Promoting health at any and every weight.

eight y W Str lth at a eg e y H

‘W ?’ hy Weight

Part 2

January 2011 1 Contents Part 2

Page

1. Executive Summary 2

2. Expansion of cross-cutting themes (tree branches) 5 2.1 Maternal and Child Health 5 2.2 Childcare, Pre-schools and Schools 9 2.3 Neighbourhoods and Communities 13 2.4 Working Lives 17 2.5 Managing Healthy Weight 18 2.6 Lifestyle and Emotional Health 22 2.7 Equally Well 23 2.8 Media, Marketing and Food Supply 25 2.9 Evaluation 26

3. National Strategies which have an impact on Healthy Weight 27

4. Local Strategies which have an impact on Healthy Weight 29

5. Memberships of the original Healthy Weight Strategy Development Group 31

6. Mapping Exercise: Initiatives relating to Healthy Weight in NHS Highland area 32

7. Links to Argyll and Bute Council Single Outcome Agreement 43

8. Links to The Highland Council Single Outcome Agreement 45

9. References 48

10. Acronyms 51

1 Healthy Weight Strategy in NHS Highland - why weight?

Executive Summary

This Strategy is for everyone living and working in Highland, Argyll and Bute. The number of overweight and obese people living in the area has risen in recent years to a level where it has serious implications for the lives of individuals, the health systems and also the local economy. Action is required at all levels of planning, policy, service development and delivery in order to enable the population to move towards a healthy weight.

The Strategy aims to take an environmental view of the influences on weight which extend beyond individual responsibilities. Whilst the consequences of living in an environment which promotes over-consumption of food and sedentary behaviour are not easy to overcome there are approaches that can help. This Strategy aims to provide guidance for a co-ordinated, consistent, and comprehensive approach to promoting healthy weight in NHS Highland. Healthy weight outcomes are now embedded in the Single Outcome Agreements of Highland and Argyll & Bute Councils, and within Curriculum for Excellence that applies to all our schools.

The aim of the NHS Highland Healthy Weight Strategy is: • To improve the health and wellbeing of the people of Highland, Argyll and Bute by working towards targets which improve diet and physical activity levels.

The objectives of the NHS Highland Healthy Weight Strategy are: 1. To develop and implement initiatives which will contribute to the NHS Highland area population maintaining a healthy weight. 2. To increase the number of people who consume a healthy diet that is consistent with the UK Dietary Reference Values. 3. To increase the number of people who are physically active in line with the recommendations in the Physical Activity Strategy. 4. To make the greatest gains in those population groups who have the highest risk of obesity and poorest health outcomes. 5. To create environments which promote and encourage healthy eating and physical activity. 6. To develop and implement a care pathway for overweight and obese individuals.

It is underpinned by the following principles. The Healthy Weight Strategy and all interventions should: Incorporate a holistic view of health Promote participation Encourage self efficacy Be without Stigma Be sustainable Be evidenced Ensure Equality of access and opportunity

2 A number of themes which impact on weight have been identified: • Maternal and Child health • Childcare, Pre-schools and Schools • Neighbourhoods and Communities • Managing Healthy Weight • Workplace • Lifestyle and Emotional Health • Deprivation • Media, Marketing and Food Supply

The themes reflect the influences and settings as people live, work, learn, relax and play, and provide a framework for segregating these aspects in promoting healthy weight. The strategy also recognises the role of public health in achieving change, both within these themes and more broadly in terms of regulatory policy to support healthy eating and physical activity.

For each theme the current and planned activity, and the available evidence, has been examined and ‘Opportunities of Action’ have been identified.

Planning of activity will be carried out locally within the four Community Health Partnership areas, with support and guidance from NHS Highland Health Improvement function. Monitoring and evaluation of local projects and initiatives will be fed back centrally to assess ongoing longitudinal performance against each of the intended objectives and the overall impact of the strategy.

In order to make the greatest impact on the health of the population of the Highlands, Argyll and Bute this strategy has been formulated with 3 main approaches: 1. Behaviour change – prevention and treatment requires changes to organisational, group, family and individual behaviour. 2. Changing the environment – influencing behaviour through changes in urban design, transport, food access etc. 3. Changing biology – mproving maternal nutrition, promoting breast feeding and appropriate weaning.

Many important interventions which are likely to have a long term impact on obesity are already taking place in NHS Highland area. However, there are gaps, there are many opportunities for action, There is a need for further local overview of policies, evidence, action and interventions to promote healthy weight, and ongoing co-ordination and partnership development.

3 There are key requirements to developing this strategy further and intervening at the range of levels necessary:

• Gain commitment for and endorsement of the strategy from key planning partners, including identifying leadership and governance arrangements within each organisation and through a multi agency strategy group. • Sustained commitment from all public agencies to implement a cross-cutting strategic approach involving evidence based interventions which are likely to have an impact on healthy weight in the Highland and Argyll & Bute populations. • Weight problems should be considered a priority, and a healthy weight perspective should be maintained when developing strategies and policies and considering funding choices. Plans should be ‘weight-proofed’. • The involvement of both private and voluntary sectors. • Review of the membership and role of the healthy weight strategy group to ensure it is fit for purpose in delivering on this complex issue, including developing monitoring and evaluation of the strategy. • The Strategy needs to integrate with other joint plans and processes, and the opportunities for action should be considered at local level, with CHPs producing local action plans. • Direct engagement with communities should be considered a key element of developments and built in to local action plans. • Ultimately the work required for the implementation of a healthy weight strategy should be embedded throughout the policies and practices of all organisations who may have an impact on the health of individuals and communities, and the environment in which we live.

