Report on Evidence Mapping for Nutrition Priority Area

Health Improvement Review- Evidence Sub Group

Health Improvement Review Report on Evidence Mapping for Nutrition Priority Area

Report structure: 1. Purpose 2. Methodology 3. Results – identification of potentially effective interventions 4. Conclusions - Implementation of potentially effective interventions in Wales

Purpose: This report has been prepared to support the Review of Health Improvement Programmes. A series of priority areas have been identified for the review derived from policy and strategy documents. The Review has a number of identified outputs, one of which is a high level summary of each priority area which highlights, based on current evidence of effectiveness, which interventions have the greatest potential to improve health in each priority area and the extent to which these are currently being delivered in Wales. The purpose of this report is to present this information for the priority area of Nutrition.

Methodology The Review is being conducted within a limited timeframe, as a result an extensive review of the literature across all of the priority areas and initiatives is not feasible. The review team has adopted the following approach:  Evidence from systematic reviews or reviews of reviews  Guidelines derived from an assessment of the available evidence  Reviews from sources which have a clearly defined methodology and quality assurance process that is nationally or internationally recognised.

The Library and knowledge management service of Public Health Wales has undertaken an initial search of the following sources using agreed search terms:  NICE Guidelines  Cochrane Database of Systematic Reviews (Cochrane Reviews Only)  Campbell Collaboration Reviews  EPPI Centre Reviews  The Community Guide Recommendations

Vision 1 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group Where limited material was identified, or specific information gaps, or where the reviews or recommendations are more than 5 years old, a further search has been undertaken of DARE and Health Evidence Canada for reviews conducted within the last five years, which are rated as moderate to good quality. Reviews have been screened for inclusion based on agreed criteria e.g. health promotion interventions, interventions which involve clinical preventative services were excluded and those which focus on primary or secondary prevention. Key information has been extracted and summarised in the ‘mapping evidence table’ (Table 1). An assessment has been made about the strength and direction of the evidence from the review based on the grading system developed and attached as Appendix 1. A subjective assessment has also been made by the reviewer of the extent of adoption or implementation of the intervention in Wales (Appendix 2). The grading of the evidence and the implementation assessment were reviewed by the team for consistency. There are a number of limitations to this approach which it is important to consider when interpreting this report:  this is not an extensive review of the evidence in each area, a large amount of material will not have been considered  the sources used mean that the interventions used are more likely to reflect established or well-tested approaches and less likely to reflect innovative technologies and approaches  the assessment of implementation is subjective and based on the knowledge of the review team  the evidence grades are designed to give an indication of the strength of the evidence and enable current understanding of the efficacy of different interventions to be compared, the quality of the studies included within the reviews is drawn from the assessment by the reviewers

Version 1 2 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group 3. Results Table 1: Evidence Mapping Table Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales 1 NICE, 2008 NHS Trusts, Commissioners & managers Seven systematic reviews Elements of A. This intervention . Adopt a multifaceted coordinated of effectiveness, one the is supported by good Interventions to improve the nutrition programme of literature review and three intervention evidence of its of pregnant and breastfeeding interventions across different settings to expert papers were are funded for effectiveness and is mothers and children in low-income increase breastfeeding rates conducted to inform the national recommended for households. including: development of this implementatio use in the UK -activities to raise awareness of the benefits guidance. The reviews n, but National Institute for Health and Clinical of/ how to overcome barriers to, drew on SRs, RCTs and implementatio Excellence, breastfeeding other study types. n is dependent - training for health professionals on local Maternal health -breastfeeding peer-support programmes There was a lack of components Early years -joint working between health professionals evidence on effectiveness which are and peer supporters of interventions targeting variable. Health services and community settings -education and information for pregnant specific socio-economic, women on how to breastfeed, followed by ethnic, low-income or In Wales proactive support during the vulnerable groups. 58.11% of postnatal period (the support may be births in Baby NICE, 2008 cont’d provided by a volunteer). The effectiveness of Friendly different components within hospitals

Version 1 3 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales Interventions to improve the nutrition Implement a structured programme that interventions was often of pregnant and breastfeeding encourages breastfeeding, using difficult to tease out. BFI scheme mothers and children in low-income BFI as a minimum standard being households. (www.babyfriendly.org.uk).The programme There was a lack of good implemented should be subject to external evaluation. quality economic studies across Wales National Institute for Health and Clinical relating to the UK and the Excellence, Ensure there is a written, audited and well- conclusions from other Most LHBs publicised breastfeeding policy that includes studies cannot readily be have BF Maternal health training for staff and support for those staff translated to a UK setting. strategy Early years who may be breastfeeding. Identify a health However, where relevant groups & professional responsible for implementing published literature exists, action plans Health services and community settings this policy. it does indicate that but content will increased breastfeeding vary Work with local partners to ensure mothers rates could produce cost can feed their babies in public areas without savings by reducing Most LHB fear of interruption or criticism. various childhood diseases have/are developing BF Health professionals training: peer-support NICE, 2008 cont’d As part of their continuing professional groups development (CPD): Interventions to improve the nutrition -train midwives, health visitors and support Most have BF

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales of pregnant and breastfeeding workers in breastfeeding and Welcome mothers and children in low-income management Scheme run by households. -train doctors, dietitians, pharmacists and L.A.s other health professionals to promote and National Institute for Health and Clinical support breastfeeding North Wales Excellence, ...using BFI training as a minimum standard. also professional- Maternal health Health professionals & service managers led BF support Early years Ensure all those who work in maternity and groups children’s services, including Health services and community settings receptionists, volunteers and ancillary staff, are made fully aware of the importance of breastfeeding and help to promote a supportive environment.

Midwives and health visitors should ensure pregnant women and their partners are NICE, 2008 cont’d offered breastfeeding information, education and support on an individual or group basis. Interventions to improve the nutrition This should be provided by someone trained of pregnant and breastfeeding in breastfeeding management and should be

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales mothers and children in low-income delivered in a setting and households. style that best meets the woman’s needs.

National Institute for Health and Clinical During individual antenatal consultations Excellence, GPs, obstetricians and midwives should encourage breastfeeding. They should pay Maternal health particular attention to the needs of women Early years who are least likely to breastfeed (for example, young Health services and community settings women, those who have low educational achievement and those from disadvantaged groups).

A midwife or health visitor trained in breastfeeding management should provide an informal group session in the last NICE, 2008 cont’d trimester of pregnancy. This should focus on how to breastfeed effectively Interventions to improve the nutrition by covering feeding position of pregnant and breastfeeding and how to attach the baby correctly. mothers and children in low-income

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales households. Contact new mothers directly within 48 hours of their transfer home (or within 48 hours of a National Institute for Health and Clinical home birth) offer mothers ongoing support Excellence, according to their individual needs. This could be delivered face-to-face, via Maternal health telephone or through local groups. Early years Health visitors and the CHPP team should Health services and community settings support mothers to continue breastfeeding for as long as they choose.

Provide local, easily accessible breastfeeding peer support programmes and ensure peer supporters are part of a multi- disciplinary team. NICE, 2008 cont’d Ensure support workers receive training in Interventions to improve the nutrition breastfeeding management from someone of pregnant and breastfeeding with the relevant skills and experience before mothers and children in low-income they start working with breastfeeding households. mothers.

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales

National Institute for Health and Clinical sure peer supporters: Excellence, attend a recognised, externally accredited training course in Maternal health breastfeeding peer support, Early years can consult a health professional and are provided with ongoing support, gain Health services and community settings appropriate child protection clearance.

