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

6. WHAT WE WILL DO

6.1 The Foresight report describes the extremely complex mix of underlying factors and causes that contribute to obesity. Foresight itself does not provide answers as to the most effective interventions at a population level. However, the report recommends four areas in which concerted action is likely to have the greatest impact on obesity prevention. These are the areas in which the relationships between weight gain and the environments to which we are exposed, and how we behave are the strongest. For this reason we have grouped the preventative actions we need to take under the following four categories as the first stage of this journey (these are not listed in priority order):

• 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

6.2 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.

6.3 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.

6.4 In the following sections we set out the range of actions we believe will be required to achieve our aim. The actions described below are aimed at the population level.

6.5 The distribution of overweight and obesity in OECD countries consistently shows pronounced disparities by education and socio-economic conditions in women, while mixed patterns are observed in men. ²¹ The most recent evidence, from the 2008 Scottish Health Survey, showed a clear linear relationship in women, with levels of obesity increasing as deprivation increases. For men there are high levels of obesity across all deprivation quintiles.

6.6 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.

Energy consumption

6.7 We need to reduce the energy intake of Scotland's population. This means consuming smaller quantities of energy from food and drink, including alcohol. The reduction in consumption need only be small, but must be supported at the food supply level. There is no need for this to have a negative impact on profitability in Scotland's food industry.

6.8 Recipe for Success: Scotland's National Food and Drink Policy is a major step forward in ensuring that for the first time public health issues, along with environmental sustainability are integral to the Scottish Government's aim to continue to support the sustainable economic growth of the food and drink industry. It highlights how food can impact on the nation's health and its environment and identifies areas where we can influence and support the Scottish supply chain to achieve a Healthier, Greener Scotland.

6.9 This Route Map is intended to build on Recipe for Success and the key proposition that there are gains to be made by bringing together the perspectives of health, sustainability and business. Historically, these three policy themes have been pursued separately and the current challenges make it imperative that we find points of synergy, growth and opportunity. To deliver the longer term solution to the obesity challenge interventions and incentives, and levers to change, need to be integrated across Government policy.

6.10 In the development of overweight and obesity the roles played by temptation and current social norms regarding body weight should not be underestimated. Multiple aisles of high energy-dense foods and drinks in retail outlets, as well as a wide range of easily accessed eateries in our high streets, present a myriad of opportunities for consumers to make less healthy choices more frequently, influenced by the balance of foods and drinks on sale. The availability of large portion sizes of high energy-dense foods, drinks and meals adds to the risk of consumers purchasing and consuming excess energy. For these reasons, we need to create environments in which access to healthier, less energy-dense, food and drink, and smaller portion sizes becomes the norm in Scotland. Providing a higher proportion of less energy-dense food as well as smaller portions or pack sizes can be a profitable goal for Scottish businesses. We can help secure this by providing clear regulation and guidance with particular support for small to medium size enterprises ( SMEs) so that businesses are competing in a fair environment.

We must work to shift social norms by increasing demand for, and affordability of, less energy-dense, lower energy healthier options and smaller portions.

We will control exposure to foods that are high in energy by:

Shops, eating out, and consuming on the move

• Working with the Scottish Retailers' Forum ²² to reduce the ratio of energy-dense food and drinks to lower energy options ( e.g. smaller and less energy-dense portions) stocked by supermarkets and convenience stores to better reflect the needs of a healthy balanced diet.
• Continuing our collaboration with key food partners in Scotland to support SMEs to reformulate ²³ mainstream food and drink options and to encourage responsible use of 'healthier' as a strategic marketing tool. Reformulation of processed and prepared foods should not focus only on the premium end of the market or on food explicitly marketed as healthy options; the highest priority should be on everyday basics and products at the more affordable end of the market.
• Using our financial support schemes and integrated impact assessment to provide incentives to producers and manufacturers of lower energy food and ingredients and to restrict subsidies for those producing high energy products.
• Continue to work with the Food Standards Agency to support the industry to reduce salt, saturated fat and sugar levels and portion sizes in their products.
• Working with producers, retailers and caterers to ensure that portion sizes served or suggested by labels better reflect consumers' energy needs. This will include activity to standardise portion sizes in ready meals and restaurants. In retail outlets it will also mean basing assessment of energy density on realistic quantities people actually eat in 'a portion' and the cumulative energy content of linked products marketed as meal deals. There need be no obstacle to marketing high-calorie meals, but consumers need to be informed.
• Where voluntary approaches to reformulation, portion size adjustment and stocking policies do not achieve sufficient progress towards a healthier balance in the meals, food and drinks sold in Scotland we will consider appropriate statutory means to increase the rate of change.
• Working with Consumer Focus Scotland to extend the Healthyliving Award to all caterers within public sector organisations and to have a stronger presence on the high street. For all organisations already participating, the Healthyliving Award Plus offers an opportunity to achieve step increases in the required ratio of healthy options to other options on menus from participating caterers.
• Encouraging the use of the Nutritional Requirements for Food and Drink in Schools (Scotland) Regulations 2008 to inform standards in commercial catering.
• Working with the Scottish Grocer's Federation ( SGF) to extend the reach of the SGF Healthy Living Programme within participating neighbourhood food shops, for example moving confectionary displays from till points and expanding the range of healthier choices offered and promoted under the scheme.