This document is just a beginning. Highland and Argyll & Bute can build on the good work already in progress. The Strategy Group looks forward to hearing the views of a wider range of partners.

4 2. Expansion of cross-cutting themes (tree branches)

In this section, the cross-cutting themes illustrated on the tree model are expanded upon. Each theme identifies certain aims. Each aim is followed by an outline of the evidence that underpins the call for action, a summary of current and planned activity within NHS Highland area, and a list of opportunities for action that will further that aim.

As with the mapping exercise that is featured in a later section, this is not intended to be an exhaustive analysis. It does, however, give a broad foundation to ongoing action planning that will improve policies, structures and services that support healthy weight.

2.1 Maternal and Child Health

Theme: Hospital and Health Care Practices; Trained and skilled staff; Maternal health.

Aim: Improve knowledge, skills and confidence of women to maintain a healthy weight pre, during and after pregnancy.

Evidence • There is currently no UK evidence-based guidance on appropriate weight gain in pregnancy. Recommendations from America give some guidance (Rasmussen and Yaktine, 2008). • Appropriate weight gain does result in fewer complications and better maternal and infant outcomes (Cedergren 2006; Stuart Ramsay and Greer, 2009). • Confidential enquiry into maternal and child health Saving Mothers’ Lives (CEMACH, 2007) reported over half of all the women who died from direct or indirect causes, for whom information was available, were either overweight or obese. • Research demonstrates that women want practitioners to address the issues of obesity and weight management directly and support them in a non-judgemental way (Som, 2009). • The importance of vitamins – especially vitamin D and folic acid (NHS Highland, 2010)

Current and Planned Activity • Monitoring of weight before, during and after pregnancy (Maternal and Child Nutrition Best Practice Guidance, May 2010). Provision of appropriate advice, interventions and resources that incorporate both nutrition and physical activity before, during and after pregnancy (Maternal and Child Nutrition Best Practice Guidance). • Increase accessibility and uptake of Healthy Start. • Delivery of effective training and support to Health Professionals focusing on motivational interviewing and negotiating behaviour change (Maternal and Child Nutrition Best Practice Guidance). • Ensure that all prenatal and pregnant women are informed about healthy weight management (Maternal and Child Nutrition Best Practice Guidance). • Ensure appropriate links with care pathways (Maternal and Child Nutrition Best Practice Guidance).

5 Opportunities for Action • Implement the Healthy Weight Management Pathway, which includes weight management during pregnancy. • Include maternal health as a strand of a Hospital Food and Health Policy and QIS Food, Fluid and Nutritional Care Standards. • Implement Healthy Weight in pre-conception and pregnancy pathway and accompanying schedule of care.

6 Theme: Maternal and Child Health: Breastfeeding; Healthy Start Scheme; Families; Parenting skills.

Aim • Increase the number of babies who are breastfed and weaned appropriately. • Ensure optimum uptake of the Healthy Start Scheme. • Improve parent knowledge, skills and confidence in supporting the development of their children’s healthy eating and physical activity habits to promote growth and development and healthy weight.

Evidence • The importance of breastfeeding as a means of reducing the risk of childhood obesity was felt to warrant more emphasis; and more support and advice around breast feeding and weaning should be provided (Scottish Executive 2006). • Breastfeeding protects against the development of obesity in children, and children who are weaned no earlier that 4 months have a lower risk of becoming overweight (Various; including Harder et al, 2005). • The World Health Organisation (WHO) have published new growth standards (used in Scotland from January 2010) based on a study of more than 8,000 breastfed babies from across 6 countries, and suggests that growth of all babies should be on a breastfed baby chart. Breastfed babies are less likely to be fat in later life and develop complications such as diabetes and coronary heart disease. • The early introduction of food (weaning) other than breast milk/infant formula and water is associated with excess weight gain. It is recommended that weaning should not commence before 6 months (Department of Health 2002). • Parents are a key influence as their child’s first educator and role model are recognised in national strategies (Early Years Framework, Scottish Government, 2008), (Delivering a Healthy Future, Scottish Executive 2007).

Current and Planned Activity • Implementation of the Breastfeeding Strategic Framework 2010-2013, the Highland Infant Feeding Strategy (NHS Highland) including use of appropriate growth charts. • Implementation of Maternal and Child Nutrition Best Practice Guidance . • Continued development of the ‘Baby Friendly Initiative’ throughout Highland (NHS Highland). • Peer Supporters network. • Development of parenting support framework (For Highland’s Children 3 - FHC3). • The development of Public Health Nurses (NHS Highland). • Implementation of Highland Information trail: Fun First Foods, Ready Steady Baby! and Ready Steady Toddler distributed to all parents. • Increase accessibility and scope of Healthy Start Scheme • Play@home programme promoted to parents (NHS Highland, The Highland Council). • Food First (Partnerships for Wellbeing). • Network of breastfeeding management trainers. • Welcome Baby Sticker Scheme – promoting and supporting breastfeeding in public places. • Delivery of effective training and support to health practitioners and partner agency staff focusing on Negotiating Behaviour Change.

7 Opportunities for Action • Extend the number and reach of community initiatives which work with families on healthy food access and availability. • Ensure that Healthy Start vouchers are redeemable at community food initiatives/community shops and that fruit and vegetable choices are improved. • Implement infant feeding (birth-6 months) pathway and weaning (6-13 months) pathway (Maternal and Child Nutrition Best Practice Guidelines). • Food preparation classes.

