Healthy weight - local health systems support for pregnant women and young children: research

4. Interventions

This chapter explores what happens after a weight issue has been identified. It considers how health professionals determine which intervention is most appropriate, and outlines the types of interventions on offer. It concludes by addressing the perceived effectiveness of these interventions.

Figure 4.1 (below) illustrates the types of interventions that may be available in health boards across Scotland. These interventions will be addressed in more detail later in this chapter.

Figure 4.1 Interventions available from pregnancy to Primary 1

Interventions in pregnancy

Clinician-led interventions

• Vitamin supplements
• Gestational diabetes tests
• Referral for extra scans
• Informal support at appointments
• Group interventions
• Leisure services referral
• Interventions for those with gestational diabetes

Midwife-led interventions

• Multidisciplinary services may involve dieticians, psychiatrists, gestational diabetes experts etc
• May replace (to some extent) midwife care, or sit alongside it

Intervention from early years – Primary 1

Health visitor-led interventions

• Monitoring and support at UHVP appointments
• Additional appointments
• Information and support to make small changes

Programmes aimed at the whole family

• Around 8-10 weeks, sometimes with follow-up afterwards
• Mix of family and parent only sessions
• May include education, cooking, exercise, mental health support

Dietician-led interventions

• Often includes food diaries, education support
• Can be more intensive, delivered in family homes

Support provided by other services and professionals

• Third sector support and family support groups/classes
• Local authority and ELC support
• Private Sector e.g. baby/toddler activity classes

Looking across the system as a whole, there were various interventions in place, and numerous plans for improvements. However, improvement plans appeared to have a stronger focus on the early years than interventions aimed at pregnant women and, as might be expected, awareness of improvement plans was higher among public health staff than those with a clinical caseload. The COVID-19 pandemic had slowed down planned progress and disrupted existing programmes, with many of the services mentioned in this chapter either moved online or halted.

Furthermore, there were health boards with no tier 2 interventions available. In these health boards, the only options available as part of the health system were for the health professional to intervene themselves, or to offer dietician referral (tier 3).

In health boards with dedicated services on offer, interventions varied by the following key factors:

• The type of health professional that leads the intervention – for example, do the parents have an existing relationship with them, or is it someone new?
• The duration of intervention – for example, does support provided during pregnancy continue postnatally?
• The level of specific focus on healthy weight – for example, is the service on offer dedicated only to weight management, or does it cover other areas of behaviour change? Does it take a holistic approach and consider all factors influencing a weight issue, or does it focus on one element (such as diet)?

Health professionals were relatively confident in their knowledge of the interventions available, and in determining the most appropriate one. Their main consideration was the circumstances and preferences of the family – whether they were comfortable with a group session, what they specifically needed support on, their capacity to engage with the interventions and so on. A further consideration factor was what had (or hadn't) worked so far. For example, if a health visitor's own intervention hadn't been successful, they may then consider referral to a service.

Health professionals would also consider the nature of the issue underlying a high weight when assessing which intervention was best suited – for example:

• If the child had a very sedentary lifestyle, referral to exercise classes might be most appropriate
• If the parents had low knowledge around healthy diets, they might find referral to a dietician most useful
• If the parents had difficulty managing their child's behaviour around food (for example, they were unable to say no to their child's requests), used food as a reward or as a sign of love, or had trouble managing their children's behaviour around screen time and activity, parenting classes or parenting support from a community worker might be beneficial.

However, it is worth noting that there were families facing all of these difficult circumstances, and that addressing a weight issue is not straightforward. In acknowledgement of this fact, a small number of health boards offered interventions that were more holistic, led by what the family felt they needed, and involved input from psychiatrists as well as other health professionals.

During the COVID-19 pandemic, it was more difficult for health visitors to establish these underlying issues when they were often undertaking appointments over the phone, missing the cues that they would normally pick up on from being in the home. Where parents had been able to join appointments by video using tools like 'Near Me'^[46], this difficulty was mitigated to an extent. However, health professionals reported that take-up of the 'Near Me' video consulting was inconsistent among both parents and health professionals.

Interventions in pregnancy

Interventions in pregnancy aimed to support pregnant women to eat well and exercise safely and to monitor the health of them and their unborn baby. The goal was not to help women lose weight during pregnancy, but rather to:

• minimise the risks to mother and baby during pregnancy and delivery
• promote healthy weight gain during pregnancy
• improve nutrition for both the mother and the unborn baby
• support healthy behaviour change
• prevent or manage gestational diabetes

The interventions on offer were either midwife-led or clinician-led and these types of intervention are discussed in turn.

