A Healthier Future: analysis of consultation responses

1. Introduction and background

1.1 In late 2017, the Scottish Government undertook a public consultation, A Healthier Future – Action and Ambitions on Diet, Activity and Healthy Weight, to gather views on its proposals for improving diet and weight in Scotland. The consultation ran from 26 October 2017 to 31 January 2018. This report presents findings from an analysis of the responses.

Policy context

1.2 In Scotland, as in many developed countries, poor diet combined with sedentary lifestyles have resulted in a high prevalence of people who are overweight or obese. The 2016 Scottish Health Survey estimates that two-thirds (65%) of adults in Scotland are now overweight, with almost one-third (29%) being obese. ^[3] Moreover, levels of obesity are linked to the circumstances in which people live, and specifically, to the level of resources (financial, power, knowledge and social) that people have. Obesity levels in Scotland are higher for adults and children living in areas of deprivation compared with those living in less deprived circumstances. ^[4]

1.3 The health, social and economic consequences of these levels of overweight and obesity are severe and include increased risks of developing a range of diseases (including type 2 diabetes, some cancers, cardiovascular disease and depression) as well as wider indirect economic costs arising from sickness absence and premature mortality. ^[5]

1.4 These challenges are long standing. In 2010, Scotland’s first obesity strategy, Preventing Overweight and Obesity: A Route Map Towards Healthy Weight, was published jointly by Scottish Government and COSLA. ^[6] Since then, a range of other relevant policy documents and initiatives have been developed on food and health, active living, health and work, health inequalities, and on reforming the public health function. ^[7] A national indicator for the percentage (%) of healthy weight children in Scotland was also introduced. The most recent measurement of this (in 2016) puts the figure at 70% (down from 72% in 2015). ^[8]

1.5 At the same time, there is an emerging body of evidence in relation to the effectiveness of specific weight loss interventions from both the UK and further afield. This evidence covers the effectiveness of (i) responses to childhood obesity and obesity in the wider adult population, (ii) interventions specifically aimed at those with type 2 diabetes, and (iii) ways of improving the obesogenic environment. ^{[9,10,11,12,13,14]} Evidence about public attitudes to obesity is also available from the recent (2017) Scottish Social Attitudes Survey. This survey found that actions to address the obesogenic environment, including actions that will make energy-dense food relatively more expensive and less widely promoted, are likely to be supported by the majority of people in Scotland. ^[15]

The consultation

1.6 The consultation paper set out proposals for (i) transforming the food environment (through, for example, a mix of voluntary and statutory measures on the promotion, advertising and labelling of specific types of food and drink); (ii) encouraging and supporting the adoption of healthier and more active lives (through, for example, initiatives aimed at young children, supported weight management for people at risk of type 2 diabetes, and increased investment in active travel); and (iii) more effective leadership and exemplary practice within both the public sector and the food and drink industry.

1.7 The consultation contained 14 questions – eight open, and six closed questions with space to provide further comments. The questions covered:

• The introduction of measures in relation to promotion, advertising and labelling and the extent to which these should vary across food and drink type and / or by sector (Questions 1-5)
• The specific support required by Scottish food and drink SMEs (small and medium-sized enterprises) (Question 6)
• Actions required to support healthier, more active lives (Questions 7-10)
• The adoption of measures on a broad, population basis (Questions 11-12)
• Additional requirements for monitoring progress (Question 13)
• Any other comments about issues raised in the consultation (Question 14).

1.8 Annex 1 contains a complete list of the consultation questions.

Aim of this report

1.9 This report presents a robust analysis of the material submitted in response to the consultation. It also incorporates findings from four engagement events carried out among specific stakeholder groups. The structure of the report follows the structure of the consultation paper, and considers the response to each consultation question in turn. Chapter 2 provides a description of the consultation respondents and participants in the engagement exercises. Chapters 3- 12 summarise the main issues raised by respondents in relation to the consultation questions. Finally, Annexes 1- 7 provide further detail about the consultation questions, the responses, the respondents, and the views expressed.

Approach to the analysis

Quantitative analysis

1.10 Frequency analysis was undertaken in relation to all the closed (tick-box) questions in the consultation questionnaire. Five of the consultation’s six closed questions were of the form ‘Do you think further or different action is required on X?’ and offered respondents the choice between ‘yes’, ‘no’ and ‘don’t know’. The sixth tick-box question asked respondents to indicate the extent to which they agreed with a proposal and offered five options ranging from ‘strongly agree’ to ‘strongly disagree’. The analysis of closed questions is presented in Annex 2, but is not otherwise discussed throughout the report, due to the limitations discussed below.

1.11 Some respondents made comments in relation to a question without ticking a response at the relevant closed question. If the respondent’s reply to the closed question could be inferred from their written comments (for example, if their comments began with the words ‘yes’ or ‘no’, or if their comments clearly indicated that they agreed or disagreed with a certain proposal), then the analysts replaced the missing data for the tick-box question with the implied response – i.e the response was imputed.

1.12 There was not always a straightforward relationship between respondents’ choice of answer to the closed questions and their comments in the accompanying qualitative comments. Upon further examination of the qualitative comments, it was clear that, in many cases, respondents (especially those in public sector and third sector organisations) ticked ‘yes’ to closed questions not because they wanted further or different action, but because they wanted to (i) explain why the proposals in the consultation paper should be implemented, or because (ii) they simply wanted the opportunity to give their perspective on the issue. Moreover, those who ticked ‘no’ often went on to say they wanted further or different action (or to maintain the status quo).

Qualitative analysis

1.13 Comments made in response to each question were analysed qualitatively. The aim was to identify the main themes and the full range of views expressed in relation to each question or group of questions, together with areas of agreement and disagreement in the views of different types of respondent.

1.14 As will be seen in the next chapter, the consultation elicited responses from a wide variety of individual and organisational respondents. Many of the individuals who responded had specific interests in the topic either because (i) they were professionally qualified in some way (some were currently working in the field) or because (ii) they had personal experience in relation to the topic (some had direct experience of weight management programmes, others were overweight or obese themselves, or had caring responsibilities for people who were affected by obesity). The analysis, therefore (i) incorporates both professionally informed, and lay perspectives, (ii) recognises that parts of the questionnaire are less relevant for some (groups of) respondents, and (iii) ensures that the views from different perspectives and groups are represented in a fair and balanced way.

1.15 Many respondents submitted lengthy responses which discussed and debated the current evidence in this area and included lists of reports and published research papers. It was not within the scope of this analysis to comment on the factual accuracy of responses or assess the quality of any evidence cited.

Comment on the generalisability of the consultation findings

1.16 As with all consultations, the views submitted in this consultation are not necessarily representative of the views of the wider public. Anyone can submit their views to a consultation, and individuals (and organisations) who have a keen interest in a topic – and the capacity to respond – are more likely to participate in a consultation than those who do not. This self-selection means that the views of consultation participants cannot be generalised to the wider population. For this reason, the main focus in analysing consultation responses is not to identify how many people held particular views, but rather to understand the range of views expressed and the reasons for these views.