8 2.2 Childcare, Preschool and Schools

Theme: Childcare, Preschool and School: food in schools; curriculum opportunities.

Aim Improve school, preschool and childcare environments that promote healthy eating and physical activity.

Evidence • The preschool years are known to be a key stage in the life course for shaping attitudes and behaviours, and childcare providers may play an important role by providing opportunities for children to be active and develop healthy eating habits and by acting as positive role models (NICE, 2006). • Recommendations in Early Years Framework (Scottish Government & COSLA, 2008) Healthy Eating Active Living Action Plan (Scottish Government, 2008), Curriculum for Excellence (CfE). • Healthy Weight interventions that incorporate fun physical activities such as dance or martial arts classes and food preparation lessons are more effective than standard programmes in helping overweight children lose weight (Summerbell et al 2005). • Almost all children are in school, most 3 and 4 year olds attend pre-school education and the number of childcare services is growing. These settings offer a major opportunity to encourage good eating patterns and physical activity. • Nutritional Guidance for Early Years; Scottish Executive 2006. • Schools (Health Promotion and Nutrition) (Scotland) Act 2007.

Current and Planned Activity • Health Promoting Schools development and compliance with the Schools Health Promotion and Nutrition (Scotland) Act. In particular involving the wider school community in a whole system approach. (Your Choice Implementation Plan - YCIP). • A framework for the Development of Health and Wellbeing across the Curriculum in Argyll & Bute Schools. • Implementation of Early Years pathway (13 months- 5years), (Maternal and Child Nutrition Best Practice Guidance). • Provision of education on living skills that include support with food preparation and developing healthy eating habits (Maternal and Child Nutrition Best Practice Guidance). • Promotion for the ban on vending machines in schools that sell unhealthy food and drink products (YCIP). • Implementation of Promoting Health and Wellbeing in 0-5 years settings - a guide. • Inclusion of home economics within schools curriculum as part of CfE. • Provision of education in infant feeding for all children (YCIP and FHC3 and Argyll & Bute Integrated Children’s Services Plan (ABICSP.) • Food and behaviour training for teachers (YCIP). • Free fruit in pre-schools and schools. • Play@home programme promoted to parents. Trainer network being established.

9 Current and Planned Activity (continued) • Participation in mini X-programme to support health and wellbeing outcomes in CfE. • Implementation of Maternal and Child Nutrition Best Practice Guidance. • Active Schools programmes and Physical Activity and Sports Strategies. • Rain Starts Play - all Highland pre-schools have waterproof suits and wellies to enable outdoor play in most weathers. • Delivery of effective training and support to health practitioners and partner agency staff focusing on Negotiating Behaviour Change.

Opportunities for Action • Cascade training by play@home trainers • Sustain and develop Fun with Fruit initiative. • Support school nurses in developing their public health role with particular reference to interventions which target sedentary behaviour. • Nutrition and physical activity interventions targeted at young people who experience social deprivation. • Review of all methods and materials used with young people, including excluded young people, young people living with physical and/or learning disabilities and develop interventions appropriate to a range of young people. • Development of mental health promotion training for teachers and others.

10 Theme: Childcare, Preschool and Schools: the wider school community.

Aim: Enhance the use of schools, pre-schools and childcare services as an avenue to strengthen the knowledge and skills of the wider community regarding healthy eating and physical activity.

Evidence • Schools are encouraged to consider the health related needs of the whole school community and work closely with partners to develop an integrated response. Evidence base suggests that if a holistic vision of health is adopted by all partners almost every aspect of an Integrated Community School has an impact in some way on the health and wellbeing of pupils, families, staff and the wider community (Scottish Office, 1998).

Current and Planned Activity • Provision of information and support for parents, grandparents and carers of children under 5 on healthy eating (Maternal and Child Nutrition Best Practice Guidance, and YCIP). • Play@home Pre-school Book used as nursery-home link resource. • Implementation of Promoting Health and Wellbeing in 0-5 years settings: a guide. • All Highland Council schools are Health Promoting Schools (YCIP). • All Argyll & Bute schools achieved health promoting schools status during 2007. • Support the use of school facilities as a community resource for activity and cooking sessions. • Distribution of guidance on healthy preparation of snacks, home-baking and celebration food, and also food and drink for off-site excursions and outdoor learning. • X-programme, child and family healthy lifestyle intervention. • Active Schools support of in-school activities, volunteer coaches and community clubs. • Implementation of Maternal and Child Nutrition Best Practice Guidance to health professionals and relevant partner agency staff engaging with women and young children.

Opportunities for Action • Evaluate the options for wider public/parent involvement in the management of healthy weight. • Collate local information from Community Health Partnerships, School Health Surveillance and other sources and use to target interventions. • Increase links between healthy weight and parenting skills support.

11 Theme: Childcare, pre-school and schools: play; sponsorship; teachers/carers knowledge and capacity; fundraising.

Aim: Enable education and childcare workers to provide healthy eating and physical activity programmes. Protect children and young people from aggressive advertising and marketing techniques.