Midwife-led interventions

For those women whose BMI was above a certain level (typically a threshold between 25 and 35), there were interventions consistently available across all health boards. Midwives would:

• initiate a discussion around the risks associated with a high BMI during pregnancy, and discuss healthy lifestyle changes
• arrange for gestational diabetes tests
• refer the women on for additional scans and tests – for example, growth scans
• recommend certain additional micronutrients or vitamin supplements (such as an increased dose of folic acid)

While these interventions were universally available, beyond these, options varied by health board.

Midwife-led interventions ranged from informal support provided during regular midwife appointments to more formalised services offered by (sometimes specialised) midwives. Midwives worked with pregnant women to help them make small changes, support them to make a plan around their own health, and discuss nutrition and infant feeding.

Midwives reported high levels of confidence around advising women on healthy lifestyles during pregnancy, but less confidence around weight management specifically. Midwives were conscious that there was little guidance around this issue, and found it difficult to advise on what constituted a healthy amount of weight gain during pregnancy^[47],[48].

If someone came to me and said, 'I've put on x amount of weight' I'm not sure I would be sure 'is that ok, is that too much weight or not enough weight?' As far as I'm aware, we don't really have guidance on how much weight they should gain during pregnancy.

Midwife

Area for consideration (national level):

Ensure healthcare professionals are aware of the current guidance on healthy weight gain in pregnancy and kept informed of any subsequent changes to this.

More formal examples of interventions delivered by midwives included group education sessions and phone clinics. In one health board, a specialist infant feeding midwife led a group intervention which focused on minimising pregnancy weight gain by advising on healthy eating and physical activity during pregnancy. Participants received dedicated support from the midwife, and met others in the same position.

In a different health board, midwives could offer referral to a dedicated group programme for pregnant women with a BMI of 30 or above. The programme was eight weeks long and run by a midwife. Pregnant women were motivated and supported to make small changes for a healthier pregnancy. Activities included walking, cooking, and talking together. However, one midwife reported that take-up is generally low, with women often citing work and family commitments as a barrier.

There were also midwives who discussed using elements of their Counterweight^[49] training (particularly around behaviour change) in their work with overweight pregnant women. This could be delivered as a formal Counterweight service, or just as someone providing support informed by their Counterweight training.

One issue with less formal examples of support, where midwives had taken it upon themselves to intervene, is the reliance on their continued time, effort and capacity. The quote below is from a midwife who ran group sessions with pregnant women at a local swimming pool and felt that it would have required funding and training to continue it.

It was a big miss because it was in a small pool with just other pregnant women - they felt safe, even those who wouldn't necessarily go for a walk on their own would go to that. I stopped due to a lack of training, lack of funding – it was just me doing it, I had no training, and then I had baby and I couldn't do evenings so it stopped.

Midwife

There were health boards where midwives could refer women to leisure centre resources for free or at a low cost. This was done either through midwives directly or via another service. One midwife expressed a wish that they could refer to exercise facilities directly – as things stood, they could only refer on to a weight management service (which many people opted-out of), which could then refer to leisure facilities.

Area for consideration (local health board level):

Facilitating healthcare professionals to refer directly to exercise facilities (rather than having to go via a weight management service)

Midwife-led interventions targeted at those with gestational diabetes also existed. For example, in one health board, a positive gestational diabetes test was followed by group education sessions, a weekly phone clinic, and four-weekly scans with a specialist midwife (this had previously been managed by a consultant, but evaluations showed better outcomes for midwife-led care). After the baby was born, the midwives would also write to the patient's GP to inform them of their patient's care. They set up annual reviews to check their blood sugar and make sure that they hadn't developed type 2 diabetes. The service therefore had a preventative element that continued beyond pregnancy, as discussed in Chapter 2.

Clinician-led interventions

Where pregnant women with high BMIs were put on clinician-led pathways, this was less to do with providing advice on weight management and more about managing the medical risks of a high BMI pregnancy.

One health board had a specialised service, funded by a charity, which offered care to women with a BMI above 40. The service was staffed by gestational diabetes specialists, consultants, midwives, and a specialist dietician, and offered frequent check-ups and personalised advice.