Schools

• Continuing the excellent progress of the Schools (Health Promotion and Nutrition) (Scotland) Act 2007 and the subsequent Nutritional Regulations in making schools exemplary health-promoting environments. We will encourage the uptake of balanced and nutritious schools meals across all age groups by:
• working towards providing free school lunches to more pupils in the earliest years of primary schools;
• working with the food industry to deliver a wider variety of reformulated popular options complying with the nutrition regulations; and
• supporting schools to make remaining in school for lunch more attractive to secondary school pupils through a range of innovative approaches.
• Exploring measures to restrict access by children to nutritionally inappropriate meals and high energy and energy-dense foods from businesses located in the vicinity of schools.
• Facilitating collaborations between schools and local food outlets to promote appealing, affordable lower energy and less energy-dense options for pupils who choose to leave school for lunch.
• Reinforce messages for parents on the content of lunchboxes and provision of snacks in and around the school day.

Communities

• Working across the public sector to promote and support the procurement of lower energy and less energy-dense products and to support the adoption of nutritional standards analogous to the school Nutritional Regulations 2008 to vending machines, retail outlets and public and staff catering facilities in NHS and Local Authority premises and other public sector organisations. The leadership of the public sector will set an important example which we would wish to see emulated by the private sector.
• Supporting implementation of the 'Beyond the School Gate' benchmarking guidance for community planning partnerships on provision of lower energy and less energy-dense food options in the community, for example through limiting the number of fast food outlets near schools, leisure centres, parks and youth centres and encouraging the provision of outlets for healthy convenience food and drink.

We will support consumers to make less energy-dense food choices by:

Labelling

• Producers, manufacturers and retailers should take a responsible approach to prioritising the clarity of health messages on food and drink packaging:
• labels identifying the salt, saturated fat and sugar content of products should be clear and easily understood by consumers who may not have high levels of literacy or health literacy;
• the FSA's recommendations for front of pack labelling should be implemented consistently across products and retailers to minimise consumer confusion;
• where images and labels are used to indicate positive features such as local provenance, premium quality or environmental credentials of high energy and energy-dense products it is important that these do not confuse or distract consumers from their nutritional properties; and
• methods for communicating the energy density of products in a simple way for consumers who may be less health-literate, for example how far you would have to walk to burn the energy contained in the product, should be investigated further.
• Increasing people's understanding related to food and diet across the population, including through the Curriculum for Excellence. Schools are a crucial setting in which to equip children and young people with the skills to choose, purchase and prepare lower energy and less energy-dense meals and snacks. While schools offer valuable opportunities to increase awareness of healthy weight, it is important that this is done in a sensitive way that does not increase stigma and undermine the mental wellbeing of children and young people.
• Investing in broadening tastes in the early years. As the Schools (Health Promotion and Nutrition) (Scotland) Act 2007 recognises, learning about healthy eating is not limited to curriculum content, but should be at the heart of all school activities. The food provided in schools has a vital role to play in developing children and young people's tastes and demonstrating that lower energy and less energy-dense meals and snacks can be appealing.
• Ensuring that everyone has access to opportunities to learn how to shop for and cook affordable healthy meals from raw ingredients.
• Using social marketing to influence social norms and empower healthier food choices. We will extend the Scottish Government's 'Take Life On' campaign to include a wider range of community partnerships including supermarkets and community food schemes to increase consumer awareness of the benefits of healthy eating and encourage healthier food choices through incentives such as price promotions.
• Ensuring simple, direct and consistent communication of what a lower energy, less energy-dense diet is for an audience that is more likely than not to be overweight. Official guidance to the public on a healthy diet needs to provide easily understood practical advice about recommended total quantities and energy consumption, not just a healthy balance when portion sizes may be excessive.

