Evaluation of the Healthy Start Scheme: An Evidence Review

3. Nutrition And Dietary Patterns In Scotland

3.1. This chapter outlines the important role of diet and nutrition during preconception, pregnancy and early years as they have been long recognized as important and critical periods of human development with tremendous impact on health outcomes in later stages of life (BMA, 2009; SACN, 2011). In particular, it discusses the current state of medical knowledge on vitamin supplementation within these periods of human life. Then, it reviews the current strategies and policies in place that aim to improve health outcomes and reduce health inequalities amongst this population and attempts to establish whether they meet their goals. Finally, this chapter engages in a discussion about the factors contributing to shaping dietary profiles and it offers some recommendations for actions that can be undertaken alongside the Welfare Foods initiative.

3.2. As emphasized in the previous chapter (sections 3.3-3.5), good nutrition is crucial for human health. Micronutrients, of which 30 are necessary and provided through dietary sources, not only contribute to regulation of various bodily functions but also play a key role in preventing diseases (Shergill-Bonner, 2013). Dietary Reference Values (DRVs) were published by the Department of Health in 1991 and they provide recommendations on most nutrients and energy intakes. For obvious reasons, women planning their pregnancies, pregnant and breastfeeding women as well as young children have been identified as having additional nutritional requirements. For more understanding of the Scottish Policy Framework on how to provide these maternal and infant guidances and services, please consult 'Improving Maternal and Infant Nutrition: A Framework for Action' (Scottish Government, 2011a).

3.3. This framework focuses on supporting maternal and children's health and nutrition, while recognizing the extent and impact of health inequalities on health outcomes and risks of inadequate nutrition resulting from "complex social, environmental and economic circumstances" (Scottish Government, 2011a:5). Therefore, improving nutrition intake especially amongst low-income mothers and children remains a priority for the Scottish Government - as advised by NICE (2008a) in 'Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households' and supported by a range of policy initiatives, strategies and guidance, some of which will be discussed in more detail further below (section 3.22).

3.4. However, while these nutrition and dietary recommendations are directed at all mothers and young children, those from disadvantaged backgrounds are more likely to be at risk of micronutrients deficiency and therefore are defined as the focus for affirmative and preventative action. A significant body of medical literature also suggests that in case of certain nutrients (e.g. vitamin D and folates) even having healthy, nutrition-rich and sustainable diets does not ensure that their adequate levels will be met. Therefore, women planning pregnancy, pregnant and breastfeeding women and young children (under 5) are recommended to take certain vitamin supplements in order to reduce the risks of birth defects and poor health outcomes in later life (Bestwick et al., 2014).

3.5. Even with a range of policies in place, there has been a growing concern about prevalence of vitamin D deficiency related diseases amongst children (Ahmed et al., 2011). Similarly, levels of folic acid supplementation before and during pregnancy have been alarmingly low and further decreasing in the UK (Bestwick et al., 2014). This leads to an important question about whether the current policies around vitamin-supplementation have been failing or even contributed to the increase in health inequalities (as Bestwick and colleagues, 2014, imply) as well as what can be done in order to reverse these effects.

VITAMINS SUPPLEMENTATION IN PREGNANCY AND EARLY YEARS

Folic acid

3.6. Recommendations regarding folic acid supplementation before and up to 12 weeks of pregnancy (Lemer, 2013) have been adopted in the UK and globally since the mid - 1990s after a growing body of medical evidence has found links with the reduction of the risk of birth neural tube defects (NTDs; Al-Gailani, 2014). To date, folic acid supplementation has been especially recommended in the countries which do not fortify foods with folic acid (such as the UK; Al-Gailani, 2014). Therefore, in accordance with highly consistent body of medical evidence, it is crucial that all women planning pregnancy and all pregnant women are provided with the information about the benefits of folic acid supplementation and about the Healthy Start vitamin supplements by health professionals (NICE, 2008b).