Evidence • Effective early education and childcare requires a well qualified workforce; and staff and carers will have differing training needs (Nutritional Guidance for Early Years, Scottish Executive 2006). • A 2001 study shows that between 95% and 99% of the food advertising during children’s programming is for fatty and/or sugary and/or salty foods. Fatty and sugary foods are advertised in proportions up to 11 times higher than that recommended in official dietary guidelines, whilst fruit and vegetables are usually not advertised at all. In addition, adverts for unhealthy foods are shown with much greater frequency during children’s television compared with adult viewing periods (Sustain 2001). Though there have been positive developments in legislation controlling the advertising of junk food, the familiarity among children remains high.

Current and Planned Activity • Continuation of support for the Health Promoting Schools Agenda in promoting good nutrition, especially in the wider school community and out of school activities (YCIP). • Ensure that nutrition education in schools is up to date and relevant. • Curriculum for Excellence (The Highland Council and Argyll & Bute Council). • Start to Play training available, linking to play@home. • Implementation of Promoting Health and Wellbeing in 0-5 years settings: a guide.

Opportunities for Action • Obtain agreement that schools will no longer accept sponsorship from manufacturers associated with unhealthy foods. • Produce guidance for the wider schools’ community on ethical fundraising.

12 2.3 Neighbourhoods and Communities

Theme: Neighbourhoods and Communities: recreation and sports facilities.

Aim: Increase the number of children and young people participating in regular exercise.

Evidence • Scottish Perspective on NICE public health guidance 17 (NICE 2009). • There is a recognised drop-off in sports participation in girls aged 11-15 years (Scottish Health Survey 2008). • UK Playday survey (2006) carried out by the British Market Research Bureau showed that 80% of 7-14 year olds prefer outdoor activities to playing indoors.

Current and Planned Activity • Establishment of cycle proficiency training in schools (Your Choice Implementation Plan (YCIP). • Extension of the Highlife scheme to include additional community leisure facilities. • Continuation and development of the ‘Active Schools’ programme • Implementation of Highland’s Play Strategy (YCIP and FHC3). • Review of PSE within school (YCIP, FHC3 and Argyll & Bute Schools Framework). • Increase the number of youth centres and youth initiatives (YCIP, FHC3 and ABICSP). • Effective inter-agency activity involving Public Health and Council services to deliver health and wellbeing policies and plans such as tackling obesity and low levels of activity in young people (FHC3 and ABICSP). • Development of Highland and Argyll & Bute Physical Activity Strategies. • Argyll Active rolling out across Argyll & Bute.

Opportunities for Action • Explore the opportunities for the provision of safe and supportive activity sessions for over weight children and teenagers, based on a needs assessment. • Conduct a consultation with teenage girls to determine which types of activity would be of inter- est to them. Develop a programme of activities based on the consultation. • Continue to support the development of the Highland Youth Strategy. • Assist with training to allow private leisure facilities to provide tailored programmes for 12-16 age group.

13 Theme: Neighbourhoods and Communities: planning; transport; walkability

Aim: Improve opportunities in Highland for individuals to use active transport

Evidence • Local authorities (including planning, transport and leisure services) should engage with the local community to identify environmental barriers to physical activity and healthy eating. (NICE Guideline 43). • Local authorities should work with local partners, such as industry and voluntary organisations, to create and manage more safe spaces for incidental and planned physical activity, addressing as a priority any concerns about safety, crime and inclusion. (NICE Guideline 43). • Towards a Healthy Weight Action Plan for Scotland; A report from NHS Scotland 2006. • The design of all buildings and spaces should encourage users to be more physically active (NICE, 2006). • The Scottish Executive’s Planning policy consultation document SPP11. • Local authorities and their partners are strongly encouraged to monitor and evaluate the impact of all local action (including action that is not directly related to health). The positive and negative impact of all policies should be considered. The evaluation of projects should be an integral part of funding (NICE, 2006). • Parents of 10-12 year old children who agreed that there was heavy traffic in their local streets were more likely to be overweight or obese. This suggests that among this age group parental perceptions of heavy traffic on local streets and concern about road safety may be indirect influences on overweight and obesity (Timperio et al 2005).

Current and Planned Activity • Promote the benefits of walking and cycling to school, work or services, not only as an option and as a recreational pastime, but as a healthy lifestyle choice (HC Access Strategy). • Promotion of the Highland and Argyll & Bute area as a walking, cycling, horse riding and water sport destination (HC Access Strategy, Argyll & Bute Sport and Physical Activity Strategy). • Work with employers to develop ‘Green Travel Plan’s or ‘Walk to Work’ schemes which can be used to encourage employees to adopt more active lifestyles as well as contributing to the sustainable transport agenda. (HC Access Strategy). • Encourage young people to walk or cycle to school through the development of schemes such as Safer Routes to School which can establish patterns of physical activity from an early age (HC Access Strategy). • Cycle proficiency training in schools (YCIP and FHC3). • Each primary school to have a Junior Road Safety Group (YCIP and FHC3). • Support Paths for All projects, Step It Up Highland and other projects such as Healthy Working Lives. (HC Access Strategy).

14 Opportunities for Action • Development of Active Travel plans by organisations. • Development and extension of walking and cycling routes. • Health impact assessments of development plans. • Adopt Health Promoting Health Service Framework which incorporates the impact of the environment on health improvement.