Consider training peer supporters and link workers to help mothers, parents and carers follow professional advice on feeding infants aged 6 months and over. The advice should promote an increasingly varied diet using NICE, 2008 cont’d food of different textures in appropriate amounts (in addition to milk), in response to Interventions to improve the nutrition the baby’s needs. of pregnant and breastfeeding mothers and children in low-income Midwives, health visitors, paediatric nurses, households. nurses working in special-care baby and neonatal units, and nursery nurses

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales National Institute for Health and Clinical should: Excellence, -show all breastfeeding mothers how to hand-express breast milk. Maternal health -Advise mothers that expressed milk can be Early years stored for up to 5 days in the main part of a fridge at 4ºC or lower, up to 2 weeks in the Health services and community settings freezer compartment of a fridge, up to 6 months in a domestic freezer, at minus 18ºC or lower. -Advise mothers who wish to store expressed breast milk for less than 5 days that the fridge preserves its properties more effectively than freezing. NICE, 2008 cont’d -Advise mothers who freeze their expressed breast milk to defrost it in the fridge and not Interventions to improve the nutrition to re-freeze it once thawed. of pregnant and breastfeeding - Advise them never to use a microwave mothers and children in low-income oven to warm or defrost breast milk. households. Pregnant women, mothers and their partners National Institute for Health and Clinical who have a family history of allergy (including

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales Excellence, eczema, asthma and hay fever) should be advised to feed the baby only on breast milk Maternal health and to continue breastfeeding while Early years introducing solid foods, when the infant is 6 months. Health services and community settings Advise mothers who choose not to breastfeed that there is insufficient evidence to suggest that infant formula based on partially or extensively hydrolysed cow’s milk protein helps to prevent allergies.

NICE, 2008 cont’d Train link workers who speak the mother’s first language to provide information and Interventions to improve the nutrition support on breastfeeding, use of infant of pregnant and breastfeeding formula, weaning and healthy eating. mothers and children in low-income households. Where link workers are not available, ensure women whose first language is not English National Institute for Health and Clinical have access to interpreting services and Excellence, information in a format and language they

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales can understand. Maternal health Early years Encourage women from minority ethnic communities whose first language is not Health services and community settings English to train as breastfeeding peer supporters.

Avoid promoting or advertising infant or follow-on formula. Do not display, distribute or use product samples, leaflets, posters, charts, educational or NICE, 2008 cont’d other materials and equipment produced or donated by infant formula, bottle and teat Interventions to improve the nutrition manufacturers. of pregnant and breastfeeding mothers and children in low-income Ensure health professionals and pharmacists households. who prescribe or dispense drugs to a breastfeeding mother consult supplementary National Institute for Health and Clinical sources (for Excellence, example, the Drugs and Lactation Database [LactMed]

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales Maternal health www.toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen? Early years LACT) or seek guidance from the UK Drugs in Lactation Advisory Service Health services and community settings (www.ukmicentral.nhs.uk/drugpreg/guide.htm ).

Health professionals should discuss the benefits and risks associated with the prescribed medication and encourage the mother to continue breastfeeding, if reasonable to do so. In most cases, it should be possible to identify a suitable medication which is safe to take during breastfeeding by analysing pharmokinetic and study data. Appendix 5 of the ‘British national formulary’ should only be used as a guide as it does not contain quantitative data on which to base individual decisions.

Health professionals should recognise that

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales there may be adverse health consequences for both mother and baby if the mother does not breastfeed. They should also recognise that it may not be easy for the mother to stop breastfeeding abruptly – and that it is difficult to reverse.

Pre-school carers and settings Support breastfeeding mothers by offering them the opportunity to breastfeed when they wish, encouraging them to bring expressed breast milk in a coolbag (labelled with the date and name of the infant) and store in the main body of the fridge. 2 Abdulwadud, OA, Snow, ME. Lack of evidence for workplace interventions No RCTs or quasi RCTs Implementatio Lack of evidence . to promote BF trials have evaluated the n not currently Breast-feeding in the workplace effectiveness of workplace taking place interventions in promoting Cochrane Database of Systematic breastfeeding among

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales Reviews women returning to paid work after the birth of their Maternal health child. The impact of such Early years intervention on process outcomes is also unknown.

3 Dyson, L et al, 2005 Findings from these studies suggest that Statistical analyses were This B. This intervention . larger increases in BF initiation rates are conducted on data from intervention is is supported by Interventions for promoting the likely to result from needs-based, informal eight trials (1553 women). implemented moderate to good initiation of breastfeeding – education repeat education sessions than more Five studies (582 women) locally in some quality evidence of sessions generic, formal antenatal sessions. These on low incomes in the USA areas but does its effectiveness findings are based only on 5 studies with typically low not have a Cochrane Database of Systematic conducted in the USA, among women on low breastfeeding rates showed consistent Reviews incomes with varied ethnicity and feeding breastfeeding education national intention, and this raises some questions had a significant effect on programme or Maternal health regarding generalisability to other settings. increasing initiation rates a co-ordinated Early years compared to standard care approach OR (risk ratio (RR) 1.57, 95% is CI 1.15 to 2.15, P = 0.005). implementatio Subgroup analyses showed n nationally on that one-to-one, needs- an ad-hoc

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales based, informal repeat basis education sessions and generic, formal antenatal education sessions are effective in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Needs-based, informal peer support in the antenatal and postnatal periods was also shown to be effective in one study conducted among Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P < 0.00001). Possible selection bias in 7/8 studies

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales and attrition bias in 4/8.

Dyson, L et al, 2005 continued The findings from 1 trial suggest that hospital The evaluation of hospital This intervention G. There is some breastfeeding promotion packs are not the breastfeeding promotion is implemented evidence suggesting Interventions for promoting the most effective use of breastfeeding packs compared to locally in some that this intervention initiation of breastfeeding – promotion resources in a context of formula-company produced areas but does is ineffective but it is not have a Breastfeeding promotion packs widespread use of formula company materials about infant not conclusive consistent promotion items. feeding (Howard 2000) national showed this intervention to programme or a be ineffective at increasing co-ordinated initiation rates of approach OR is breastfeeding. This trial implementation was of high quality. nationally on an ad-hoc basis Dyson, L et al, 2005 continued Lack of evidence relevant to UK on effect on The evaluation of early Elements of Lack of evidence BF of early mother-infant contact. mother-infant contact the Interventions for promoting the immediately after birth prior intervention initiation of breastfeeding: to complete separation until are funded for Early mother-infant contact discharge on breastfeeding national initiation rates (Lindenberg implementatio 1990), which was the only n (Baby

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales study included in this Friendly review that was conducted Initiative), but in a low- to middle income implementatio country setting (Nicaragua), n is dependent found no effect. on local components which are variable 4 Lee, SJ et al, 2008 There is no evidence to support antenatal No RCTs were found by Implementatio Lack of evidence . breast examinations in promoting the search. Quasi-RCTs n not currently Antenatal breast examination for breastfeeding, nor any evidence on other were excluded therefore taking place promoting breastfeeding potential effects of antenatal breast there is a possibility that examination, such as the detection of breast relevant information may Cochrane Database of Systematic anomalies or satisfaction with care. have been missed. Reviews

Maternal health Early years

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales 5 Lumbiganon, P et al, 2011  18/19 included studies had either unclear or 14 studies involving 6932 Elements of C. There is some .  high risk women contributed data to the evidence supporting Antenatal breastfeeding education for  of bias. There were wide variations in the the analyses intervention the use of this increasing breastfeeding duration -  nature of BF educational interventions as Five studies compared a are funded for intervention but it is routine BF education, formal BF  well as in type and completeness of reported single method of BF national not conclusive education, outcomes between education with routine care. implementatio printed information, video, peer studies. Therefore the internal validity of the Peer counselling n, but counselling and lactation results of this review is limited. significantly increased BF implementatio consultation. initiation. n is dependent Because there were significant Three studies compared on local Cochrane Database of Systematic methodological limitations and the observed one form of BF education components Reviews effect sizes were small, it is not appropriate versus another. No which are to recommend any specific form of antenatal intervention was variable Maternal health BF education. There is an urgent need to significantly more effective Early years conduct RCTs with adequate power to than another intervention in evaluate the effectiveness of antenatal BF increasing initiation or education. duration of BF. Seven studies compared NB BF education is usually a formalised, multiple methods versus a defined, descriptive and goal-orientated single method of BF programme with a specific purpose and education. Combined BF

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales target audience. BF education differs from educational interventions BF support. BF support is usually aimed at were not significantly better the individual person as the need arises and than a single intervention in is defined as a person, a group or an initiating or increasing BF organisation providing support in many ways. duration. However, in one trial a combined BF education significantly reduced nipple pain and trauma. One study compared different combinations of interventions. There was a marginally significant increase in exclusive BF at six months in women receiving a booklet plus video plus lactation consultation (LC) compared with the booklet plus video only. Two studies compared

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales multiple methods of BF education versus routine care. The combination of BF booklet plus video plus LC was significantly better than routine care for exclusive BF at three months.