In another health board, women with a BMI over 30 were offered referral to another multidisciplinary service. Women who agreed to referral were seen by a midwife, a physiotherapist, and a dietician at every appointment. They were tested for gestational diabetes, and seen every four to six weeks. The approach was person-centred, with the support guided by what the woman felt she needed. The service aimed to prevent weight gain, maintain the health of mother and baby, and minimise risk. That support continued for up to six months after the baby was born.

Dietician support was a further option for referral. Dieticians would talk with the pregnant woman about what her diet looked like (possibly keeping a food diary) and how to eat healthily during pregnancy, and would make a plan together about changes they could make. Dietician support alone was generally considered to be less effective than approaches that were more holistic, and approaches that were multi-disciplinary and included dietician help alongside support from other health professionals (physiotherapists, psychologists, midwives, healthcare assistants and so on). There was also frustration expressed around long wait times and long periods between appointments, although this was not the case in every area.

Intervention in the early years

Where BMI was used (for children over two), a BMI above the 91^st centile was generally the threshold at which health visitors would identify a weight issue. Interventions in the early years (from birth to Primary 1 age) fell into the following categories:

• health visitor-led interventions
• programmes aimed at the whole family
• dietician-led interventions
• support provided by other services and professionals

If health professionals suspected a medical reason for high weight (particularly for the youngest children and those with the highest weights), they would tend to suggest referral to the GP first, to rule out medical causes.

Health visitor-led interventions

The first line of intervention, particularly for children younger than two years, tended to be monitoring and support provided by health visitors themselves. This was especially, though not exclusively, the case in health boards where there was no tier 2 intervention to refer to. Health visitor-led interventions benefitted from the relationship already existing between parent and health professional, although high caseloads and low confidence could serve as barriers.

Typically, health visitors would initiate a conversation with parents about their child's weight (as discussed more fully in Chapter 3). Rather than suggesting large-scale changes to the family's diet or routines, they proposed small changes like walking more often or adding frozen vegetables to meals. To a lesser extent, health professionals discussed other relevant areas like sleep and screen time with parents.

I'm also very mindful to look at the child as well and not just the numbers, and then just discussing meals and healthy eating and portion size and sometimes as well getting them to write down what their child is eating for a week, so that we can go back through it.

Health visitor

Health visitors then scheduled extra visits (often three months from the core visit) to review a child's weight and check in on the family. Other instances in which they would schedule additional visits were where a parent had raised concerns, or if the family had already been referred to a dietetics or paediatrics team, who (during the COVID-19 pandemic) had requested weighing between their appointments.

Health visitors reported that they had to make a judgment as to whether to begin this type of intervention with a family. For example, a health visitor might identify a weight issue but recognise that a family was facing complex circumstances such as financial issues, relationship breakdown, or parental mental health issues. They may determine that the family was not in a position to address their child's weight. In these circumstances, a health visitor might make more frequent visits, so that they are there to support the family once they are better placed to begin making changes. As one participant put it, parents need to be 'ready, willing and able' to make such changes – they might be ready and willing but not able, or be willing to make changes but not yet ready.

I've found it's most effective to identify one small change they want to make, and then follow up – if they're at the motivated stage. If they're in denial, and they don't want to change, they don't want a referral, then I'd say 'let's review in three months'. I'd just want to keep in there with that family.

Health visitor

Another factor influencing whether health visitors initiated their own interventions was their own confidence and capacity. Health visitors who were more newly qualified, who had received minimal training on child healthy weight, who had overwhelming caseloads, or who generally felt less comfortable addressing the issue, seemed more likely to choose to refer to a different service rather than intervene themselves.

Where health visitors did intervene themselves, their intervention generally continued for a few months, or until it became clear their intervention wasn't working. They would then refer on to other services.

Programmes aimed at the whole family

Health visitors noted that a child's weight rarely exists in isolation, but is often a family issue that is influenced by that family's circumstances. For this reason, and because it was less stigmatising for the child, they felt that a whole family approach was often most appropriate.

In one health board, children under five years had access to a ten-session family programme, involving either group or individual family sessions (parent's choice). The focus of this dietician-led service was on making small achievable goals with the family. Again, it aimed to take a more holistic approach and consider the factors contributing towards a weight issue in a family.