3.7. On the other hand, the question of mandatory fortification of certain foods (e.g. flour and other grain products) with folic acid continues to be under on-going debate (Al-Gailani, 2014). Currently, mandatory fortification of flour with folic acid in the UK is recommended by SACN (2009). In particular, it is emphasized that it would improve the folate status of women who are at risk of pregnancies affected by NTDs. In the light of the findings that 1 in 6 of pregnancies are unplanned and 1 in 4 or even 1 in 3 are ambivalent (Wellings et al., 2013), fortification has been seen as a preferable alternative to supplementation given that the effect of the prevention of birth defects only occurs if provided before and in the first 12 weeks of pregnancy. Moreover, a qualitative study by Barbour and colleagues (2012) conducted in Scotland shows that one of the main causes for pregnant women not taking the recommended dosage of folic acid is due to unplanned pregnancies, followed by: being too busy to take folic acid every day, experiencing nausea or making decisions based on their closest networks' experiences. In particular, it should be especially stressed that participants often made statements about the influence of family and friends suggesting that societal factors can and do have impact on women's choice on using vitamin supplements during pregnancy (Barbour et al., 2012).

3.8. Similarly, the findings of the longitudinal study by Bestwick and colleagues (2014) seem to support the necessity of fortifying flour and other cereals or grains with folic acid in the UK. They reported low and decreasing level of preconception folic acid supplementation amongst women attending the Wolfson Institute of Preventive Medicine in London before pregnancy, from 35% in 1999-2001 to 31% in 2011-2012. Furthermore, a significant gap in folic acid uptake was found across different age and ethnic minorities groups. In particular, young women under 20 were least likely to use folic acid pre-pregnancy (5-6%) in comparison with women aged 35-39 (40% level of uptake). Non-caucasian women were also reported to be less likely to use folic acid supplementation than those of caucasian origin. These results highlight the importance of using a variety of methods to increase vitamin-intake, including campaigns promoting behavioural change within local/community contexts or directed at specific age and ethnic groups (McGee and Show, 2013; NICE, 2008b).

3.9. On the other hand, opponents argue that fortifying foods with folic acid may lead to exceeding its Dietary Reference Value (DRV) levels which can be especially risky for people whose diets are lacking in vitamin B12 (as it may cover the signs of anaemia). Some research has also linked excessive folic acid intakes (at doses higher than 1 mg/day) with an increased risk of the development of certain cancers (Hubner, Houlston, & Muir, 2007 cited in Al-Gailani, 2014). Nevertheless, following SACN (2009) guidance, mandatory fortification of grain products could be an option worth considering if a range of safety measures are introduced alongside it, such as:

• Restrictions on voluntary folic acid fortification of certain foods (e.g. cereals);
• Adjusted guidance on supplement intake by various populations - including pregnant women;
• On-going monitoring of any new evidence on any negative impact of long term folic acid intake.

3.10. In case mandatory fortification of grain products with folic acid in the UK is implemented, women planning pregnancy as well as pregnant women up to the twelfth week would still be recommended to use folic acid supplements (SACN, 2009:8; for details see: the UK Government website^[5]).

Vitamin D

3.11. In recent years, the importance of vitamin D supplementation has received an increased attention, not only in relation to health and wellbeing of at-risk groups as defined by the Department of Health (2012, which includes pregnant and breastfeeding women and children under 5; for details see the Department of Health website^[6]), but also - to the whole UK and European population (NICE, 2015; Sinha et al., 2013).

3.12. This report attempts to summarize the state of the current medical knowledge on the role played by vitamin D in the health of pregnant and breastfeeding women and their children as it is a main component of the Healthy Start Vitamins (for both mothers and children). This preliminary review should be complemented by a more thorough one given that recent research has contested the evidence in support of vitamin D supplement-intake during pregnancy. For example, Lawlor and colleagues (2013) recently reported no relevant association between levels of vitamin D during pregnancy and bone - mineral content (BMC) in late childhood, seriously undermining previous evidence widely cited across medical literature and used to support claims of importance of vitamin D supplementation during pregnancy and early years.

3.13. The following section is an attempt to contextualize such research within the Healthy Start framework in order to determine the best possible way of supporting low-income pregnant women and young children. In particular, the widely debated issue of the universal provision of free vitamins to all pregnant and breastfeeding women and young children against the targeted provision (as set up by the Healthy Start) will be investigated and critically assessed in the Recommendations section.