6 Renfrew, MJ et al, 2012 P Effective 52 studies contributed Some of the A. These . o Postnatal hospital stay outcome data to the review interventions interventions are Support for healthy breastfeeding  • Skilled breastfeeding support, peer or (56,451 mother-infant are funded for supported by good mothers with healthy term babies  professional, pairs) from 21 countries. All national evidence of  proactively offered to women who want to forms of extra support implementatio effectiveness and are Cochrane Database of Systematic  breastfeed analysed together showed n (Baby recommended for Reviews • Preventing the provision of discharge packs an increase in duration of Friendly use in the UK containing ’any breastfeeding’ Initiative), but Maternal health  formula-feeding information and samples (includes partial and implementatio Early years  • Unrestricted feeding from birth onwards exclusive breastfeeding) n is dependent  • Unrestricted mother-baby contact from birth (risk ratio (RR) for stopping on local Hospital and community setting  onwards any breastfeeding before components

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales • Unrestricted kangaroo care/skin-to-skin six months 0.91, 95% CI which are care from birth 0.88 to 0.96). All forms of variable onwards extra support together also • Avoiding supplementary fluids for babies had a positive effect on unless medically indicated duration of exclusive • Regular breast drainage/ continued breastfeeding (RR at 6 breastfeeding for months 0.86, 95% CI 0.82 mastitis to 0.91; RR at four to six • Antibiotics for infective mastitis weeks 0.74, 95% CI 0.61 to 0.89). Extra support by Postnatal care in the community both lay and professionals • Skilled breastfeeding support, peer or had a positive impact on professional, breastfeeding outcomes. proactively offered to women who want to Maternal satisfaction was breastfeed poorly reported.

Ongoing care in the community Support is likely to be more • Skilled breastfeeding support, peer or effective in settings with professional high initiation rates, so efforts to increase the uptake of breastfeeding

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales should be in place. Support may be offered either by professional or lay/peer supporters, or a combination of both. Strategies that rely mainly on face-to-face support are more likely to succeed. Support should be tailored to the needs of the setting and the population group Renfrew, MJ et al, 2012 cont’d A “Promising or well-grounded in theory” 52 studies contributed Elements of C. There is some In pregnancy outcome data to the review the evidence supporting Support for healthy breastfeeding • Group, interactive, culture-specific (56,451 mother-infant interventions the use of these mothers with healthy term babies education sessions pairs) from 21 countries. All are funded for interventions but it is • Group education sessions on positioning forms of extra support national not conclusive and attachment analysed together showed implementatio • Antenatal education individually tailored to an increase in duration of n (Baby the needs ’any breastfeeding’ Friendly of low-income women (includes partial and Initiative), but exclusive breastfeeding) implementatio

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales Immediate postnatal care (risk ratio (RR) for stopping n is dependent • Basing prevention and treatment of sore any breastfeeding before on local nipples on six months 0.91, 95% CI components principles of positioning and attachment 0.88 to 0.96). All forms of which are • Cabbage leaves/extract for treatment of extra support together also variable engorgement had a positive effect on • Systemic antibiotics for infected nipples duration of exclusive breastfeeding (RR at 6 Postnatal care in the community months 0.86, 95% CI 0.82 • Self-monitoring daily log for women from to 0.91; RR at four to six higher socio- economic groups weeks 0.74, 95% CI 0.61 to Combination of supportive care, teaching 0.89). Extra support by breastfeeding both lay and professionals technique, rest and reassurance for women had a positive impact on with ‘insufficient milk’ breastfeeding outcomes. • Division of the frenulum in infants with signs Maternal satisfaction was of poorly reported. congenital ankyloglossia [tongue tie] and breastfeeding difficulties Support is likely to be more effective in settings with Wider social/political issues high initiation rates, so

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales • National policy of encouraging maternity efforts to increase the units to adhere to the UNICEF Baby Friendly uptake of breastfeeding Initiative (BFI) should be in place. Support • Regionally/nationally determined targets may be offered either by with professional or lay/peer supporting activities, and/or penalties and/or supporters, or a incentives combination of both. Strategies that rely mainly Multifaceted interventions (across time on face-to-face support are periods and more likely to succeed. types of interventions) Support should be tailored • Tailored antenatal education combined with to the needs of the setting proactive postnatal support in hospital and and the population group the community • Combining antenatal education with partner support, postnatal support and incentives for women in low income groups Renfrew, MJ et al, 2012 cont’d A Potentially ineffective As above Elements of G. There is some In pregnancy the evidence suggesting Support for healthy breastfeeding • Self-help manual used alone interventions that these mothers with healthy term babies • Antenatal education by a paediatrician are funded for interventions are • Providing materials produced by formula national ineffective but it is milk companies on infant feeding in early implementatio not conclusive pregnancy n, but implementatio Immediate postnatal care n is dependent • Separating mothers and babies for on local treatment of components jaundice which are variable Postnatal care in the community

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales • Written educational materials used alone • GP clinic visit at one week postpartum • Single home visit by community nurse following early discharge • Dopamine antagonists for ‘insufficient milk’

Ongoing care in the community • Dopamine antagonists for ‘insufficient milk’

Renfrew, MJ et al, 2012 cont’d A Ineffective As above This H. There is moderate In pregnancy intervention is to good evidence Support for healthy breastfeeding • Conditioning nipples in pregnancy implemented that these mothers with healthy term babies • Hoffman’s exercises for inverted and non- locally in some interventions are protractile areas but does unlikely to be nipples in pregnancy not have a effective • Breast shells for inverted and non- consistent protractile nipples in pregnancy national programme or Immediate postnatal care a co-ordinated • Restricting the timing and/or frequency of approach OR

Priority Area Nutrition Sub Division Breastfeeding Study Details Main findings Results Current Evidence Grading Implementati on Wales breastfeeds is • Restricting mother/baby contact from birth implementatio onwards n nationally on • Routine use of supplementary fluids an ad-hoc • Provision of discharge packs containing basis samples or information on formula feeding • Topical agents for the prevention of nipple pain • Breast pumping before the establishment of breastfeeding in women at risk of delayed lactation

Multifaceted interventions • Combined antenatal education and limited postnatal telephone support for high-income women and women who intend to breastfeed (existing high rates suggest resources are better spent elsewhere)

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales 7. Jepson J et al., 2006 Counselling patients in primary care can One moderate quality This intervention C. There is some improve dietary habits. More intensive systematic review of RCTs may be evidence Counselling patients in primary care counselling, particularly that aimed at higher (1+, C)1 evaluated the implemented supporting the risk patients, may produce larger changes in effectiveness of counselling locally in some use of this Adults, older people behaviour. in the primary care setting to areas but does intervention but it promote a healthy diet not have a is not conclusive Primary care (Ammerman et al, 2002). consistent national programme Jepson J et al., 2006 It was not possible to show whether or not One moderate quality This type of D. The evidence Continued healthy eating interventions in pregnancy systematic review of mixed intervention may be is inconsistent implemented locally are effective. study types (1&2+, A) in some areas but and it is not Healthy eating interventions in evaluated the effectiveness does not have a possible to draw pregnancy of interventions to promote consistent national a conclusion healthy eating in pregnant programme or a co- ordinated approach women and women of OR is childbearing age (van 83 implementation Teijlingen et al, 1998) nationally on an ad- hoc basis

1 The review uses the following grading system for the individual SRs it included: ++= good quality SR += mod quality 1=SR used RCTs 2= SR used designs other than RCTs A=directly relevant to UK B=some relevance to UK C=may be relevant

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales Jepson J et al., 2006 Traditional, video or computer-based One moderate quality This intervention Lack of evidence Continued teaching methods were successful at systematic review of mixed may be increasing nutrition knowledge, and their study types (1&2+, A) implemented Interventions to promote healthy effectiveness was enhanced by including evaluated the effectiveness locally in some eating in preschool children parents. of interventions to promote areas but does However, there is insufficient evidence healthy eating in preschool not have a available to predict the format of successful children aged 1 to 5 years consistent healthy eating interventions that are likely to (Tedstone et al, 1998). national be effective at improving the nutritional well- programme or a being of UK pre-school children. co-ordinated approach Jepson J et al., 2006 The results of the meta-analysis revealed One moderate quality SR of This intervention B. This intervention Continued that these kinds of interventions have a mixed study types (1&2+, A) may be is supported by small, but significant positive effect. Pooled evaluated interventions to implemented moderate to good Interventions to promote to children estimates from the nineteen studies suggest promote healthy eating in locally in some quality evidence of its effectiveness aged 4-10 that implementation of these interventions order to evaluate the barriers areas but does will, on average, increase children’s fruit to, and facilitators of, healthy not have a intake by one-fifth of a portion per day and eating amongst children consistent their vegetable intake by a little less than aged four to 10 years old national one-fifth of a portion per day. The results of (Thomas et al, 2003). This programme the meta-analysis suggest that it is easier to review combined both increase children’s consumption of fruit than qualitative and quantitative vegetables. studies. The types of interventions evaluated by these studies were largely school-based, and often combined learning about the health benefits of fruit and vegetables with ‘hands-on’ experience in the form of food preparation and taste-