15 Theme: Neighbourhoods and Communities: community clubs and facilities

Aim: Support and encourage sedentary individuals to become more physically active

Evidence • Prescribing exercise to prevent a further rise in childhood obesity could be very effective (Carrel et al 2004). • SIGN National Clinical Guidlines 115, 2010. • Let’s Make Scotland More Active, 2003 + 5 Year Review, 2009 • Scottish Perspective on NICE guideline 8, Physical activity and the environment: promoting and creating built or natural environments that encourage and support physical activity, 2008

Current and Planned Activity • Argyll & Bute Council and The Highland Council Physical Activity and Sport Strategies. • High Life Scheme. • Step It Up Highland and Paths for All Health Walk initiatives in Argyll & Bute. • Lifestyle Health Checks. • Local and national campaigns. • Provision of standard information about path networks including suitability for different users, length, gradient and links to points of interest (Core Paths Plans HC and A&BC). • Access Officers and Countryside Rangers will work closely with health professionals to ensure that the (path) network is used as a tool for health promotion strategies. This will develop and direct awareness of the benefits of walking, cycling and horse riding towards the least physically active individuals.

Opportunities for Action • Support Leisure Centres to improve access and availability of activities for those who have physical disabilities. • Implement national activities locally – for example Active Nation personal pledges. • Evaluation and development of active referral scheme. • Continue to develop Step It Up Highland and similar initiatives in Argyll & Bute • Ensure urban and natural environments provide sustainable opportunities for people to be active. • Develop community based self-care lifestyle programmes. • GPs in the area should be encouraged, where appropriate, to recommend exercise to patients as part of the general Practitioners Active Referral Scheme (e.g. Argyll Active) in conjunction with other stakeholders.

16 2.4 Working Lives

Theme: Workplace

Aim: Increase the proportion of workplaces supporting employees to be physically active and eat healthily through policies, programmes and supportive environments for all staff.

Evidence • Workplaces should provide opportunities for staff to eat a healthier diet and be more physically active. As such, all food provision for staff and clients should actively and continuously promote healthier choices, in line with existing guidance from the FSA. Workplaces should implement tailored physical activity programmes, which include ensuring a supportive physical environment, working practices and policies and recreational opportunities, use of leisure facilities (NICE, 2006). • Occupational health services are often poorly funded, especially in small organisations. They are often overstretched and not always well advertised or accessible. Most of the workforce in Britain does not have access to Occupational Health Services (Gruer, 2006). • There is considerable cost to the economy and individual organisations as a result of days taken off work for physical illness and depression by people who are overweight. If the rise of obesity continues, the combined direct and indirect costs may rise to an estimated £3.6 billion per year in England in 2010 (National Audit Office, 2001). • Scottish Breastfeeding Act (2005).

Current and Planned Activity • Continuation and development of Healthy Working Lives initiative. • Cycle to Work Scheme. Supporting workplaces to subsidise the purchase of bicycles for staff. • Develop ‘Green Travel Plans’ or ‘Walk to Work’ schemes which can be used to encourage employees to adopt more active lifestyles (HC Access Strategy). • Encouraging workplaces to provide cycle to work incentive schemes e.g. cycle storage, showers and changing facilities (Healthy Working Lives). • Promoting breastfeeding within organisations so that they will support and provide facilities for a mother to continue breastfeeding on return to work.

Opportunities for Action • Encourage stair use and review building codes to allow better access and availability of stairs (within current disability legislation requirements) (Gruer, 2006). • Support the Healthy Working Lives initiative; ensure HWL advisors incorporate healthy weight management during advisory sessions with employers. • Invite employers to awareness raising event. • Work toward the Healthy Living Award in all relevant premises. • Development of guidance for toolkit regarding workplace weight management. • Delivery of weight management support by Occupational Health Departments. • Encourage and provide guidance on weight management in the workplace. 17 2.5 Managing Healthy Weight

Theme: Managing Healthy Weight: referral opportunities; access to NHS services.

Aim: All patients in NHS Highland area should have equitable access to NHS weight management services through the implementation of the Adult Patient Pathway for Healthy Weight Management. Develop an effective Healthy Weight Management patient pathway for children and young people.

Evidence • SIGN 115 Management of Obesity. • Weight loss programmes (including commercial or self-help groups, slimming books or websites) are recommended only if they: are based on a balanced diet; encourage regular physical activity; expect people to lose no more than 0.5 -1kg a week (NICE, 2006). • The Counterweight Programme supports the delivery of a weight management programme within GP practices, whereby a dietitian provides training and mentoring for practice staff who deliver individual and group interventions. • Family based interventions are more effective than work with individual children.

Current and Planned Activity • The Healthy Weight Management pathway details treatment options, principles of treatment, and referral pathways for patients in NHS Highland. • Counterweight is being rolled out through GP practices in NHS Highland (target 40 practices by 2011) • Well North Healthy Weight, a community development approach to weight management in primary care, is underway in Skye and Lochalsh (2009-2011). • A primary care approach to weight management in anticipatory care, incorporating a community participation element. • Childhood healthy weight management pathway group has been established. • Highland Infant Feeding Strategy acts on breastfeeding and appropriate nutrition for the under fives.

Opportunities for Action • Development of the role of Dietetic mentors within the Patient Care Pathway. • Include aspects of healthy weight management in the development of the role of Community Health Nurses. • Support implementation of the pathway in GP practices. • Develop a proposal for a secondary care service (psychologist and dietetic) for patients previously referred directly to tertiary care. • Development of services/interventions for the management of children who are severely obese. • Ensure that local developments are well co-ordinated and linked into regional and national developments and guidelines. • Identify and define links between GIRFEC, Hall 4, FHC3, ABICSP, YCIP and the patient pathway. • Research and develop innovative methods to support patients to maintain a healthy weight e.g. internet. • Engage with GP Practices and healthcare staff who have, to date, not shown an interest in healthy weight. 18 Theme: Managing Healthy Weight: Professional knowledge and skills.

