Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight

EXECUTIVE SUMMARY

In common with most of the developed world, Scotland is experiencing the obesity epidemic. Scotland has one of the highest levels of obesity in OECD countries; only the USA and Mexico having higher levels. In 2008, 26.8% of adults in Scotland were obese and 65.1% were overweight; for children the corresponding rates were 15.1% and 31.7%. As overweight has become the norm, we have developed a distorted view of normal body shape and just how many people in Scotland are overweight and obese.

Attainment of the Government's purpose of a flourishing economy requires a healthy population. Overweight and obesity pose real risks to the health of the population in Scotland and its ability to meet its overarching purpose of sustainable economic growth because of the burden of disease that accompanies overweight and obesity.

In addressing one of the main causes of premature mortality and ill-health in Scotland, the Route Map can make a significant contribution to delivering the Government's purpose to deliver sustainable economic growth and, in particular, is a key driver underpinning efforts to increase healthy life expectancy.

Obesity cannot be viewed simply as a health issue, nor will it be solved by reliance on individual behaviour change. A successful approach will require cross-portfolio and cross-sector collaboration and investment to make deep, sustainable changes to our living environment in order to shift it from one that promotes weight gain to one that supports healthy choices and healthy weight for all. As a Government we are committed to taking action now, across the whole of society, to prevent this threat becoming a reality.

The Scottish Government and COSLA are equal partners in the development and delivery of this Route Map. The policy direction set out in this document are aimed at central and local government decision-makers working with their partners in agencies, the third sector, NHSScotland and business to develop and subsequently deliver the long-term solutions to this problem.

The challenge of obesity

Obesity occurs when energy intake from food and drink consumption, including alcohol, is greater than energy requirements of the body's metabolism over a prolonged period, resulting in the accumulation of excess body fat. Being obese or overweight can increase the risk of developing a range of serious diseases, including type 2 diabetes, hypertension, heart disease, some cancers and premature death. The risks rise with weight levels and are greatest for obese individuals. Obesity has been shown to be associated with at least as much ill-health as poverty, smoking and problem drinking and with as much premature mortality as smoking.

We estimate that the total cost to Scottish society of obesity in 2007/8 was in excess of £457 million and it is likely that this is an underestimate. Much of this cost is avoidable.

We predict that by 2030 adult obesity in Scotland could reach over 40% even with current health improvement efforts, an increase of more than 50% over 2008 levels. Alongside the increase in these levels are significant increases in the health problems associated with obesity.

These consequences of obesity will reflect, perpetuate and potentially increase social inequalities in health in Scotland.

We estimate that the direct NHSScotland costs of obesity will almost double by 2030. Using assumptions made in previous estimates, the total cost to Scottish society of obesity, including both direct and indirect costs, range from £0.9 billion-£3 billion.

This Route Map sets out the further direction of national and local government decision-making in the short and medium term to avoid these predicted consequences becoming a reality.

What we are aiming to achieve

We are aiming for the majority of Scotland's population to be in a normal weight range throughout adult life thus avoiding the adverse consequences of overweight/obesity. By achieving this aim we will impact on our economic purpose, through impacting on healthy life expectancy and a number of national outcomes, including:

• Our children have the best start in life and are ready to succeed
• We live longer, healthier lives
• We have tackled significant inequalities in Scottish society
• We have improved the life chances for children, young people and families at risk

This is a long-term aim and will take many years to achieve due to the scale of the action required. What is clear is that we must start to act now, using the best available evidence and advice, without waiting for experimental evidence for preventative measures and recognising that there will be challenges to all sectors of society.

We have already identified a national indicator to ' reduce the rate of increase in the proportion of children with their Body Mass Index outwith a healthy range by 2018'. To highlight our commitment to this issue we will work towards developing a further indicator which will cover the whole population. Additionally, we will identify a series of milestones that must be met if we are to achieve our aim.

The challenge for Scotland is to make significant cross-portfolio investment leading to fundamental change in the environmental, social and cultural circumstances under which people continue to become more overweight and obese. Our policies need to be directed at supporting people to achieve and then maintain a healthy weight. Given that the majority of the Scottish population are already overweight or obese and will only become more so over the coming years, this will in practice mean policies directed at sustained weight loss for affected adults and children growing into a healthy weight.