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales testing. The majority targeted parents and/or involved them in intervention delivery alongside teachers and health promotion practitioners. Some included environmental modification involving, for example, changes to the foods provided at school. Jepson J et al., 2006 Several multi-component interventions A moderate quality SR of This intervention B. This Continued complementing classroom activities with mixed study types (1&2+, A) may be intervention is school wide initiatives + involving parents evaluated healthy eating implemented supported by Healthy eating interventions in were found to have positive effects. interventions in young people locally in some moderate to young people aged 11-16 years aged 11-16 years (Shepherd areas but does good quality et al, 2002). not have a evidence of its consistent effectiveness national programme Jepson J et al., 2006 Dietary interventions in the workplace can 6. One moderate quality This intervention B. This Continued achieve small effects (<0.5 portions/day). SR of mixed study types may be intervention is (1&2+, A) identified two implemented supported by Dietary interventions in the studies of interventions locally in some moderate to workplace with adults in the areas but does good quality workplace (Ciliska et al, not have a evidence of its 1999).4 The results of the consistent effectiveness national first trial indicated that programme the intake of fruits and vegetables increased from 2.6 to 2.8

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales servings/day in the intervention group, compared with 2.58 to 2.6 servings/day in the control group (p<0.001). The results of the second trial showed that there was no post-test difference in the mean servings per month of fruit. The intervention group also experienced significant mean reduction in the servings/week of margarine and butter.

Jepson J et al., 2006 There is limited evidence of the One moderate quality SR of This intervention B. This Continued effectiveness of interventions to promote mixed study types (1&2+, C) may be intervention is healthy eating in older people. A strategy of evaluated 23 studies of implemented supported by Interventions to promote healthy individual feedback and goal-setting tended interventions aimed at locally in some moderate to eating in older people. to be associated with a positive intervention. promoting healthy eating in areas but does good quality older people (Fletcher & not have a evidence of its Rake, 1998). The consistent effectiveness interventions included: national nutrition education targeted programme at the individual or the community; individual counselling; and policies to facilitate healthy eating

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales behaviour, but not the provision of a meal. There was limited evidence for effectiveness of healthy eating interventions in this age range. Jepson J et al., 2006 Giving tailored information was ineffective as A moderate quality SR of U. G. There is some Continued was having a Healthy Heart Coalition. mixed study types (1&2+, B) Implementation evidence evaluated three non-worksite status is suggesting that Non-worksite healthy eating interventions with adults (see unknown this intervention interventions in adults above Ciliska et al, 1999) is ineffective but (only 2 met inclusion criteria it is not for Jepson review). No conclusive details of what interventions were.

Jepson J et al., 2006 The authors concluded that they found clear One moderate quality SR of This intervention D. The evidence Continued evidence in 15/25 recent controlled studies mixed study types (1&2+, A) may be is inconsistent that, despite difficulties inherent in achieving evaluated health promotion implemented and it is not Interventions to promote healthy dietary change in the general population, interventions to promote locally in some possible to draw eating in the general population healthy eating interventions were effective in healthy eating in the general areas but does a conclusion but a variety of settings and populations. population (Roe et al, 1997). not have a there is some The greatest magnitude in change in diet There was a range of consistent evidence of was seen in studies with highly motivated settings in the studies national effect volunteers in intensive programmes. including school/ university, programme The majority of interventions in supermarket workplaces, primary care, and catering settings showed a positive and communities. Seventy effect on food purchases in six studies were included the short term, that is, while the intervention (over 100000 participants in was in place. total). Most good quality

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales studies, which reported a dietary outcome measure, showed a benefit of intervention (15 studies out of 25). Long-term interventions in the population achieved reductions in dietary fat of 1 to 4% of energy intake. A substantial number of studies showed no effect of the intervention on the main outcomes measured, compared with controls. 3. 8. NICE (2008) Guidance recommends: Some elements A. This 3 implemented intervention is National Institute for Health and Clinical Health professionals training locally in some supported by Excellence. Health professionals should have the areas but does good evidence of appropriate knowledge and skills to give not have a its effectiveness Vitamin supplements – advice and advice on: consistent and is supply -the nutritional needs of women/importance national recommended Healthy Start Programme of a programme for use in the UK balanced diet before, during and after Maternal health pregnancy Early years -the rationale for recommending certain dietary supplements eg vitamin D Primary care -the nutritional needs of infants and young Pre-school children Settings -strategies for changing people’s eating behaviour, particularly by offering practical, food-based advice.

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales

Ensure local education initiatives aimed at health professionals include information on the importance of folic acid supplements.

Dietitians and public health nutritionists should educate health professionals about the importance of vitamin D supplements for all pregnant and breastfeeding women.

NHS Commissioners/ managers Ensure an adequate supply of Healthy Start application forms is available and that the uptake of Healthy Start benefits is regularly audited.

Consider distributing the maternal Healthy Start vitamin supplement (folic acid, vitamins C and D) to all women who receive Healthy Start benefit for children aged 1–4 years, particularly those who may become pregnant.

Health professionals Use any appropriate opportunity to advise women who may become pregnant to take a suitable source of folic acid supplements (400 micrograms (μg) daily

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales before pregnancy and throughout the first 12 weeks), even if they are already eating foods fortified with folic acid or rich in folate Encourage women to eat foods rich in folic acid (eg, fortified breakfast cereals and yeast extract, peas and beans and orange juice).

Promote the Healthy Start scheme.

Advise pregnant women and parents of children under 4 years about the Healthy Start scheme. Ensure all women who may be eligible receive an application form as early as possible in pregnancy.

Provide the maternal Healthy Start vitamin supplements (folic acid, vitamins C and D) for eligible women. Ensure women who are not eligible for these can obtain the supplements from their local pharmacy.

Ensure an adequate supply of Healthy Start vitamin supplements for children from 6 months to 4 years is available for distribution by health professionals when they see parents of children under 4 years.

Use every opportunity to offer those parents who are eligible for the Healthy Start

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales scheme practical, tailored information, support and advice on how to: use Healthy Start vouchers to increase their fruit and vegetable intake, initiate and maintain breastfeeding, introduce foods in addition to milk as part of a progressively varied diet when infants are 6 months old.

Take particular care to check that women at greatest risk of deficiency are following advice to take a vitamin D supplement during pregnancy and while breastfeeding. These include women who are obese, have limited skin exposure to sunlight or who are of South Asian, African, Caribbean or Middle Eastern descent.

Primary care GPs should prescribe 5 milligrams of folic acid a day for women who are planning a pregnancy, or are in the early stages of pregnancy, if they (or their partner) have a neural tube defect, have had a previous baby with a neural tube defect ,(or their partner) have a family history of neural tube defects, have diabetes.

During the booking appointment at the beginning of pregnancy, midwives

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales should offer every woman information and advice on the benefits of taking a vitamin D supplement (10 micrograms [μg] per day) during pregnancy and while breastfeeding.

Midwives and health visitors should advise all pregnant and breastfeeding women about the availability of suitable vitamin D supplements such as the Healthy Start vitamin supplements.

GPs and health visitors should offer children’s Healthy Start vitamin supplements (vitamins A, C and D) to all children aged from 6 months to 4 years in families receiving the Healthy Start benefit.

Community pharmacists should ensure the Healthy Start maternal vitamin supplements are available for purchase by women who are not eligible to receive them free of charge.

Midwives, obstetricians, GPs, health visitors and dietitians should: -Early in pregnancy, discuss the woman’s diet and eating habits and find out and address any concerns she may have about her diet. -Provide information on the benefits of a healthy diet and practical advice on how to

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales eat healthily throughout pregnancy. This should be tailored to the woman’s circumstances. The advice should include: eat five portions of fruit and vegetables a day and one portion of oily fish a week.