3.14. In the light of well-established clinical literature, vitamin D is argued to be important for healthy bone development (e.g. Blann, 2014; Lewis, 2014; Michie & Sanchez, 2011). However, the role vitamin D plays during pregnancy and in the formation of the foetal skeleton remains contested (SACN, 2015). Major deficiency in vitamin D has been associated with serious bone diseases such as rickets in childhood, osteomalacia in youth and adulthood and falls in adults over the age of 50 (Pai and Shaw, 2011; SACN, 2015; Sinha et al., 2013) even though the evidence has been mainly observational (SACN, 2015). The most recent Scientific Advisory Committee on Nutrition (SACN, 2015) draft report evaluated up-to-date research on vitamin D in human health, concluding that evidence regarding positive impact of vitamin D on musculoskeletal health has been sufficiently established and that the links between vitamin D deficiency and bone diseases justified enough to inform policy making.

3.15. It is worth noting that the emerging body of evidence has also linked vitamin D with positive non-musculoskeletal health outcomes, sometimes very prominent. For example, vitamin D supplementation during infancy and early years was reported to positively "affect long-term programming of the immune response pattern" of the human body (Hyppönen et al., 2007:1136), to reduce low birth weight (Blann, 2014), incidence of diabetes or pre-eclampsia (Hyppönen et al., 2001 & 2007). However, SACN (2015) regarded such evidence to be insufficient and inconclusive.

3.16. Pregnant and breastfeeding women, infants and children under 5 years old are therefore advised to take vitamin D supplements (Decsi & Lohner, 2014; DH, 2012; Leaf, 2007) and they have been classified as one of the at-risk groups of vitamin D insufficiency (DH, 2012; Wood and Cheetham, 2015), alongside those with darker skin (i.e. South Asian, African, Caribbean or Middle Eastern origin), those who are obese or those with limited exposure to sunlight (such as the Scottish population as a whole during the winter months). Such recommendations are based on the evidence of the impact of vitamin D on musculoskeletal health outcomes only (DH, 2012; SACN, 2015).

3.17. To date, policies and recommendations alongside information and support have not always been successful at reaching groups at risk of vitamin D insufficiency. Of major concern is the recent increase in rickets caused by vitamin D deficiency (as opposed to various forms of the inherited rickets), which is on the rise amongst large parts of populations in many developed countries (Decsi & Lohner, 2014; Pai and Shaw, 2011; Sinkha et al., 2013). For example, Ahmed and colleagues' (2011) research seems to confirm an increased occurrence of symptomatic vitamin D deficiency in the west part of Scotland (Glasgow area). These alarming findings have been highlighted as an indication of public health policies failing to effectively support at-risk groups in adequate vitamin D supplementation (Ahmed et al., 2011; Sinkha et al., 2013).

3.18. Moreover, the recent draft report by SACN (2015) which evaluates up-to-date evidence about the impact of vitamin D on people's health extends recommendations about vitamin D supplementation to the whole UK population (RNI - reference nutrient intake is set up at 10 μg/d or 10 micrograms per day for the whole year and is argued to work as a protective measure). SACN's (2015) findings suggest that the risk of vitamin D deficiency in the UK (and many other countries) is much more widespread than previously argued (Sinha et al., 2013). A variety of reasons which may have contributed to vitamin D insufficiency/deficiency in children, pregnant and breastfeeding women but also in adolescents and adults in the UK were identified. These include living in northern latitudes; changes in lifestyle, e.g. more time spent indoors, the blocking of ultra-violet rays responsible for triggering the production of vitamin D (e.g. by wearing sunscreen in order to protect oneself from sunburn or skin cancer), decrease in the use of supplements and on-going changes in diet (e.g. consuming less oily fish; Michie and Sanchez, 2011; Sinha et al., 2013).

3.19. Yet, how to improve the UK population vitamin D status (and in relation to pregnant and breastfeeding women and young children in particular) remains a key public health issue to resolve. Universal provision of the Healthy Start vitamins to all pregnant and breastfeeding women and young children, fortifying foods with vitamin D, national and local-level activities promoting the importance of vitamin D supplements serve as examples of actions that can be undertaken by Department of Health, local authorities and a range of public and third sector organizations (NICE, 2014; McFadden et al., 2013; Scottish Government, 2015b). The recommendations section will further explore the actions that can be undertaken in order to achieve this objective, within and alongside the Healthy Start Scheme.