Aim: Promote and support practitioners to effectively implement the Adult Patient Pathway for Healthy Weight Management including the use of the Healthy Weight Toolkit.

Evidence • Obesity education for all health care professionals, including training on psychological models of motivation and information on support options available locally; incorporating modules on physical activity and diet in NVQs. In particular, obesity is a topic missing from current dietetic training. Follow-up support post training was thought to improve implementation of changes to practice (Gruer, 2006)

Current and Planned Activity • The Healthy Weight Toolkit will provide guidelines and resources for a health behaviour change approach to healthy weight • Training in Negotiating Behaviour Change is available and a topic specific course will be developed. • Counterweight, which is being rolled out to 40 practices in NHS Highland, incorporates training in Health Behaviour Change knowledge and skills. • Training will be delivered to NHS Highland and partners to support the implementation of the Maternal and Child Nutrition Best Practice Guidance.

Opportunities for Action • Identify training needs of practitioners. • Deliver effective training which meets specified competencies. • Develop a network of Health Behaviour Change trainers. • Ensure the effective dissemination of the Toolkit and availability on the Intranet • Toolkit information to include directional information on where to access health behaviour change training.

19 Theme: Managing Healthy Weight: access to information.

Aim: Encourage and support the community to be effectively informed about current evidence-based weight management strategies.

Evidence • Plethora of ‘diet’ stories, products (pills, drinks, bars), slimming groups and other information in the media and community.

Current and Planned Activity • YCIP – Work in collaboration with Highland libraries to ensure access to appropriate, recommended supporting resources and information on health improvement. • Health Information and Resources (HIRS) Information Point at Raigmore Hospital.

Opportunities for Action • Development of a directory of Healthy Weight services for both the public and health professionals, as part of the Healthy Weight Toolkit which may be distributed via the web. • Toolkit to include guidance on weight management strategies. • Ensure that the ‘Healthy Weight Toolkit’ links with the local opportunities. • Development of a checklist of key components for ‘weight management’ groups.

20 Theme: Motivation and Emotional Wellbeing.

Aim: Promote holistic approach to healthy weight management that takes account of emotional wellbeing.

Evidence • Multi-component interventions are the treatment of choice. These should encompass behavioural treatments to increase physical activity and decrease inactivity, improve eating behaviour and quality of diet (SIGN 115). • Combining dietary therapy with increased physical activity and/or behavioural therapy has been found to increase effectiveness of several different outcomes: the amount of weight loss, long term weight maintenance and prevention of type 2 diabetes and high blood pressure. (SIGN 115)

Current and Planned Activity • Counterweight training to primary care settings throughout NHS Highland • Exploration of the opportunities and evidence for emotional support for young people who are overweight (YCIP, FHC3 and ABICSP). • Provision of training in Negotiating Behaviour Change. • All pathways are based on a Health Behaviour Change approach

Opportunities for Action • Roll out training in brief interventions and Motivational Interviewing to health professionals and community development workers involved in weight management (Health Behaviour Change). • Develop a network of Health Behaviour Change trainers. • Raising the Issue training for practitioners both general, core skills and topic specific. • Toolkit information to include directional information on where to access health behaviour change training. • Psychological assessments to be included within Patient Pathway. • Challenge stereotypes associated with overweight and obesity.

21 2.6 Lifestyle and Emotional Health

Theme: Lifestyle and emotional health.

Aim: Increase the number of adults in Highland who adopt healthy behaviours.

Evidence • Heavy alcohol intake (≥30g/day) contributes directly to weight gain and obesity irrespective of the type of alcohol consumed (Wannamethee et al 2003). • The experimental metabolic evidence suggests that the consumption of moderate amounts of alcohol has to be accounted for in the energy balance equation and may represent a risk factor for the development of a positive energy balance and thus weight gain (Suter, 2005). • Research shows that people who currently smoke had higher waist to hip ratios and bigger waists than former smokers and people who have never smoked. People who have smoked heavily or for long periods of time may need a longer period of smoking cessation than other smokers before they bring their waist to hip ratio down (Dobson, 2005). • Whilst the relationship between self-esteem and obesity has not received a great deal of empirical evaluation using strong research methodologies, there is evidence from psychological studies that overweight adults and adolescents are more likely to experience lack of confidence, low self esteem and depression (Johnston et al, 2004; Erermis et al, 2004). This may also be exaggerated by stigma and other barriers experienced by overweight people.

Current and Planned Activity • Collaboration with Argyll & Bute and Highland libraries to ensure access to appropriate resources and information on health improvement. • HADPs and ABADP strategy. • Healthy living advice guidelines are included within a Health Weight Management Toolkit and are accessible to the public. • Public Health campaigns. • Extension of training to practitioners working in smoking and alcohol services.

Opportunities for Action • Evaluate literature available within Health Information and Resource service. • Ensure health implications are included within education and prevention work of HADP and ABADP delivered to schools, community groups and workplaces. • Awareness raising campaigns. • Local and national communication strategies. • Identify or develop community based programme for self-care and lifestyle change.

22 2.7 Equally Well

Theme: Equally Well: access to locally grown food; cost of food.

Aim: Improve the access to appropriate and affordable food supplies, in particular for vulnerable groups and in rural areas.

