A healthier future - action and ambitions on diet, activity, and healthy weight: consultation

2. Living Healthier and More Active Lives

2.1 As well as creating the conditions for healthier weight and diet, we want to enable personal change, allowing all of us to start, live and age well.

Health inequalities

2.2 The overarching aim of the Scottish Government is to create a fairer Scotland and reduce inequality. It is not fair that those with the poorest health outcomes are those living in poverty. The obesity strategy will seek to prioritise work with families in poverty and on low incomes to design services and approaches that meet their specific needs and are impactful. This will be aligned to existing approaches to create a fairer Scotland such as the Child Poverty Strategy.

2.3 The devolution of the Healthy Start Vouchers provides an opportunity to tailor the scheme to Scottish needs and better support families on the lowest incomes.

Developing a positive relationship with food from birth to adulthood

2.4 We want Scotland's future generations to start life with a healthy weight (both under and over); grow at a healthy rate; and have a positive attitude to, and experience of, food. Our plans for maternal and infant health, building on our achievements through the Maternal and Infant Nutritional Framework, are therefore integral to this strategy and the action we propose for improving diet and weight. Also important will be opportunities offered through increased professional support via the Family Nurse Partnership and Universal Health Visiting Pathway in Scotland.

2.5 Beginning, where possible, with breastfeeding, our aim is to establish good overall food behaviours, including healthy food and healthy eating patterns, as part and parcel of Scottish family life.

2.6 We want to ensure children start school with a healthy weight. This means getting better at prevention, starting with children in the early years, providing support to parents on the need for good food, good sleep and healthy weight to get them ready to learn. This means continuing to offer support to children, their parents and carers, and wider families when weight becomes an issue. We must also exploit the widest range of opportunities in children's surroundings to promote healthy living including, for example, through nursery and school meals, their learning, and play spaces.

70% of children's excess weight gain is achieved by age 5

2.7 For long-term benefit, we want to see effective support and advice maintained as children progress through school and emerge into adulthood. We want to ensure that they are equipped with the knowledge to make positive choices in life, both for themselves and as the potential parents of the future. That means information and advice for families – delivered at the right time and in the right way – about physical activity, sleep, dental health, food and cooking are vital.

2.8 In our schools, through the Curriculum for Excellence, every child and young person in Scotland is entitled to a broad general education which includes learning about food and health. This ensures pupils develop a full understanding of food issues in their widest sense. As well as learning how to cook, food education encompasses food choices and the influences of advertising and culture. Since 2015 we have provided free school meals to every child in Primary 1 to 3 at all publicly funded schools in Scotland. This targets our resources to the youngest school children, giving them the opportunity to benefit from a nutritious meal at a crucial stage of their education, and encourages the development of healthy eating habits which can be sustained as they grow older.

2.9 We know that conversations with parents about weight and the food children eat, can be sensitive and difficult, and we recognise how the realities of parenting can present challenges. That is why we seek to enable, empower and support parents, building on existing strengths and assets to help deliver improved outcomes.

2.10 We will improve the way in which services engage, inform and support women before first pregnancy to ensure they start their pregnancy at a healthy weight and in good physical health – and are given support to breastfeed. We will specifically target women and families who are most at risk.

2.11 To reduce the percentage of children starting primary school overweight or obese, we will use a preventative approach through the health visitor pathway and wider early years workforce to engage with families to promote healthy eating, portion control and mealtime behaviours and, where appropriate, offer referrals to family healthy living and weight interventions.

2.12 We will use social marketing, building on Eat Better Feel Better, to help young families and other groups – such as teenagers and young people leaving home for the first time – improve the way they shop, cook and eat.

2.13 We will develop training and resources to ensure front-line staff across a range of disciplines have the knowledge, skills and confidence to discuss weight, portion control and good mealtime behaviours to give the right advice and refer appropriately. This will be built into wider work with families.

2.14 We will complete the school food and drink regulation review with a view to moving them closer towards the Scottish Dietary Goals. This includes ensuring the regulations can support children – especially primary school pupils – to have access to more fruit and vegetables as part of their school day.

2.15 We will work with NHS Boards to maintain and examine expanding the child healthy weight work as a core part of preventative service provision. Together with healthy weight interventions, this will include work in schools and communities on healthy diet and physical activity, and targeted work with vulnerable children and their families.

2.16 Healthy weight, diet and nutrition already fit with our Maternal and Infant Nutrition Framework, but will also play a role within the forthcoming ten year Child and Adolescent Health and Wellbeing Action Plan which will be launched during the Year of Young People.

2.17 During 2018, the Year of Young People, we will set up collaboration with Young Scot and the Scottish Youth Parliament to better understand and respond to children and young people's perceptions and experiences of food; the role it plays in their lives; and their food behaviours.

Question 7

Do you think any further or different action is required to support a healthy weight from birth to adulthood?

Yes / No / Don't know

Please explain your answer.

Supported weight management

2.18 As already stated, the majority of adults in Scotland are overweight (65%) ^[12] , bringing a higher risk of developing serious diseases. In particular we are seeing a worrying increase in type 2 diabetes. That is why, in our Programme for Government, we have made a commitment to deliver a new approach to weight management for people with, or at risk of, this disease.