Vitamin supplementation in early years

3.20. "Infants have special nutritional requirements because of their rapid growth and development and vulnerability to infection. Optimal nutrition in infancy is essential for normal cognitive and physical development and may protect against obesity and chronic disease in adult life" (BMA, 2009:49). Alongside vitamin D (discussed above in relation to both, mothers and children) recommendations on vitamins A and C supplementation for young children under 5 have been sustained by the 'Setting the table' guidance (NHS Health Scotland, 2015). Diets rich in iron are also recommended due to evidence suggesting that iron deficiency (ID) when concomitant with a poor diet and often predominant in low socio-economic backgrounds (Decsi and Lohner, 2014) is "the most common micronutrient deficiency worldwide and young children are a special risk group because their rapid growth leads to high iron requirements" (Domellöf, et al., 2014: 119; Eussen et al., 2015; Paoletti et al., 2014).

HEALTH AND HEALTH INEQUALITIES IN SCOTLAND

Significant inequalities exist with those in the most deprived areas, the lowest income households or routine and semi-routine households found to have worse health outcomes, and higher exposures to risks for poor outcomes, than their more advantaged counterparts. (Scottish Government, 2010b:13)

Giving every child the best start in life is crucial to reducing health inequalities across the life course. The foundations for virtually every aspect of human development - physical, intellectual and emotional are laid in early childhood. What happens during these early years, starting in the womb, has lifelong effects on many aspects of health and well-being - from obesity, heart disease and mental health, to educational achievement and economic status. (Marmot et al., 2010:94)

3.21. The Scottish Government has long been expressing its dedication to improving health outcomes across Scotland. Healthy diets, good nutrition and healthy lifestyles are extensively promoted by the Scottish Government while special attention is paid to pregnant women and breastfeeding mothers or young children.

3.22. In particular, consumption of a wide variety of healthy foods (including fruit and vegetables, but also from the remaining four food groups as identified by the eatwell plate; PHE, 2014a) alongside taking vitamin and mineral supplements is recommended for this group (Kaiser & Campbell, 2014). Therefore, a variety of guidelines and initiatives has been set up in order to promote healthy and sustainable diets, food standards, nutrition, in general and especially before and during pregnancy and breastfeeding and in early years.

In particular:

• Eat Better Feel Better is a national campaign that aims to promote and influence healthy changes in diets in Scotland (see: the Scottish Government Healthier Scotland website^[7]).
• The eatwell plate (PHE, 2014a) is a guidance advising on the types and portions of foods that constitute healthy, nutrition rich and well-balanced diets (see: the UK Government website^[8]).
• Dietary Reference Values for Food Energy and Nutrients for the United Kingdom (DH, 1991) provides current recommendations for daily requirements of foods and nutrients intake (Reference nutrient intake - RNI).
• Scottish Dietary Goals (SDGs, Scottish Government, 2013b) set up the policy goals that would contribute to improving health outcomes of the Scottish population through positively influencing dietary choices (for details see: the Scottish Government website^[9])

• Improving Maternal and Infant Nutrition: A Framework for Action (Scottish Government, 2011a) is a 10 year action plan directed at a range of organisations (e.g.: the NHS, local authorities, employers, the community and voluntary sector) in order to improve nutrition in preconception, during pregnancy and in children up to the age of 5 (especially amongst low income families) and promote breastfeeding as the best form of nutrition and immunisation for infants as well as a good form of breast cancer protection for mothers (McAndrew et al., 2012).

• The Breastfeeding etc. (Scotland) Act 2005 is a piece of legislation that makes it an offence "to prevent or stop a person in charge of a child from feeding milk to that child in a public place or on licensed premises".
• Setting the table (NHS Health Scotland, 2015) focuses on promotion of healthy eating, physical activities and a healthy weight during early years - in order to improve health outcomes and reduce health inequalities. Moreover, it highlights the role of childcare providers and education in shaping dietary patterns in young children as it has been argued that infancy and early years is a crucial time for development of healthy dietary profiles (Lioret et al., 2015). As such, the framework recognises that providing healthy and nutritionally balanced meals and snacks in childcare settings is hugely important, particularly in meeting the needs of vulnerable families.
• Preventing Overweight and Obesity in Scotland (Scottish Government, 2010a) highlights the importance of healthy lifestyles and physical activities from the early years in order to prevent overweigh and obesity and negative health outcomes they are associated with.