Evidence • All community programmes to prevent obesity, increase activity levels and improve diet should consider the fundamental concerns of local people from the outset, including cost and availability; pre-existing concerns such as perceived poorer taste of healthier foods and confusion over mixed messages, and perception of risk associated with walking and cycling (NICE 2006). • There is a marked difference in diet between affluent and deprived areas, demonstrated clearly by fruit and vegetable consumption (Scottish Government, 2008). • Healthy Eating, Active Living describes the development of a National Food and Drink Policy as providing us with an opportunity to reshape and influence the environment in which food is produced, processed and eventually finds it’s way onto our plates (Scottish Government, 2008).

Current and Planned Activity • Argyll & Bute Food and Health Plan (2007). • Food First community food project in Inverness (seeking continued funding). • Green Tree Community Café in Rothesay, Isle of Bute. • Development of growing, community supported agriculture and social enterprise schemes.

Opportunities for Action • A replacement structure for Highlands and Islands Local Food Network: supporting the production of local food for local communities. • Develop and continue to support food co-operatives and community food initiative mobile vans. • Support current food initiatives and replicate in other areas. • Assess healthy food availability for Healthy Start.

23 Theme: Equally Well: health promoting environments.

Aim: Increase the opportunity for physical activity, including sport, recreation and play in communities.

Evidence • Scottish Perspective on NICE Guideline 8, Physical activity and the environment: promoting and creating built or natural environments that encourage and support physical activity, 2008 • Physical activity does not need to be strenuous to have significant effects on people’s health and general wellbeing and productivity. Let’s Make Scotland More Active (Scottish Executive, 2003) suggests the emphasis should be on: be active most days, moderate activities are good for you and be active for at least 30 minutes in total or 1 hour if you are a child or young person. • To meet the 2022 physical activity targets, the percentage of the population meeting current recommendations will need to increase annually by an average of 1%. (Scottish Government 2008).

Current and Planned Activity • Increase participation in sports, arts and cultural activities. • Encourage and support community managed facilities to promote and extend the High Life Leisure Scheme • Continued extension of High Life Scheme to private facilities – for example it now includes MacDonald Highland Resort in Aviemore • Step It Up Highland and Paths for All Health Walk initiatives in Argyll & Bute. • Physical Activity and Sport Strategy for The Highland Council and Argyll & Bute Council. • Highland Homeless Active Referral Scheme.

Opportunities for Action • Provide outreach support staff to enhance opportunity for accessing leisure and recreational facilities in the community, for example: - interpreting for deaf people at exercise classes - promoting activity using literature with large print - where necessary via vehicles adapted for wheelchair users - review of public transport to access leisure facilities

24 2.8 Media, Marketing and Food Supply

Theme: Media, marketing and food supply.

Aim: The population is well informed about healthy eating and physical activity though the promotion of consistent messages in NHS Highland area, especially in public sector organisations. Increased community awareness of the importance of ‘health at any and every weight’. Utilise social marketing techniques to assist balanced messages to populations

Evidence • Environmental influences on patterns of food and drink purchase and consumption and of physical activity uptake are varied and complex (Foresight 2007). • Sustain, TV Dinners, 2001.

Current and Planned Activity • Health Promoting Health Service. • Implementation of the ban on children’s TV advertising of ‘junk food’ before the 9pm watershed.

Opportunities for Action • Staff catering facilities within the NHS, The Highland Council, Argyll & Bute Council, Northern Constabulary, appropriate part of Strathclyde Police Force, HM Prison and Higher Education premises should be supported in applying for the Healthy Living Award. • Catering guidelines should be developed and implemented for staff functions (working lunches, training events, etc). • Support the national campaign with local work in youth and community organisations. • Explore the value of social marketing in developing messages/campaigns on eating better and increasing physical activity.

25 2.9 Evaluation

Theme: Evaluation.

Aim: Contribute to the evidence base on lifestyle interventions by ensuring that an evaluation process is included in all projects and initiatives.

Evidence • “A co-ordinated research strategy is desirable to answer key research questions relating to effectiveness, including those concerning inequalities dimensions and with attention to intended/ unintended psychological outcomes” NHS Health Scotland comment on NICE Guideline 43 (2006). • There is a need for evidence on the effectiveness of multi-component interventions among key at risk groups/vulnerable groups and people at vulnerable life stages (for example, women during and after pregnancy and people stopping smoking). There is a pressing need for controlled trials of tailored interventions for these groups with comparison to the general population. (NICE 2006). • Gaps in data, particularly around specific age groups e.g. 16-25 (NHS Scotland 2006). • There is very little good data on the best way of preventing and treating people who are overweight. Despite the long history of research into this issue and the vast array of studies, most of the funding seems to have been directed into understanding the causes of overweight. This has resulted in a very poor arsenal for tackling the problem of overweight in society. (Tayside 2005). • Small, local projects are not often evaluated and this limits their implementation elsewhere.

Current and Planned Activity • Development of common performance assessment framework for use across four CHP’s and Raigmore to monitor impact of Healthy Weight Strategy. • NHS Highland Lifestyle survey. • Use of Logic Modelling.