The Health Service spends around 9% of its total health expenditure treating type 2 diabetes

Scottish Health Survey 2016: Obesity

Two thirds (65%) of adults in Scotland were overweight, including 29% who were obese, in 2016

These figures are largely unchanged since 2008

Source: Scottish Health Survey 2017

2.19 While we do not know the exact cause, we know that obesity and being overweight are the most significant factors that increase the risk of diabetes. The risks of developing type 2 diabetes are seven times higher for people who are obese compared to those with a healthy weight, and three times higher for people who are overweight. Latest data show that 87% of adults with type 2 aged 16-54 years are overweight ^[13] .

2.20 The number of people in Scotland with Type 2 Diabetes is significant and growing. In 2016, over 250,000 people were diagnosed with Type 2 in Scotland, with 17,000 new cases each year. Diabetes UK estimates suggest that over 500,000 people in Scotland are at risk of developing type 2 diabetes ^[14] .

2.21 Type 2 diabetes has a serious impact on people's lives, with real risks of cardiovascular disease, sight loss and amputation. Moreover, it puts pressure on our health services, with treatment costs accounting for around 9% of total health expenditure. It also affects productivity and, ultimately, our economy due to increased sickness absence and early retiral due to ill-health.

2.22 However, for many, type 2 diabetes can be avoided which is why – with the Scottish Diabetes Group – we are developing a prevention framework in which diet and exercise are key components. This is drawing on studies showing that significant changes in diet and exercise leading to weight loss can delay or prevent the onset of diabetes and its associated morbidity. Encouragingly, evidence is also beginning to demonstrate that weight loss, along with lifestyle behaviour changes, can reduce – and in some cases halt – reliance on medications. These types of behaviour changes can even reverse the type 2 diagnosis.

2.23 To implement our Programme for Government commitment, we will invest £42m over five years to establish supported weight management interventions as a core part of treatment services for people with, or at risk of, type 2. We propose to target 95,000 people (30% of those diagnosed) in order to make an impact on population health.

2.24 We will measure the effectiveness of interventions through existing databases; specifically, we will track the reduction in drug prescriptions and, in the longer term, the reduction and delay of complications such as cardiovascular disease, sight loss and amputation.

Question 8

How do you think a supported weight management service should be implemented for people with, or at risk of developing, type 2 diabetes – in particular, the referral route to treatment?

Healthy living and other interventions

2.25 We also want to ensure a wide range of support is available to help people eat better, eat less, and be more active, no matter where they live in Scotland. Clearly interventions must be able to demonstrate positive outcomes.

2.26 We want to support opportunities to make more use of 'health defining' moments by bringing together healthy living interventions and services in health settings. The Actwell pilot in breast screening, funded by the Scottish Government, is illustrating what can be achieved, as it supports women to make lasting changes with a focus on physical activity, diet and weight.

2.27 The added bonus is that we can expect the effectiveness of the outcomes of these interventions to increase as improvements are made to the environment.

Obese people are 7 times more likely to develop Type 2 Diabetes than those with a healthy weight

2.28 We will continue to support the delivery and development of healthy living interventions as a treatment through the NHS and the third sector, such as the innovative Football Fans In Training ^[15] .

2.29 To improve the quality of services across Scotland and equality of access, we will work with the NHS and partners to develop guidance on minimum standards for programmes and sustainable weight management pathways for children and adults, taking account of the evidence on effectiveness and cost effectiveness.

2.30 As part of the action outlined above, we will look specifically at non-health referral pathways through other partners such as employment and social work services.

Question 9

Do you think any further or different action on healthy living interventions is required?

Yes / No / Don't know

Please explain your answer.

Physical activity

2.31 Evidence ^[16] shows that physical activity is one of the best things we can do to improve our health, whether we are overweight or not. The Active Scotland Outcomes Framework sets out the Scottish Government's vision for an active nation. Physical activity is about getting people moving. Daily walking, playing in a park, going to a gym, training with a team, or aspiring to win a gold medal – it doesn't matter how people get active it just matters that we do. We want more people to be more active, more often.

2.32 The 2014 Commonwealth Games Legacy programme has funded a range of targeted interventions with relatively inactive groups such as the elderly, disabled people, teenage girls and those with lower socio-economic status. We are committed to Scotland becoming the first 'Daily Mile' nation, with roll out to nurseries, schools, colleges, universities and workplaces.

2.33 We are also committed to putting active travel at the heart of our transport planning. Investment will increase from £40 million to £80 million per year, from 2018-19, to make our towns and cities friendlier and safer spaces for pedestrians and cyclists. We will also appoint an Active Nation Commissioner to ensure delivery of world-class active travel infrastructure across Scotland.

2.34 As important as it is to our health, modern life – including sedentary jobs – means that, for most of us, being active is not enough. Action on diet and behaviour change, alongside physical activity, remain essential to our goal of helping everyone live healthier, longer lives.

2.35 We will use our increased investment in active travel to encourage more to walk and cycle and link this with our efforts to support weight management activity and use the existing network of clubs and volunteers that support people to become active. As well as having a positive impact on our environment and reducing congestion, this will support our ambitions to become a more Active Scotland and will play an important role in us all being healthier.

2.36 We will use the improvements to our planning system to ensure that the places and spaces we live in enable active travel and healthy choices. This will build on the work we have done with the Place Standard ^[17] to support the development of healthy, sustainable communities and ensure everyone has the opportunity to shape and influence the places in which we live.

2.37 We will give further thought to how to create active places to make it easier for everyone to be more active.

2.38 We will use existing programmes, such as Active Schools and the Daily Mile, to ensure being active continues to play an important role in maintaining a healthy weight.

Question 10

How can our work to encourage physical activity contribute most effectively to tackling obesity?