Infant feeding Midwives should ensure mothers who choose to use infant formula are shown how to make up a feed before leaving hospital or the birth centre (or before the mother is left after a home birth). This advice should follow the most recent guidance from the DH (‘Guide to bottle feeding’ 2011).

Health visitors and the CHPP team should: -support mothers to continue breastfeeding for as long as they choose -provide mothers and other family members with support to introduce a variety of nutritious foods (in addition to milk) to ensure the child is offered a progressively varied diet from 6 months -encourage and support parents and carers to make home-prepared foods for infants and young children, without adding salt, sugar or honey -encourage families to eat together and encourage parents and carers to set a good example by the food choices they make for

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales Dietary advice themselves -advise parents and carers not to leave infants alone when they are eating or drinking.

Early years Health professionals, community and day care nursery nurses, home-based child carers and others who work with young children should encourage parents and carers to: -use a bottle for expressed breast milk, infant formula or cooled boiled water only -offer drinks in a non-valved, free-flowing cup from age 6 months to 1 year -discourage feeding from a bottle from 1 year onwards -limit sugary foods to mealtimes only -avoid giving biscuits or sweets as treats & Infant feeding advice encourage snacks free of salt and added sugar (such as vegetables and fruit) between meals -provide milk and water to drink between meals (diluted fruit juice can be provided with meals – 1 part juice to 10 parts water).

Teachers, teaching assistants, nursery nurses, home-based child carers and those working in pre-school day care settings such

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales as nurseries, creches and Playgroups should: -Implement a food policy which takes a ‘whole settings’ approach to healthy eating, so that foods and drinks made available during the day reinforce teaching about healthy eating. -Take every opportunity to encourage children to handle and taste a wide range of foods that make up a healthy diet by providing practical classroom-based activities, ensuring a variety of healthier choices are offered at mealtimes, and snacks offered between meals are low in added sugar and salt, ensuring carers eat with children whenever possible.

Dietary advice for early years

Interventions in pre-school settings

4 9. D’Souza et al., (2007) Only one case control study Some elements Lack of evidence was found about the intake implemented Dietary counselling of oily fish or omega-3 locally in some Pregnant women Evaluation of the role of dietary counselling supplements (Odent 1996 +). areas but does in improving the diets of pregnant women is This study could not not have a held back by the lack of high quality studies. demonstrate any differences consistent in birth outcomes between national ------controls and women given programme or a Improving access to healthy foods Studies on improvement in access to healthy tailored advice to eat more co-ordinated foods, food shopping, storage and fish. approach

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales preparation are lacking. A review by van Teijlingen Advice about food hygiene ------reported that there was some There was no evidence to answer questions evidence to suggest that Advice on how to avoid allergies about the best way to provide advice about educational interventions food hygiene or the best way to provide have a modest effect but Home support for dietary change advice about how to avoid allergies. much of this evidence was ------flawed. The van Teijlingen There was insufficient evidence to evaluate review concluded that there Dietary advice for dietary behaviour home support. was a dearth of research in change ------this area and that high There is no evidence to indicate that diet quality research was needed. advice alone is sufficient to change dietary Only one study was found Provision of food supplements behaviour but many strategies have not that evaluated advice or been evaluated. information on its own ------(Anderson 1995+). This There is a lack of high quality studies that study undertaken in Scotland have evaluated the provision of food found that dietary advice and supplements in different populations. information alone helped improve knowledge about diet but did not improve dietary behaviour. This suggests that dietary advice alone is not sufficient for behaviour change. Evidence on the effectiveness of food supplementation to pregnant women came from US studies that evaluated individual parts of the WIC programme and a study

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales undertaken in Finland. Many of the studies evaluating WIC were found to be flawed. A trial by Metcoff (+) looked at the provision of vouchers exchangeable for milk, eggs and cheese. After adjusting for baseline differences in maternal weight no significant difference in mean birth weight was found between the intervention and control groups However in a sub set of smokers the intervention had a positive impact on birth weight. It is possible that food supplement interventions are more effective in those at highest risk. A more recent study from Finland (Piirainen et al, 2006+) is interesting as it suggests that a combination of the free provision of healthy foods and appropriate dietary advice can improve diet but this improvement might not be sufficient to influence commonly measured birth

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales outcomes such as birth weight and head size at birth. It seems likely that in many populations, particularly in developed countries, that it would be difficult to for a dietary intervention in pregnant women to achieve statistically significant changes in birth outcomes. It was also notable that none of the studies evaluating different aspects of food support programmes during pregnancy had long term follow up. Therefore the long term impact of such programmes on child development is unknown.

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales 10. NICE (2006) Local authorities and NHS workplaces: See guidance for details. Some elements A. This should ensure on-site catering promotes implemented intervention is National Institute for Health and Clinical healthy food and drink choices (for locally in some supported by Excellence. example by signs, posters, pricing and areas but does good evidence of positioning of products). not have a its effectiveness Obesity: prevention, identification, consistent and is assessment and management. Community national recommended Local authorities should engage with the programme or a for use in the UK Early years, Children & adults local community, to identify environmental co-ordinated barriers to healthy eating. This should approach Community, workplace, Schools involve: • an audit, with the full range of partners including PCTs or local health boards, residents, businesses and institutions • assessing (ideally by doing a health impact assessment) the affect of their policies on the ability of their communities to eat healthily; the needs of subgroups should be considered because barriers may vary by, for example, age, gender, social status, ethnicity, religion and whether an individual has a disability. Barriers identified in this way should be addressed.

Local authorities should facilitate links between health professionals and other organisations to ensure that local public policies improve access to healthy foods.

Local authorities, through local strategic

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales partnerships, should encourage all local shops, supermarkets and caterers to promote healthy food and drink, for example by signs, posters, pricing and positioning of products, in line with existing guidance.

All community programmes to improve diet should address the concerns of local people. Concerns might include the availability of services and the cost of changing behaviour, the expectation that healthier foods do not taste as good and confusion over mixed messages in the media about weight, diet and activity.

Interventions to improve diet (and reduce energy intake) should be multi-component (for example, including dietary modification, targeted advice, family involvement and goal setting), be tailored to the individual and provide ongoing support.

Interventions may include promotional, awareness-raising activities, but these should be part of a long-term, multicomponent intervention rather than one-off activities (and should be accompanied by targeted follow-up with different population groups).

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales Health professionals should work with shops, supermarkets, restaurants, cafes and voluntary community services to promote healthy eating choices that are consistent with existing good practice guidance and to provide supporting information.

Early years Nurseries & childcare facilities should: -implement Department for Education and Skills, Food Standards Agency and Caroline Walker Trust guidance on food procurement and healthy catering. -ensure that preventing excess weight gain and improving children’s diet and activity levels are priorities. -ensure all action aimed at preventing excess weight gain, improving diet (and reducing energy intake) and increasing activity levels in children should involve parents and carers. -ensure that children eat regular, healthy meals in a pleasant, sociable environment free from other distractions (such as television). Children should be supervised at mealtimes and, if possible, staff should eat with children.

Schools All schools should ensure that improving

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales the diet of children and young people is a priority for action to help prevent excess weight gain. A whole-school approach should be used to develop life-long healthy eating practices.

Head teachers and chairs of governors, in collaboration with parents and pupils, should assess the whole school environment and ensure that the ethos of all school policies helps children and young people to eat a healthy diet in line with existing standards and guidance. This includes policies relating catering (including vending machines) and the food and drink children bring into school, the taught curriculum, policies relating to the National Healthy Schools Programme and extended schools.

Head teachers and chairs of governors should ensure that teaching, support and catering staff receive training on the importance of healthy-school policies and how to support their implementation.

Interventions should be sustained, multi- component and address the whole school, including after-school clubs and other activities. Short-term interventions and one-off events are insufficient on their own

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales and should be part of a long-term integrated programme.

Children and young people should eat meals (including packed lunches) in school in a pleasant, sociable environment. Younger children should be supervised at mealtimes and, if possible, staff should eat with children.

Staff planning interventions should consider the views of children and young people, any differences in preferences between boys and girls, and potential barriers (such as cost or the expectation that healthier foods do not taste as good).

Where possible, parents should be involved in school-based interventions through, for example, special events, newsletters and information about lunch menus and after-school activities.