3.23. The ever growing body of evidence produced in the UK around health inequalities show that dietary patterns and nutrient-intake (amongst other health-related factors) remain socially graded as members of lower socio-economic populations are more likely to have less healthy diets than their more affluent and/or better educated counterparts. Unfortunately, even though a range of initiatives and strategies have been implemented, no significant changes leading to a reduction in health inequalities have occurred yet (Dowler, 2008). For example, as Rowett Institute of Nutrition and Health (Presentation to Child & Maternal Health Policy, January 20, 2015) reports, women living in high deprivation areas are more likely to be underweight or obese which is further related to their children health outcomes. These figures are especially alarming as Scottish women who are nutritionally vulnerable are also more likely to deliver babies that are under- or overweight at birth: adolescents - 1 in 20 births; underweight women - 1 in 10 births and obese women - 1 in 5 births

Do we achieve healthy diets in Scotland?

3.24. The National Diet and Nutrition Survey (PHE, 2014b) and Diet and Nutrition Survey of Infants and Young Children in Scotland (Scottish Government, 2013a) provide information on dietary habits, nutrient intake and nutritional status of adults, children above 1.5 and infants (4-18 months) in Scotland. Their findings suggest that average daily intakes of most vitamins and minerals from food sources are above or close to the Reference Nutrient Intakes (RNI) for all age and sex groups, except for vitamin D and folate intakes. Yet, the Scottish nation undoubtedly struggles with meeting dietary and nutrition recommendations, especially relating to the consumption of 5 portions of fruit and vegetables per day. For example, only 1 in 5 adults and 1 in 8 children consume 5 portions of fruit and vegetables a day as recommended in the eatwell plate (PHE, 2014a). Supplement-intake also remains low, with only 30% of women using some kind of vitamin or mineral supplements. In particular, very few women use folic acid supplements (only 4% of those 16-24, which increases to 10% amongst 25-34 year olds only to decrease again to 4% amongst those over 34; Scottish Government, 2014; for details see the Scottish Government report^[10]). At the same time, the intake of saturated fatty acids, non-milk extrinsic sugars (NMES) and salt remains above dietary recommendation levels (PHE, 2014b). Similarly, national intake of daily energy requirements is still too high with, for example, three quarters of children aged 4-18 months exceeding their daily energy requirements (Estimated Average Requirement, EAR; Scottish Government, 2013a).

3.25. Moreover, alarming and increasing levels of obesity have been reported in Scotland, with 68% of men and 61% of women being overweight or obese, and 1 in 3 children being at risk of becoming overweight or obese (Scottish Government, 2014). As such, it can be argued that the diets of a considerable number of adults and children in the UK remain relatively unhealthy: high in energy (from refined carbohydrate and saturated fats) but poor in micronutrients and dietary variety - with still insufficient consumption of fruit, vegetables and oily fish (SACN, 2011).

3.26. Furthermore, Westland and Crawley (2012) point out that even though the key principles of healthy diets for children and adults are the same, nutritional demands of children significantly differ from those of adults due to their rapid growth ("a regulated process by which the organism increases in mass, size and complexity"; SACN, 2011:115). Unfortunately, many children remain at risk of deficiency of vitamin A, riboflavin, vitamin B6, folate, vitamin D, calcium, iodine, iron, magnesium, potassium and zinc (Westland & Crowley, 2012). Additionally, findings from clinical literature suggest that vitamin D, iron and n-3 PUFA (polyunsaturated fatty acids) are nutrients that are potentially insufficient in all toddlers and young children's diets. This evidence shows the need of vitamin and mineral supplementation to diets which also should be richer in fruit, vegetables and oily fish (Decsi & Lohner, 2014).

3.27. The most worrying findings, perhaps, suggest that some proportion of the UK population have very low intakes (below the Lower Reference Nutrient Intake, LRNI) for most of the nutrients (PHE, 2014b). In particular, around 8% (or less) of children aged 4-18 months) were reported to have a daily intake of vitamins and minerals from all dietary sources below LRNI (except for iron - with intake below LRNI recorded for as many as 10-14% of children; Scottish Government, 2013a).

Dietary patterns of low income families in Scotland:

3.28. While overall health behaviours of low income families remain the same for the general British population, some aspects of diets, energy and nutrient intake continue to differ (Nelson et al., 2007; Scottish Government, 2014). Low income populations, in comparison with those more affluent, are reported to consume:

• less wholegrain bread, fruit and vegetables (for example consumption of fruit and vegetables by children aged 4 to 18 months in receipt of the HS vouchers is significantly lower in comparison to the average consumption by this age group; Scottish Government, 2013a);
• more non-milk extrinsic sugars (NMES), soft drinks (not diet drinks), processed meats and whole milk (Nelson et al., 2007).