Marketing

• Working with retailers to target all promotional activity on food and drink towards incentivising eating for a healthy weight, including price promotions, vouchers, in-store product placement, direct mail marketing and multiple-buy offers such as 2 for 1s. This means:
• removing incentives for consumers to purchase high energy and energy-dense food and drink, particularly incentives to buy these products in large quantities, for example bulk value pricing structures; and
• introducing incentives for consumers to purchase lower energy and less energy-dense food and drink options.
• We are exploring opportunities to restrict advertising of foods high in fat, salt and sugar ( HFSS) foods through non-broadcast media as outlined in the National Food and Drink Policy and we will continue to support a pre-9pm ban on advertising in broadcast media of HFSS.

Energy expenditure

6.11 As discussed in Chapter 4, the majority of the population in Scotland are overweight and may require up to 60 minutes of moderate physical activity every day in order to achieve or maintain a healthy weight. To make this achievement realistic, this activity needs to be integrated into people's everyday routines. One of the most effective ways to absorb this much activity in a busy day is to reduce reliance on motorised transport, changing our means of everyday travel to walking and cycling.

6.12 Currently almost two-thirds of adults in Scotland are not even achieving 30 minutes moderate physical activity a day ²⁴ and only 13% of journeys to work are made by bicycle or on foot. ²⁵

Foresight is clear that we cannot simply depend on individuals changing their travel habits without modifications to our physical and cultural environments. We need to make walking and cycling accessible, safe and appealing enough to be the default means of travel for short and local journeys.

National and local government needs to support this shift towards active travel as a mainstream choice by considering how all our policies impact on built environments so that they represent opportunities for rather than barriers to active travel.

We will create environments that make walking and cycling part of everyday life for everyone by:

Transport policy

• Addressing obesity prevention through active travel specifically in the review of the National Transport Strategy.
• Encouraging Regional Transport Partnerships to work towards conducting integrated impact assessments on all Regional Transport Strategies.
• Delivering the Cycle Action Plan for Scotland. This draft plan proposes that by 2020 10% of all journeys are made by bicycle.
• Continuing to provide support to Sustrans to maintain and extend the National Cycle Network and provide safe routes to schools for children who wish to cycle or walk to school and to Cycling Scotland to promote cycling more generally.
• Ensuring that in all our actions responding to the national indicator to reduce the proportion of driver journeys delayed due to traffic congestion we are promoting active travel, not creating incentives for greater personal car use for short and local journeys.

Planning policy

• Using the opportunity afforded by the National Planning Framework for Scotland 2 ( NPF2), which specifically seeks to ' promote development which helps to improve health, regenerate communities and enable disadvantaged communities to access opportunities', to ensure that policies in development plans have a positive impact on active living and healthy weight.
• Implementing the lessons learned from pilots such as the Equally Well Test Site in Glasgow about ways community partners can work effectively together to integrate health improvement into city planning.
• Applying robustly, in development plans and development management decisions, the priority order for personal travel opportunities (walking, cycling, then public transport, followed by the car and other means of motorised vehicles) as set out in Scottish Planning Policy ( SPP).

Design and placemaking

• Ensuring that the placemaking provisions of the SPP, in particular those in ' Designing Places', ' Designing Streets' and the provisions for open space and physical activity from the SPP are put into practice through ongoing training, promotion and dissemination.
• Encouraging excellence and innovation in designing communities that incorporate a range of features that reduce car dependency, increase active travel and create attractive, accessible open spaces for recreation through the Scottish Sustainable Communities Initiative. The sharing of this innovation and practice will help improve the quality of Scotland's built environment.
• Working with Architecture and Design Scotland to investigate the potential to improve standard practice in the design of new and refurbished buildings on issues such as:
• safe direct access by pedestrians and cyclists;
• sufficient secure storage for bicycles;
• facilities for cyclists to shower and change; and
• stairs which are at least as accessible as lifts.
• Supporting the creation and maintenance of safe, attractive and accessible greenspace, including green transport corridors, close to where people live.