Workplaces Workplaces should provide opportunities for staff to eat a healthy diet through active and continuous promotion of healthy choices in restaurants, hospitality, vending machines and shops for staff and clients, in line with existing Food Standards Agency guidance

Incentive schemes, such as policies such as on the price of food and drinks sold in the workplace should be sustained and part of a wider programme to support staff in improving diet.

Workplaces providing health checks for staff should ensure that they address diet and provide ongoing support.

Action to improve food and drink provision in the workplace, including restaurants, hospitality and vending machines, should be supported by tailored educational and promotional programmes, such as a behavioural intervention or environmental changes (for example, food labelling or changes to availability). For this to be effective, commitment from senior management, enthusiastic catering management, a strong occupational health lead, links to other on-site health initiatives, supportive pricing policies and heavy promotion and advertisement at point of purchase are likely to be needed.

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales 11. Rees, R et al. (2012) Only 1/5 studies (Food Clubs [people >65 Thirteen studies were Local F. The evidence in sheltered housing in a deprived area] included. All 13 of the home implementation is inconsistent EPPI-Centre SR Moynihan et al 2006) was used to judge cooking courses aimed to in some areas and it is not effectiveness after assessment for bias. teach cooking skills to low but does not possible to draw Interventions to introduce adults to The reviewers agreed with the study’s income groups in order to have a a conclusion but home cooking. authors that there was no evidence that the improve diet and health. The consistent it tends towards Food Club had an effect a year after its courses were all similar and national no effect Adults delivery on any other aspects of diet introduce participants to programme or a Community measured. practical cooking skills, with co-ordinated some courses emphasising approach food safety and hygiene, and others shopping on a budget. Five studies that used a comparison group design were used to evaluate effectiveness.

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales 12. Schwann et al 2010 Generic message Results from review of 12 Some elements A. This NICE evidence reviews: implemented in intervention is National Institute of Health and Clinical  multi-component interventions some areas but supported by Excellence are commonly more effective than Community/whole does not have a good evidence of single-component interventions population consistent its effectiveness Characteristics of health systems • more intensive interventions tend to be Promotional campaigns, national and is and services: at national, regional more effective including media programme or a recommended and local levels that promote and • school-based and workplace-based interventions, can co-ordinated for use in the UK support health-related behaviour interventions can be effective in the short increase awareness of approach change. term, but longer-term benefits are less clear what constitutes a healthy diet and may Early years • involving parents and carers is important in subsequently improve School children effecting behaviour change for children Adults of working age • family-based interventions focusing on dietary intakes. Whole population obesity prevention are effective There is little evidence of • programmes focusing on CVD risk factors benefit from locally Pre-school settings show the strongest effect in dietary change implementable city- and School and body mass index (BMI) Workplace state-wide interventions Primary care • policy related to the physical environment to prevent CVD in and transport systems makes a difference to relation to diet and/or physical activities such as walking, although physical activity the size of the effect varies across studies outcomes. • mass media campaigns can be effective in increasing levels of awareness and Interventions may be knowledge, but there is less evidence on ineffective unless their effects on behaviour, and the evidence fundamental issues are that exists is mixed addressed, such as • methods such as telephone counselling individual confidence to and postal prompts can be effective change behaviour, cost • incentives to participants (not financial and availability; pre-

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales incentives) seem to work in the short term or existing concerns such as while the intervention lasts. poorer taste of healthier foods and confusion over mixed messages; the perceived ‘irrelevance’ of healthier eating to young people.

Tailoring dietary advice to address potential barriers (taste, cost, availability, views of family members, time) is key to the effectiveness of interventions and may be more important than the setting.

Point-of-purchase schemes in shops, supermarkets, restaurants and cafés can be effective in improving dietary intake, at least in the short term, particularly if accompanied by supporting education, information and promotion. There is some

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales evidence that longer- term, multi-component interventions may show greater effects.

Early years Improvements in the food service to pre- school children can result in reductions in dietary intakes of fat and improved weight outcomes.

2–5 years is a key time to establish good nutritional habits, especially when parents are involved.

There is evidence for small but important beneficial effects of interventions that aim to improve dietary intake (such as videos, interactive demonstrations, and changing food provision

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales at nursery school) so long as these interventions are not solely focused on nutrition education.

School children Food promotion can have an effect on children’s food preferences, purchase behaviour and consumption. The majority of food promotion focuses on foods high in fat, sugar and salt and therefore tends to have a negative effect. However, food promotion has the potential to influence children in a positive way.

Multi-component interventions addressing various aspects of diet and/or activity in school, including the school environment, are

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales effective in improving physical activity and dietary behaviour, at least while the intervention is in place. However, UK-based evidence to support multi-component interventions (the ‘whole- school approach’) is limited.

Short- and long-term school-based interventions to improve children’s dietary intake may be effective, at least while the intervention is in place. This includes interventions aiming to increase fruit and (and to a lesser extent) vegetable intake, improve school lunches and/or promote water consumption.

Interventions that incorporate novel

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales educational and promotional methods, such as videos and computer programmes, may improve dietary intake.

Most of the evidence for school-based interventions is non-UK- based. However, it is likely that the findings are generalisable to the UK.

Young people Young people’s views of barriers and facilitators to healthy eating indicated that effective interventions would (i) make healthy food choices accessible, convenient and cheap in schools; (ii) involve family and peers; and (iii) address personal barriers to healthy eating, such as

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales preferences for fast food in terms of taste, and perceived lack of will- power.

Workplace/Adults A body of UK-based case studies suggests that factors most likely to make a canteen-style five-a-day intervention work are: commitment from the top, enthusiastic catering management, a strong occupational health lead, links to other on-site health initiatives, free or subsidised produce, and heavy promotion and advertisement at point of purchase.

Worksite behaviour- modification programmes, such as health screening followed by counselling and, sometimes,

Priority Area Nutrition Sub Division General nutrition (where applicable) Study Details Outcome measures Main findings Results Current Implementation Evidence Grading Wales environmental changes, can lead to improvements in nutrition and physical activity while the intervention is in place.

Provision of healthier food choices can encourage consumption of a healthier diet.

Adults Briefer interventions, such as brief counselling/dietary advice by GPs or other health professionals, can be effective in improving dietary intake, but tend to result in smaller changes than intensive interventions.

4. Comparability of key messages with other evidence reviews: The Community Guide The Community Guide13 is a product of the Community Preventative Task Force in the US. The Community Preventive Services Task Force was established by the U.S. Department of Health and Human Services (DHHS) in 1996 to develop guidance on which community- based health promotion and disease prevention interventions work and which do not work, based on available scientific evidence. The Centers for Disease Control and Prevention (CDC) is the DHHS agency that provides the Task Force with technical and administrative support following a systematic review process. These recommendations are made in a US policy and services context and may not apply fully to the UK. In the field of Nutrition, the following recommendations have been made: Maternal and infant health Date of latest ‘finding’

Community-wide education campaigns to promote the use of folic acid supplements among women of childbearing age to increase the number of these women who consume folic acid supplements.

 The overall body of evidence represents women of childbearing age (18–45) with varying levels of education and social economic status. Recommended June 2004  The intervention was delivered in urban, rural, and suburban settings in various international communities with high-income economies.

Recommended Fortification of food with folic acid to increase folic acid intakes June 2008

School aged children

Multi-component school-based nutrition interventions in increasing fruit and vegetable Insufficient evidence June 2003 intake and decreasing fat and saturated fat intake among school-age children.

Forty-five reports in forty-one studies qualified for the systematic review.

 A wide variation was seen in:

o Combinations of components (activities)

o Length of study (< 3 months to 60 months)

o Age of study population (K–12, median age 9.3 years; most students were in grades 3–5)

o Length of follow-up period (55% immediate follow-up to 2% at 48 months)

 Results were measured in terms of behavioural outcomes including changes in intake of fruit and vegetables, fat, and saturated fat.

 Study outcomes were based on self-report of dietary intake, which is probably subject to reporting bias (e.g., social desirability—the possibility that answers may be influenced by what the respondent thinks is socially acceptable).

 Although reported changes were in the desired direction, they were small and are questionable because of the potential bias of self-reports.