3.29. What is more, economic factors, such as inadequate financial resources were reported as the most common barrier in achieving healthy diets (e.g. 1 in 3 of the survey participants reported that the food prices were the key factor influencing their food choices; Nelson et al., 2007). Similarly, in a qualitative study by Dowler and Lambie-Mumford (2015:420) low income families reported that buying "much cheaper food (which they usually also regard as of poorer quality or unacceptable to cultural patterns) or so - called 'fast food' because it requires no cooking" is one of their main food management strategies under austerity and on low budgets. As such, factors that contribute to poor diets in low income families have predominantly fiduciary and economic causes including the unaffordability and difficulty accessing fresh food as well as the rise in food prices (McFadden et al., 2014). Income was found to be a crucial constraint in accessing healthy foods and consequently a restrain on dietary choices (Lucas et al., 2015). Accordingly, the links between poor diets and dietary choices and poverty and deprivation are clearly visible (Attree, 2006; Khanom et al., 2015).

3.30. Findings of the health, nutrition and diet surveys (Nelson et al., 2007, Scottish Government, 2013a & 2014) lead to another important question, namely, whether the public health strategies aiming to improve diets and nutrition are effective and actually lead to the reduction of health inequalities. In order to attempt to answer these question one would at first have to determine which factors actually contribute to shaping dietary profiles.

3.31. A considerable body of research suggests that dietary profiles and preferences emerge in infancy and early years and are socially constructed (Lioret et al., 2015). Furthermore, health behaviour is found to be affected by a set of interwoven determinants: both individual (motivation and abilities) and environmental (opportunities that emerge from various environments; Brug et al., 2008). A narrative review by Brug and colleagues (2008) informed by a number of systematic reviews identified:

i) Individual-level motivational factors influencing health behaviour that encompass:

• tastes and preferences;
• nutritional knowledge;
• attitudes and intentions ;
• abilities;

ii) Environmental (or opportunities) factors that include:

• availability of and access to healthy or unhealthy choices;
• economic costs of healthy or unhealthy foods;
• political regulations/strategies that affect dietary choices (taxing unhealthy products, subsidies on healthy foods, food standards etc.) and
• social networks, communities and cultural norms - "the social and cultural subjective and descriptive norms and other social influences"; Brug et al., 2008:309; Dowler, 2008).

3.32. A qualitative study by Khanom and colleagues (2015) examining the barriers low-income parents with infants from Wales encounter in achieving healthier diets seems to support the theory that dietary behaviour is influenced by a complex and multidimensional relationship that exists between individual and environmental level determinants. The interplay of a number of factors that contribute to unhealthy dietary choices have been identified by participants themselves and include: shift work, lack of access to personal transport, inability to cook, accessibility of fast foods and unavailability of healthy foods (also due to the high prices), family income, own childhood diets, peer pressure, food preferences of the family members, especially that of a father (Khanom et al., 2015).

3.33. Yet, as Brug et al. (2008) point out, the majority of the research on dietary behaviours is too excessively focused on the individual-level factors influencing such behaviours, while neglecting to situate them within a broader micro- (e.g. home, schools, restaurants, workplaces etc.), and macro-environmental contexts (such as political regulations and strategies that indirectly affect dietary choices).

3.34. Similarly, multiple dietary and nutritional policies and strategies currently operating in the UK tend to be mostly informed by individual-level factors research (Brambila-Macias et al., 2011). This is therefore the basis for an argument that current responses to health inequalities which attempt to achieve better health outcomes through influencing individuals to adopt healthier lifestyles (ergo - through tackling individual-level motivational determinants of eating behaviours; Brambila-Macias et al., 2011; Brug et al., 2008; Dowler, 2008) remain too narrow. Consequently, their success is hampered as they are poorly supported by initiatives that recognise an adverse impact of broader structural inequalities and environmental factors at diets and dietary patterns (Attree, 2006). This is especially true in the light of evidence suggesting that in environments which provide opportunities for healthy eating, the role of individual factors may be much less significant (Brug et al., 2008).