The scale of change required for both diet and physical activity to reduce obesity across the population cannot rely on individual behaviour change alone. We need to act at the population level so that these changes become the norm in Scottish society.

Current Government actions contributing to tackling obesity

It is estimated that the Scottish Government's total investment between 2008 and 2011 in the kinds of activity directly and indirectly contributing to tackling obesity could be as much as £200 million. This total includes the £56 million investment from Health budgets, but excludes spending by the NHS, local government and NDPBs from their own core budgets. Local authorities are also tackling obesity both directly and indirectly through contributing to the national outcomes and local priorities in their Single Outcome Agreements ( SOAs).

This is a significant level of effort and investment and it is encouraging that a broad range of policies and initiatives across portfolios and across the public sector are seeking to address healthy weight outcomes. There are, however, a number of respects in which our current delivery falls short of what is required from a concerted, sustainable and successful approach to tackling obesity in the long term. We need to redress the balance and join up initiatives such that we spend more on prevention, leading to the need for less to be spent on treatment of the effects of obesity in years to come. Scotland must be prepared to consider radical action.

A significant proportion of Government's current actions that contribute to tackling obesity do so as a secondary benefit of achieving other primary goals, for example reduction of carbon emissions. We now also require healthy weight outcomes to be amongst the explicit objectives of action across portfolios to ensure that their achievement is actively promoted and that the necessary resources are prioritised in future plans and policies.

We also need to identify where our objectives may unintentionally work against the maintenance of a healthy weight. We must be alert to these unintended consequences and seek to minimise their impacts.

By prioritising obesity prevention across Government we can ensure that policies act as drivers for maintaining healthy weight rather than contributing to weight gain.

What we will do

Section six of the Route Map groups the preventative actions we need to take under the following four categories, as the first stage of this journey:

• Energy consumption - controlling exposure to, demand for and consumption of excessive quantities of high calorific foods and drinks
• Energy expenditure - increasing opportunities for and uptake of walking, cycling and other physical activity in our daily lives and minimising sedentary behaviour
• Early years - establishing life-long habits and skills for positive health behaviour through early life interventions
• Working lives - increasing responsibility of organisations for the health and wellbeing of their employees

Significant investment in both the short and medium term across all four of these areas is needed to make an impact on current obesity trends. Delivering policy responses goes far beyond individual initiatives. It will require systemic and far-reaching change in infrastructure, environments, culture and social norms and we will not see these changes or outcomes overnight.

The combined effect of these actions will impact on the level of obesity in society, however, we cannot yet predict accurately the contribution of each element or precisely how much we need to invest in each area. For this reason we will put in place a review mechanism through which emerging evidence of effective interventions, any resulting changes to policy required and our progress towards meeting our aim will be considered. We will use this mechanism to refine the actions indicated by the Route Map.

The Route Map sets out the range of actions we believe will be required to achieve our aim. The actions described below are aimed at the population level. Our aim in implementing the Route Map is to have population wide impacts which should benefit all in society but we will also remain vigilant to ensure that we do not disadvantage any one group above another and widen health inequalities.

Management and treatment of obesity are outwith the scope of this Route Map, as it focuses on prevention. However, we are committed to ensuring that cost effective and appropriate weight management services and treatments for obesity are provided for patients in Scotland.

Alongside the preventative actions we have identified in the four broad categories above, we will take action to ensure that we raise awareness of the real threat of obesity, measure our progress and learn from our actions and support further research to continue to manage obesity prevention appropriately.

Next steps

We will establish a joint governmental leadership group, including Ministers, COSLA leaders and key stakeholders including the NHS and the public health community, to be the visible focus of the Route Map, to ensure its implementation by holding decision-makers to account. This group will:

• Oversee the development during 2010 of an action plan and identification of key milestones to support delivery of the Route Map
• Periodically, reflect on progress against key milestones and targets and consider whether decisions being taken at both local and national level are sufficient to ensure progress
• Provide governance of the integrated research strategy to ensure that emerging evidence and external developments (such as European policy or food pricing policies) are incorporated into reviews of the Route Map
• Oversee and publish in 2013 a report of the progress and actions taken towards the policy direction set out in this Route Map

In addition, we will fund a national event during 2010 to be organised by the Scottish Public Health Network to allow stakeholders from all sectors an opportunity to be involved in helping shape actions that come out of the policies identified in this Route Map.