We see a sibling group who all have the same challenges, and so [the new programme is] looking at how supporting families […] in their kind of day to day, basically to kind of change the sort of mind-set hopefully for the longer term benefit of all of the children within the family, but making it as the family doing it together as opposed to this is particularly about the child.

Health visitor

Participants were also very conscious of the mental health aspects of child healthy weight issues. In one health board, which was about to implement a child healthy weight programme with psychologist input, a public health professional spoke about how unusual it was to have the involvement of psychologists or psychiatrists. They recognised that these professionals were very stretched, and were generally only available for the most serious issues. However, where they were involved, there was the benefit of helping families work through underlying issues and relationships, rather than focusing on an area like diet in isolation.

Another programme on offer in a different health board offered support to families and focused on developing a healthy relationship with food, enjoying physical activity, and overall positive health and wellbeing. It was a family intervention for parents of children up to age 15, and is still being improved and rolled out.

In at least four health boards, plans were underway to bring in HENRY^[50] training for staff and/or the 'HENRY' programme for families. Health visitors were positive about the introduction of HENRY as it was seen to address a child's involving the whole family and recognising the various factors influencing it.

Dietitian-led intervention

Referral to dietician was an option available to health visitors across Scotland, although access varied, and those in health improvement roles reported difficulty accessing funding to recruit the dieticians needed.

The level of support provided by dietetics varied. It would typically involve a series of appointments to talk about the child's diet and make a plan together. The dietician might ask the family to keep a food diary, talk with them about what constitutes a healthy diet, and check progress at subsequent appointments.

In one health board, there were plans to offer more intensive dietetics support for children identified as being above the 98^th centile at the 27-30 month development review. This would involve 1-1 dietetics support delivered in the family home, covering topics like portion sizes, sleep, play, physical activity and hidden sugars.

In more remote health boards, it was harder for health visitors to refer to a dietician who was trained on child healthy weight issues. This was because local dieticians were more generalist, and those trained in child healthy weight were based further afield.

Support provided by other services and professionals

Health visitors could also refer to professionals such as link workers, family support workers, community food workers, or nursery nurses.

In one health board, when health visitors identified that a family needed more support to help a child (or children) to maintain a healthy weight, they could request that a nursery nurse work with them over about six weeks. The nursery nurses were considered to be particularly adept at providing support with behaviour management, helping parents meet their child's emotional needs and giving them 'permission' to tell their children 'no'.

Another option was referring to local third sector. For example, toddler walking groups, free cooking classes, or referral to charities supporting families with low incomes. Referring families directly on to leisure centres for exercise (at no cost or a low cost) was also an option in health boards where there was a level of integration with leisure facilities.

Intervention at Primary 1

In the first instance, school nurses would follow up with parents of children who have a high BMI (generally over the 91^st centile) after the Primary 1 assessments, and try to provide support (as discussed in the previous chapter – assessing the parents' position, discussing the factors behind the issue, making a plan of small changes or offering referral).

Professionals did not talk in detail about the options available for Primary 1 children – the research was focused largely on the early years and intervention for Primary 1s would tend to be those available for school age children more generally. They were also likely to have been more established than those for the early years. However, the following are examples of the types of interventions available:

• a family-based weight management programme for families with a child aged five to fifteen who is above a healthy weight. It was a group-based intervention and ran weekly for an hour over 8 weeks. Sessions focused on healthy eating, physical activity and positive health behaviour change. Although the programme lasts eight weeks, ongoing support is available beyond that for up to a year.

• a programme for those aged five to seventeen placed a focus on feeling good and having fun. Families took part in physical activity together, parents received support from a coach, and children could make friends and have fun while being active. The sessions took place weekly over nine weeks. Beyond these nine weeks, support was available at regular review points.

Effectiveness of interventions

Overall, health professionals were generally positive about interventions where they existed in their health board. However, they stressed that the effectiveness of services depended greatly on parents' willingness to engage with them. Even where research participants were positive about the interventions on offer, this was sometimes followed up with a caveat about low take-up among parents. Furthermore, communication between different services varied, so that, even when (for example) a health visitor referred a family, and that family accepted the referral, the health visitor would not necessarily hear from the service about that family's engagement or progress. This (combined with the often low take-up from families) meant that participants didn't always feel sure about how effective the programmes were. This issue of parental engagement will be discussed in more detail in Chapter 6.