3.35. Moreover, health promotion campaigns, such as social marketing and nutrition education (e.g. Eat better, feel better or eatwell plate campaigns discussed in more detail in section 3.22), were found to improve public awareness of healthy diets and lifestyles but ineffective at getting these recommendations adopted by the target-populations (Brambila-Macias et al., 2011, Griffin et al., 2015). The currently high and increasing part of the population that is overweight or obese can serve as another example of the relatively low rates of success of initiatives promoting healthy lifestyles amongst the British population. Similarly, Attree's (2006:75) attempts to critically assess contemporary public health policies in the UK led her to the conclusion that "the emphasis in policy documents on individual choice, coupled with an ethos of empowered consumerism, underplays the limitations on achieving a healthy and nutritious diet experienced by low-income households." Therefore, it is broadly argued that health promotion strategies, in order to be effective, should be combined with the micro- and macro-level strategies protecting individuals from availability of opportunities for unhealthy choices while providing them with more opportunities for healthy options (protectionist approach; Attree, 2006). Notably, such a combined approach (of health promotion strategies with a protectionist approach) has been found to be rather effective in the history of public health (e.g. in reducing or even eradicating certain diseases, reducing smoking etc.; Brug et al., 2008).

3.36. As such, in order to support low-income families in making healthier dietary choices as well as to reduce barriers to making such choices, different types of interventions have been suggested at both - local/community and national levels (Khanom et al., 2015), including:

• subsidising healthy foods by the state;
• taxing unhealthy foods or removing VAT from healthy foods (Scottish Government, 2015b)
• improving access to affordable and good quality healthy foods in the local areas and local supermarkets while reducing access to fast foods;
• reducing promotions of unhealthy foods in the supermarkets and increasing promotions on healthy foods;
• legislation in place ensuring that food manufacturers produce good quality and healthier food products, low in fats, sugars and salt;
• providing practical advice on healthy cooking - e.g. through offering community cooking classes for adults/parents;
• improving school cookery classes directed at children and young people;
• recognising the role of schools/education in influencing healthy diets;
• providing information about healthy lifestyles in workplaces.

Interestingly, most of above interventions, proposed by low-income parents in Wales (Khanom et al., 2015), seem to be compatible with a body of research suggesting a combined approach to be the most effective strategy in influencing and improving diets and nutrition of low income populations (Attree, 2006).

3.37. Nevertheless, it seems that the Scottish Government's most recent initiatives acknowledge the importance of combining health promotion initiatives with protectionist approaches (as defined in section 3.34), at least to some extent and in relation to micro-environments such as schools. For example, the previously mentioned guidance 'Setting the table' (NHS Scotland; 2015), attempts to shape dietary patterns as early as possible through providing opportunities for healthy choices and restricting access to unhealthy ones in childcare settings. The effectiveness of this strategy has not yet been assessed; but the evidence presented above does suggest that the improvements in Setting the table (NHS Scotland, 2015) are likely to be successful. Furthermore, in the Improving Maternal and Infant Nutrition (Scottish Government, 2011a) action plan, the Scottish Government has expressed its commitment to implement strategies that would target a range of organisations (including private sector companies) in order to influence the ways in which they produce food products directed at children or market them. Their role in supporting healthier eating-behaviours could be crucial, especially given that the evidence suggests that policy initiatives targeting markets and food manufacturers (e.g. through introduction of taxes and/or subsidies and nutrient and food standards) have been the most effective, despite also being more intrusive (Brambila-Macias et al., 2011).

3.38. This chapter summarised the current research on nutrition, diet and vitamin supplementation before and during pregnancy and early years. This was done for two main reasons. Firstly - in order to provide policy makers with the most up-to-date evidence on the impact of nutrition, diet and vitamin supplements on achieving good health outcomes amongst pregnant and breastfeeding women and for normal growth and healthy development of young children (e.g. Baskin et al., 2015; Westland and Crawley, 2012). Secondly - in order to inform an on-going discussion on the universal provision of free vitamins to all pregnant and breastfeeding women and young children against the targeted provision (as set up by the Healthy Start) that will be investigated and critically assessed in the recommendations chapter). It also discussed the policy framework that focuses on supporting maternal and children's health, diet and nutrition, while also recognising the extent and impact of structural barriers experienced by low income populations. The literature highlighted that the visible links exist between poor diets and dietary choices and poverty and deprivation. Finally, this chapter examined whether and to what extent a range of public health strategies aiming to improve diets and nutrition are effective and contribute to the reduction of health inequalities in Scotland. The following chapter will attempt to evaluate the operation of one of such strategies, the Healthy Start Scheme.