self catering facilities
1 Supported accommodation project
79 single homeless participants
Those who agreed to participate out of 111 individuals approached
My research project was planned to investigate some of the factors underlying food, health and homelessness. In July/August I interviewed the managers of four service providers in Southampton, who had agreed to participate, and undertook a survey of service users. Out of 111 service approached 79 agreed to complete the questionnaire.

12. Homeless peoples’ food patterns
63% of participants ate at least 2 meals daily
14% ate only one small meal daily
2 individuals ate no regular meals
Rough sleepers and those not engaged with homeless services most at risk of poor nutrition.
The following slides are an overview of some of the research findings.
Two-thirds of participants were apparently eating enough food, however this also means that a third (30 individuals) were eating one meal or less daily, of these 11 ate only one small meal and 2 no regular meals at all.
Rough sleepers and those not engaged with homeless services were at most risk of poor nutritional outcomes.

13. Where do homeless people eat?
Food sources 4-7 days weekly
n =79
Nearly half of participants used hostels as a regular source of food. (4-7 days weekly). The next most frequently used food sources were shopping for food, fast food and family and friends.
Day centres and churches were an important source of food, but were used less frequently during the week (1-3 days). (Not shown in this diagram).
Hostels were a regular food source for nearly half of the survey participants.

14. Alternative food sources
Despite most of those surveyed having access to subsidised food or free food, and being in receipt of welfare payments a large proportion reported using alternative and sometimes illegal methods to get food.
The research also showed that 69% would regularly spend, money on cigarettes, alcohol or drugs instead of food; this may offer some explanation towards the use of alternative other food acquisition practices.
Begging for money for food, stealing, raiding bins and selling property were commonly used

15. Barriers to homeless people eating well
Service provider:
Food availability
Variety of food
Cost
Nutritional quality
Service user:
Lack of nutritional knowledge and skills
Addictive behaviours of clients
Poor physical and/or mental health
Lack of interest
Further barriers to access and availability to healthy and nutritious food included:
The choice and variety of food available from service providers was at times limited with few healthy options.
Food service by homeless providers was not supported by any policy guidance or financial support. No minimum standards for food service exist, with exception of health and hygiene minimum standards.
Many of the service users did not like to pay for food – even though this was at a subsided price. The day centre was considering returning to free food to help ensure people did eat.
Addictive behaviours are associated with:
- low interest in food
- craving for sweet-food (drug addicts particularly eat a lot of sugar, thought to be associated with an opioid effect in brain, similar to drugs (4))
- poor dental health making it more difficult to eat food (this is associated with diets high in sugar, low in fibre and with smoking drinking and drug taking).
- nausea and lack of appetite
Poor physical and mental health which can reduce individuals ability to access food to be able to look after themselves.

16. Factors influencing food related health and wellbeing
This conceptual model pulls together the main points of my findings and the review of the limited literature which was relevant to the study.
It helps to describe the various influences on homeless peoples eating habits and food acquisition practices. Starting at National level the layers move inwards to the homeless person at the centre.

17. What next for food and health?
Food, nutrition and homelessness policy
Multi-sector approach
Using food as centre of community and skills building
Cooking, shopping, budgeting skills
Local needs assessments
Screening for nutritional needs
A National ‘Food, Nutrition and Homelessness’ policy is needed to introduce minimum standards for food-related provision and to provide guidelines and bench-marking for this. This policy needs to outline best practice, using case studies, and to include recommendations for how provisions should be financed.
Resources should be made available for service providers to refer to (ie web based); these can be outlined within the food-related policy, but also developed locally.
To achieve change will require joined up working practices which involve all relevant stakeholders. With the on-going changes to the NHS structure, including Public Health England, it is vital that local decision making on Joint Strategic Needs assessments, commissioning and budgets takes into account homeless peoples health needs, including their nutritional needs. This is going to require collecting local evidence of homeless health needs and presenting these to Local Authorities and NHS Health and Wellbeing boards.
St Mungo’s report that despite being the largest homeless service provider in London, they had not once in 30 years had been approached by the Director for Public Health regarding health needs of their homeless clients. It is clear that homeless services, health and nutrition service will need to be proactive to raise awareness and take opportunities to create and evidence base including examples of good practice.

18. Summary Good food and nutrition are vital for health
Homeless people have worse health outcomes than the general population
Little guidance or financial help for food-related homeless services
There are numerous barriers to eating well
To improve nutritional health and wellbeing a multi-sector, practical and educational approach is needed.

19. References
Fitzpatrick S Pawson H Bramley G Wilcox S. The Homelessness Monitor: Great Britain London: Heriot Watt University, University of York Crisis, 2012.
Maslow A. Motivation and Personality. New York: Harper; 1954.
Department of Health. The Eatwell Plate Resources. DoH. London: TSO; 2011.
Saeland M Haugen M Eriksen F Wandel M Smehaugen A Bohmer T and Oshauger A. High sugar consumption and poor nutrient intake among drug addicts in Oslo, Norway. Br J Nutr. 2011;105:
Royal College of Physicians of the United Kingdom. Food poverty and health: Briefing statement. London: Faculty of Public Health, 2005.
St Mungo's. Homelessness: It makes you sick. London: St Mungo's, 2008Homeless Link. The Health and Wellbeing of People who are Homeless. London: Homeless Link, 2010.
Homeless Link. The Health and Wellbeing of People who are Homeless. London: Homeless Link, 2010.
Crisis. Homelessness: A silent killer - a research briefing on mortality amongst homeless people. London: University of Sheffield, 2011.

20. Thank-you! alimckay@ekit.com
A Summary report will be available in due course. Please contact me with any questions or suggestions: Or
Or contact me directly at WCNS