Supporting behaviour change

• Make our communities safer and stronger and reduce the fear of crime through the Safer Streets Programme and the Safer Communities Programme so that more people feel comfortable and secure being active outdoors in their neighbourhoods.
• Divert young people away from crime and disorder by getting them involved in sporting activities through the CashBack for Communities Programme.
• Responding to people's concerns about the safety or convenience of active travel by using a diverse range of means including:
• expanding safe cycling and pedestrian routes to link key community destinations including public transport hubs, hospitals, supermarkets and centres of employment;
• publicising the availability and benefits of local pedestrian and cycle routes and improving signage to popular destinations;
• clearing up environmental dereliction such as poor lighting, vacant sites and animal faeces that discourage people from walking in their local neighbourhoods; and
• using social marketing approaches tailored appropriately to audiences depending on their current levels of activity and motivation, with particular attention on those who are especially inactive or vulnerable in other respects.
• Implementing widely the lessons learned from the Smarter Choices Smarter Places active travel demonstration towns about which interventions, including both incentives for active travel and disincentives for car use, are most effective in achieving greater uptake of travel options, particularly by the least active groups.

Sport and recreation

• Providing and maintaining physical environments in every community that promote healthy lifestyles for children including opportunities for play, physical activity and healthy eating.
• Working with sportscotland to ensure the provision of opportunities for all children and young people to participate in physical activity and sport and enabling the creation of pathways from the school to the wider community.
• Working together to find realistic ways of maximising physical activity within the school environment.
• Developing curricular and non-curricular activities for children to gain the skills and confidence to enjoy more active lives, through Active Schools, Safe Routes to Schools and opportunities for outdoor learning.
• Maximising the opportunities of the Active Nation campaign to encourage people of all ages and abilities to become more physically active in the run up to the 2014 Games and beyond.

Early years

6.13 To give children the best start in life, early life interventions need to begin before and during pregnancy, continue through infancy, in early years settings such as nurseries and childminders and onto school. The early years offer the best opportunity to put in place healthy behaviours around food and physical activity which will be sustained into adulthood. Central to this is the involvement of families, and every opportunity must be taken by all involved to shape and deliver services using health professionals and the Third Sector in a way which best provide support.

6.14 The rise in the number of women who are obese during pregnancy gives cause for concern due to the risks that obesity poses to the health of both the mother and infant, as well as its influence on long-term adult health. Maternal obesity can have an adverse effect on birth weight which, in turn, may affect risk of obesity later in life.

6.15 In infancy there is evidence that breastfed babies show slower growth rates which may contribute to the reduced risk of obesity later in life shown by breastfed babies. ²⁶ Infants who gain weight rapidly in the first two years of life are more likely to be overweight later in childhood. There is also evidence to suggest that infants who are weaned onto solid foods at an early age (before 15 weeks) are more likely to be overweight later in childhood. ²⁷

We will encourage healthy behaviours around food and physical activity in the early years by:

• Promoting positive environments for children and families through all our planning, regeneration and transport policies.
• Implementing the forthcoming Maternal and Infant Nutrition Strategy.
• Continuing to develop and roll out the Getting it Right for Every Child change management programme for services affecting children and young people, founded on wellbeing indicators including healthy and active that encourage attention to diet and activity.
• Investing to ensure that all pregnant women, and women of children aged under 4 who are eligible for Healthy Start are aware of, and apply for the Healthy Start vouchers.
• Investing to ensure that more babies are breastfed, and for longer.
• Investing to support pregnant women and new mothers to develop healthy lifestyle behaviours, for example through the key elements of parenting programmes and community capacity building in the Early Years Framework.
• Investing to support parents knowledge about how they feed themselves and their babies particularly when babies make the transition onto solid foods.
• Investing in a programme of education and support for health professionals on maternal and infant nutrition to provide the best quality information and support to all women about how they feed themselves and their babies.
• Investing in communications aimed at women of childbearing age pre-conception about the relationship between maternal obesity and adverse outcomes in pregnancy.
• Ensuring that the guidance set out in Nutritional Guidance for Early Years is implemented across all services for children between 1 and 5 years, regardless of the providers of those services.
• Supporting the third sector to increase opportunities for play through our investment in Inspiring Scotland's Go Play Programme.
• Ensuring that nurseries and other childcare facilities minimise sedentary activities during playtime, and provide regular opportunities for enjoyable active play and structured physical activity sessions.