Work-site programmes

Recommended o Informational and educational strategies aim to increase knowledge about a healthy February 2007 diet: Lectures, Written materials (provided in print or online), Educational software

o Behavioural and social strategies target the thoughts (e.g. awareness, self-efficacy) and social factors that effect behaviour changes: Individual or group behavioural counselling, Skill-building activities such as cue control, Rewards or reinforcement

o Inclusion of co-workers or family members to build support systems

o Policy and environmental approaches aim to make healthy choices easier and target the entire workforce by changing physical or organizational structures: Improving access to healthy foods (e.g. changing cafeteria options, vending machine content)

o Policy strategies may also change rules and procedures for employees such as health insurance benefits or costs or money for health club membership.

Assessment of health risks with feedback plus Health Education with or without other interventions Recommended February/2007

Insufficient Evidence Assessment of Health Risks with Feedback Alone June 2006

Version 1 62 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group 5. Conclusions: The priority area of Nutrition comprises breast-feeding and nutrition across the life- course.

The evidence sources utilised in this summary are NICE recommendations which draw from mixed sources of evidence, not all good quality systematic reviews, as well as other systematic reviews. The assessment of current implementation in Wales is based on a subjective assessment by the Evidence Review Team using personal knowledge and the information available to them, this may not be the full picture.

Breastfeeding: This review included both initiation and duration of breast-feeding. Evidence gaps are widest in clinical issues, public policy and those that address women’s key concerns and problems. A key message which emerges is the need for a coordinated approach to the implementation and monitoring of breast-feeding policy and action plans, ensuring a two-way flow of information to enable both a bottom-up and a top-down approach.

A successful breast-feeding programme will require the wholehearted involvement and support of: • Clinical professionals in community and hospital settings • Community based workers • Managers with responsibility for health and social services and staff • Those with responsibility for collecting health and health service-related data • Educators in the fields of health and social services; schoolteachers and those responsible for the school curriculum in primary and secondary schools • Employers in large and small organisations • Politicians and policy makers at local, regional and national levels • Those with influence over public opinion • Families and the public at large.

NICE guidance (2008) recommends a multi-faceted approach involving education, professional and peer-support and the evidence indicates that these interventions may result in some improvements in the number of women beginning to breast feed and in the duration of breast-feeding. Where these were compared (evidence table 3,6), peer counselling and needs-based informal education was significantly better than formal breast-feeding education, in initiation of BF. The importance of involving culturally relevant peer-support workers is stressed.

Evidence (evidence table 6) supports the delivery of tailored teaching and knowledge based interventions and intensive support (multiple methods) from a skilled professional, for low income women for those who intend to breastfeed. NICE Guidance (2008) suggests that targeting of interventions is important if inequalities are not to increase as better educated/higher income women have the potential to benefit more from generic interventions.

There is a gap in the evidence base in terms of views of childbearing women and their families, and the staff who care for them, on the effectiveness of/barriers to, interventions.

Nutrition For many interventions aimed at improving nutrition, good quality evidence of potential effectiveness is either lacking or equivocal, nevertheless, there is some evidence (drawn from all sources) which suggests that interventions are more likely to be effective if they are:

 from multiple sources  multi-faceted (individual and environment)  inter-agency  intense and sustained  aimed at multiple behaviours  address concerns and perceived barriers to change  individually-tailored and aimed at the highest risk individuals  followed up  supported by or otherwise involve family and social groups  characterised by feedback, advice, and goal-setting with incentives

Effects of interventions are however generally described as small to modest, hence the importance of multi-component strategies.

With the exception of children and young people in school settings there is a paucity of good quality information about population sub-groups. There is some suggestion within the evidence that is available (drawn from multiple sources), that unless care is taken to target interventions, greater benefit will be gained from the better educated, those in higher income groups and certain ethnic groups, thus potentially increasing inequalities.

The systematic reviews consulted often commented on the lack of high quality, more reliable, studies and on the heterogeneity of both interventions and outcomes measured plus the lack of measurement of effect over the longer-term. Too many studies rely on self-reports of dietary intake and too few measure dietary change directly as an outcome, often relying on proxy measures such as infant weight-gain, which can be subject to confounding factors.

It is also important to consider that many studies are not UK-based and local implementation factors could radically affect the effectiveness of an intervention. Reviews note a lack of process evaluation and qualitative research about implementation which might inform local delivery. The evidence reviewed suggests some generic characteristics of interventions which, if followed, may increase the potential for effectiveness, but if we are to have confidence in the effectiveness of interventions delivered in Wales we need to ensure robust monitoring and evaluation of appropriate outcome indicators.

A core message emerging from the literature included in this review is of the importance of national leadership and policies that address not only the individual but also the environment in which that individual lives, their access to high-quality information and health care, as well as to appropriate food choices and opportunities for other positive lifestyle choices, such as decreasing inactivity. This suggests, that if we are to effect change in Wales, we need an evidence-based strategic framework at national level which guides local action, supported by a Standard Evaluation Framework which ensures robust data on core process and outcome indicators are collected, collated and used to inform future action and which add to the evidence-base. A Public Health research strategy (conducted collaboratively across academic units and public health teams) might seek to address some of the identified gaps in primary research.

Interventions with evidence of effectiveness currently being implemented in Wales The Early Years Pathfinder project is monitoring implementation of guidance about breast-feeding and reports demonstrate that effective interventions are being implemented across Wales, albeit with some variation across LHB in extent and approach.

The most wide-spread intervention which is supported by some evidence of potential effectiveness (evidence table 7, 12) is the Healthy Schools Scheme however, there is not an extensive evidence-base drawn from the UK and the available evidence suggests effects on diet are not large. Further, as the scheme is implemented at a local level, there will be variation in the different components of the programme and thus in potential effectiveness. It is therefore important to ensure that a locally

Version 1 65 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group relevant evidence-base is being built systematically through monitoring and evaluation of appropriate indicators.

Interventions with evidence of effectiveness not currently being implemented, or with limited implementation or where no information was available The evidence-base for dietary interventions in pregnancy is limited due to a lack of high quality studies. NICE guidance (2008) recommends training health professionals (by dietitians) to give advice to pregnant women about diet and vitamin supplements (Folic acid, C, D), full implementation of the Healthy Start scheme (with audit of uptake) and prescribing of folic acid in primary care. There is a lack of information about the extent to which NICE guidance on nutrition in pregnancy is being implemented through-out Wales and there may be potential for greater benefit from systematic and widespread implementation. Much of this NICE guidance relates to Healthy Start Scheme which is not implemented in Wales.

There is some evidence (to support a whole-setting approach to encouraging healthy eating in pre-school child-care settings (evidence table 7,12, NICE guidance 2006, 2008) but there is a lack of information as to the extent of implementation in Wales.

There is some evidence (evidence table 7) to suggest that dietary counselling in primary care can be effective, particularly when intensive and targeted at the highest risk individuals. For older adults, individual feedback and goal setting improves effectiveness. The extent to which dietary counselling takes place in primary care across Wales is unknown.

NICE guidance (2006) recommends a partnership approach to assessing the impact of public policy on opportunities for, audit of barriers to, healthy eating in the community and working with local businesses to promote healthy eating. This would need implementation at local level and the extent to which this is happening across Wales is unknown.

There is some evidence (evidence table 7,12, US Community Guide) that ‘whole- setting’ programmes in workplaces can be effective in promoting some dietary change. Healthy Working Wales and the associated programmes have the potential to support health improvement through employment and the workplace but there was a lack of information about the extent and nature of initiatives within workplaces which aim to support healthy eating.

Interventions with evidence of limited, or no, effect, currently being implemented in Wales There is some evidence (evidence table 3, 6) which suggests that hospital-produced breastfeeding promotion packs may be ineffective in promoting initiation or duration

Version 1 66 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group of breastfeeding in a context where there is also widespread availability/use of, formula company promotion items. The extent to which these are produced across Wales is unknown and likely to vary across LHBs.

There is some evidence (evidence table 6) to suggest that the following interventions may be ineffective in, or counter-productive to, promoting duration of breastfeeding, although the evidence on these was not conclusive: In pregnancy  Self-help manual used alone  Antenatal education by a paediatrician  Providing materials produced by formula milk companies on infant feeding in early pregnancy Immediate postnatal care  Separating mothers and babies for treatment of jaundice  Hospital-produced breastfeeding promotion packs Postnatal care in the community  Written educational materials used alone  GP clinic visit at one week postpartum  Single home visit by community nurse following early discharge  Dopamine antagonists for ‘insufficient milk’ The extent to which these are practiced across Wales is unknown and likely to vary across LHBs.