Working lives

6.16 As noted in the Scottish Government's recently published Health Works Strategy, a healthy workforce is essential to help Scotland increase sustainable economic growth. It has been shown ²⁸ that:

• Physically active employees take 27% less sick days than non-active employees
• Individual work performance ²⁹ can be improved by between 4% and 15% when people engage in regular physical activity
• An on-site fitness programme can reduce staff turnover by between 8% and 15%

6.17 Rising levels of obesity will make a significant and growing contribution to levels of illness and subsequently sick absences in the workforce and whilst employers alone cannot solve the obesity problem, they can contribute to the solution. Currently 2.5 million people in Scotland are in employment with total weekly hours of work of 81 million. ³⁰ Their work sustains the economy and is critically dependent on their working capacity. Given the amount of time individuals spend at work, there is a real opportunity to engage a large proportion of the adult population in activities to prevent obesity.

6.18 It is unlikely that the business plan of any new business, or the core aim of an established business will explicitly include addressing preventing obesity in their workforce, and yet a healthy, motivated workforce is essential for high productivity levels. With more than 50% of the Scottish workforce in organisations with fewer than 250 employees and 99% of all businesses in Scotland employing fewer than 250 people, ³¹ we have to recognise that there is a disparity in what we can expect large corporate employers, such as the public sector to achieve, and what is reasonable to expect of smaller businesses. Our Route Map identifies a range of actions that will support both small and large businesses.

6.19 Most employers are already aware that a healthy workforce is important to their continued success, and many are now more active in supporting their employees in achieving a healthier lifestyle. Our primary challenge is to raise the awareness of all employers of the potential costs to their business of obesity, and of the benefits of health promotion policies and practices that can contribute to prevent their workforce from becoming overweight or obese in the first place or helping them achieve and maintain a healthy weight.

6.20 We already have in place the Scottish Healthy Working Lives Award and we want to motivate and make it possible for the diverse range of employers established in Scotland to achieve it, or to initiate other health promoting activity for the benefit of both their employees and ultimately the productivity of their business.

We will invest in encouraging public and private sector employers to increase their responsibility for the health of their employees, and support them to do so where possible by:

• Working together to develop a clear vision of the role of the public sector in promoting the healthy working lives approach, given that the public sector in Scotland accounts for around 25% of the workforce.
• Continuing to invest in the Scottish Centre for Healthy Working Lives and ensuring that obesity prevention is embedded in its strategy.
• Continuing to invest in the Healthyliving Award by securing commitment from all other public sector employers with catering outlets to register for and achieve the Healthyliving Award in the first instance and thereafter the Healthyliving Award Plus.
• Encouraging all private sector employers with canteen/cafeteria facilities to participate in the Healthyliving Award.
• Following up CEL 14 (2008), Health Promoting Health Service - Action in Acute Care Settings, to ensure that action is being taken by NHS Boards to achieve the eight health promoting actions (alcohol, smoking, healthy eating, etc); that all hospitals with catering facilities for staff and/or the public have achieved the Healthyliving Award and that those who have held the Award for 2 years are now working to achieve the Healthyliving Award Plus Award.
• Encouraging NHS Boards to consider possible roles for public health and occupational health in supporting the establishment of partnerships involving local businesses, and in supporting the implementation of workplace programmes for the promotion of healthy weight management, taking account of any relevant national and local schemes.
• Encouraging all public sector organisations to set an example to other landowners by using their estate to support greater activity by signposting walks and cycle routes.
• Supporting Paths for All to increase coverage of their workplace walking programme.
• Encouraging employers to support their workforce to adopt more active means of travelling to and from work as a contributory element to an individuals levels of physical activity.
• Encouraging businesses to support their employees to participate in Active Nation: A Games Legacy for Scotland.
• Continuing to fund the national Institute for Sport, Parks and Leisure physical activity accreditation award and encourage NHS and local authority engagement.