There is evidence to suggest that the following interventions may be ineffective in promoting the duration of breastfeeding: In pregnancy • Conditioning nipples in pregnancy • Hoffman’s exercises for inverted and non-protractile nipples in pregnancy • Breast shells for inverted and non-protractile nipples in pregnancy Immediate postnatal care • Restricting the timing and/or frequency of breastfeeds • Restricting mother/baby contact from birth onwards • Routine use of supplementary fluids • Provision of discharge packs containing samples or information on formula feeding • Topical agents for the prevention of nipple pain

Version 1 67 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group • Breast pumping before the establishment of breastfeeding in women at risk of delayed lactation Multifaceted interventions • Combined antenatal education and limited postnatal telephone support for high- income women and women who intend to breastfeed (existing high rates suggest resources are better spent elsewhere)

Interventions across the life-course Prenatal maternal health and early years: Evidence of the effectiveness of interventions to encourage pregnant women (and women of child-bearing age) to eat healthily is lacking although NICE guidance makes some recommendations. There is a lack of information about the extent to which NICE guidance on nutrition in pregnancy is being implemented through-out Wales and thus there may be potential benefit to be gained from a more strategic approach to implementation.

There is a good level of evidence available to guide a coordinated approach to the development, implementation and monitoring of breast-feeding policy and action plans across Wales. The development of a standard set of outcome indicators for routine monitoring of breastfeeding across Wales would inform this process. The extent to which this could be/will be achieved through the Early Years Pathfinder project is unclear. The Baby Friendly Initiative is being implemented across Wales. This is supported by some (but not conclusive) evidence of effectiveness and thus continued monitoring of outcome indicators is important.

There is a lack of evidence to guide the development of healthy eating interventions that are likely to be effective at improving the nutritional well-being of pre-school children. NICE recommends the training of health professionals to provide nutrition advice and a whole settings approach in pre-school day-care settings. There is potential for benefit from more widespread and systematic implementation of this guidance.

School-age children and young people: There is evidence of good quality that shows an effect of multi-component interventions complementing classroom activities in school wide initiatives, which address perceived barriers to healthy eating and which involve parents, on promoting healthy eating, particularly the promotion of fruit and vegetables. The development of a standard framework for monitoring and evaluation of school-based initiatives would aid sharing of good practice and monitoring of outcomes nationally.

Adults:

Version 1 68 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group There is a lack of evidence about the effectiveness of specific interventions aimed at promoting good nutrition and healthy eating amongst adults, although there is some evidence to suggest that intensive counselling in primary care, targeted at higher risk patients, which is tailored and addressed potential barriers, might be effective. There may be potential benefit to be gained from more systematic implementation and monitoring of such interventions.

Workplace settings appear to have potential for promoting healthy eating and there may be benefit to be gained from more widespread implementation of certain workplace-based interventions.

Evidence about the effectiveness of community-based, population level interventions aimed at increasing healthy eating is very limited however, a multi-faceted, multi- agency, intense and targeted approach is more likely to be successful. This suggests that the development of a standard strategic framework with an associated evaluation framework might be helpful in supporting the development of local strategies whilst retaining some consistency in approach at a national level.

Version 1 69 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group References

Abdulwadud O & Snow M, 2007. Interventions in the workplace to support breastfeeding for women in employment. Cochrane Database of Systematic Reviews (3)-CD006177 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006177.pub2/

D’Souza L et al, 2007. The effectiveness of public health interventions to improve the nutrition of pregnant women. London:NICE. Available at: http://www.nice.org.uk/nicemedia/live/11943/45033/45033.pdf

Dyson L et al, 2005. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systematic Reviews (2)-CD001688 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001688.pub2/pdf

Jepson R et al, 2006. A review of the effectiveness of interventions, approaches and models at individual, community and population level that are aimed at changing health outcomes through changing knowledge attitudes and behaviour. London: NICE. Available at: http://www.nice.org.uk/nicemedia/live/11868/44521/44521.pdf

Lee S & Thomas J, 2008. Antenatal breast examination for promoting breastfeeding. Cochrane Database of Systematic Reviews (3)-CD006064 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006064.pub2/pdf

Lumbiganon P et al, 2012. Antenatal breastfeeding education for increasing breastfeeding duration. Cochrane Database of Systematic Reviews (9)-CD006425 Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006425.pub3/pdf

National Institute for Health and Clinical Excellence, 2006. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children.CG43. London: NICE. Available at: http://www.nice.org.uk/cg043

National Institute for Health and Clinical Excellence, 2008. Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households. PH11. London: NICE. Available at: http://www.nice.org.uk/nicemedia/live/11943/40097/40097.pdf

Rees R et al, 2012. Communities that cook. A systematic review of the effectiveness and appropriateness of interventions to introduce adults to home cooking. London: EPPI-Centre, Social Science Research Unit, Institute of Education, University of London. Available at: http://eppi.ioe.ac.uk/cms/Default.aspx?tabid=3322

Renfrew M et al, 2005. The effectiveness of public health interventions to promote the duration of breastfeeding. Systematic review Part 1. London: NICE. Available at: http://www.nice.org.uk/niceMedia/pdf/Breastfeeding_vol_1.pdf

Swann C et al, 2010. Health systems and health-related behaviour change: a review of primary and secondary evidence. London: NICE. Available at: http://www.nice.org.uk/media/0E6/62/SpecialReportHealthSystemsAndH ealthRelatedBehaviourChange.pdf

U.S. Department of Health and Human Services Community Preventive Services Task Force. Guide to Community Preventive Services. Promoting good nutrition. Available at: http://www.thecommunityguide.org/nutrition/index.html

Version 1 71 November 2012 Public Health Wales Observatory Health Improvement Review- Evidence Sub Group Appendix 1: Evidence grading scheme

A. This intervention is supported by NICE Recommended Intervention OR good evidence of its effectiveness systematic review, of moderate to good and is recommended for use in the quality studies, with meta-analysis of majority UK of studies favouring intervention effect B. This intervention is supported by systematic review of moderate to weak moderate to good quality evidence of studies with meta-analysis favouring its effectiveness intervention effect or narrative review including moderate to good quality studies with majority demonstrating positive effect C. There is some evidence supporting systematic review of moderate to poor quality the use of this intervention but it is not studies with majority favouring intervention conclusive D. The evidence is inconsistent and it Systematic review with significant weakness is not possible to draw a conclusion and high risk of bias (positive results) or but there is some evidence of effect review of moderate quality with inconsistent findings in favour of the intervention E. There is good evidence to suggest Moderate to good quality systematic review that this intervention has a sound of observational or qualitative studies which theoretical basis or that work in this suggest that the intervention addresses a area is likely to have an impact but significant risk factor or determinant of the this has not been demonstrated in behaviour of interest trials (this would apply particularly to pilot or novel interventions) F. The evidence is inconsistent and it Systematic review with studies judged as is not possible to draw a conclusion significant weak/risk of bias (evidence of no but it tends towards no effect effect) or review of moderate quality studies with inconsistent findings in favour of no effect G. There is some evidence systematic review of moderate to poor quality suggesting that this intervention is studies with majority favouring no effect ineffective but it is not conclusive H. There is moderate to good systematic review of moderate to weak evidence that this intervention is studies with meta-analysis, majority of unlikely to be effective studies in favour of control/no effect K. There is high quality evidence of NICE specifically recommends this ineffectiveness or a specific intervention should not be adopted or there is recommendation that these high quality review level evidence from meta- interventions should not be introduced analysis of good quality studies that in the UK demonstrates no effect Appendix 2: Implementation grading scheme

Current Implementation in Wales The intervention is funded for widespread national implementation in Wales (e.g. dedicated staffing, implemented in all HB areas (this can include targeted implementation)) OR this policy/legislative approach has been implemented in Wales Elements of the intervention are funded for national implementation, but implementation is dependent on local components which are variable Elements of the intervention are funded for national implementation, but monitoring information is not available to confirm widespread adoption/reach or information suggests implementation is sub-optimal This intervention is implemented locally in some areas but does not have a consistent national programme or a co-ordinated approach OR is implementation nationally on an ad-hoc basis P This intervention is currently being implemented on a pilot basis U Implementation status is unknown Implementation is not currently taking place

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