Opportunities for Action • Development of a Highland monitoring and surveillance system that looks at nutrition and physical activity. • Identify data available from Scottish Health Survey and other national sources including Child Health Surveillance System. • Evaluate the effectiveness of weight management initiatives. • Examine the evidence base for interventions that lead to health improvements rather than weight loss. • Ensure that all new healthy weight initiatives and interventions are developed on a sound evidence base. • Develop a co-ordinated research strategy to answer key questions relating to effectiveness. • Identify data available through primary care records. • Obtain statistics from fitness testing in schools. • Develop evaluation techniques that focus on measuring improvements in eating habits, activity patterns, self esteem and self-efficacy rather than on weight. • Identify intermediate performance measures. • Identify measures to capture qualitative as well as quantitative data. 26 3. National Strategies which have an impact on Healthy Weight

Early Years Framework Focuses on giving all children the best start in life from Government (2009) through to practitioners and service provision. Commitments include providing children with good nutrition and diet, and opportunities for play and physical activity.

Maternal and Infant Scottish Government Strategy that build on the work of CEL36 – Feeding Strategy improving the nutritional and healthy weight outcomes for women (forthcoming) and children from pre-conception to early years.

Preventing Overweight COSLA and Scottish Government document outlining the role and Obesity in Scotland: of local authorities in supporting healthy weight. Cuts across all A Route Map Towards departments and services, aimed at decision-makers in central and Healthy Weight (2010) local government, emphasises working together across all public sector, third sector and business.

NHS HEAT Targets and H3 – child healthy weight interventions. Family behaviour change Chief Executive Letters (for through building confidence, healthy eating, increased physical review 2011) activity and decrease sedentary behaviours. H7 – Breastfeeding. Target of 33.3% of new mother exclusively breastfeeding at 6-8 weeks. CEL14 – Health Promoting Health Service Action in Acute Care Settings. Boards are to implement specified health promoting actions to ensure that acute care settings provide targeted action to improve health: including breastfeeding; food and health; and health at work. CEL 36 - improving the nutritional and healthy weight outcomes for women and children from pre-conception to early years.

Let’s Make Scotland More Adopts national targets, over a 20 year period, on activity levels for Active - Physical Activity adults and children with four implementation plans: Active Homes, Strategy(2003) Active Schools, Active Communities and Active Workplaces. A 5- year review (released 2009) confirmed the physical activity targets and identified some progress towards achieving them, but an acceleration of progress is required to meet the increases specified.

The 2014 Games Legacy This features a key programme: Active Nation. This encourages people to be more active in their daily lives, through personal pledges. It includes any kind of physical activity (walking, gardening, dancing, organised sports).

Schools (Health Promotion Legislation to ensure the provision of nutritious food in schools for and Nutrition) (Scotland) all children within the ethos of health promoting schools. Act 2007

27 Better Health Better Has three main themes including helping people to sustain and Care Action Plan (2007) improve their health, particularly in disadvantaged communities. This sets out actions to increase healthy life expectancy; break the link between early life adversity and adult disease; reduce health inequalities and risks factors to a healthier life. Specific actions include the improvement of Scotland’s diet through a Food and Health Delivery Plan (including the promotion of infant nutrition) and the development of a national food policy; work with partners to address the environmental influences on obesity; extension to free school meals entitlement (subject to legislation); piloting new approaches to anticipatory care; and rolling out health promoting interventions within acute care settings.

Healthy Eating Active An action plan to improve diet, increase physical activity and tackle Living (2008) obesity (2008 – 2011)

Eating for Health 2004 A strategic framework to be used as a basis for developing further food and health policy and to guide national and local food and health action plans. It should inform and co-ordinate work between partner agencies, local government and communities.

Review of the Scottish An independent review of the progress and impacts of the 1996 Diet Action Plan (2006) plan which set targets to change consumer demand, food supply, training and education, influences on diet. The review details significant progress in breastfeeding, community food initiatives, health education and food in schools but poor progress in achieving dietary targets, increasing fruit and vegetables intakes, reducing the production of dairy fat and improving basic nutrition training in the food industry.

Improving Scotland’s A strategic framework for health improvement policy which sets a Health: The Challenge vision of health to 2020 with 4 pillars (early years, teenage transitions, (SE 2003) workplace, communities) and seven special focus programmes including diet/healthy eating and physical activity.

Delivering for Health The programme set out in this document describes in practical terms (2005) what action we will take to turn the Scottish Government’s vision of the health service into reality.

28 4. Local Strategies which have an impact on Healthy Weight

Single Outcome Contains the outcomes which each local authority seeks to achieve Agreements (SOAs) with its community planning partners. These reflect local needs, 2008 circumstances and priorities related to the Scottish Government’s 15 national outcomes. These outcomes include: our children have the best start in life and are ready to succeed; we live longer, healthier lives; we have tackled the significant inequalities in Scottish society. Both the Argyll & Bute SOA and the Highland SOA were submitted to the Government in June 2008. They reflect a range of partnership targets and indicators on improving health and reducing inequalities. The second iteration of the SOAs is to be presented to the Government by March 2009 and will reflect wider partnership involvement. The second Highland SOA will serve as the new Community Plan for the Highland area.

Fairer Argyll & Bute Plan An integrated plan which incorporates actions on the wider socio- 2008-2011 (FAB) economic factors that influence health, as well as lifestyle behaviours. It will replace the former Regeneration Outcome Agreement and the JHIP, and provide a strong focus on tackling health inequalities. The FAB plan sits within the SOA. However there are some health improvement areas that are within the main body of the SOA but not specifically in the FAB plan. An implementation plan is currently being considered that will encompass health improvement actions that require to be delivered, whether in the FAB plan section of the SOA or the wider SOA itself.

Argyll & Bute Sets out the key priorities for the Community Planning Partnership for Community Planning the next 10 years and expresses the commitment to provide for the Partnership Community wellbeing of communities in Argyll and Bute Plan (2007 -17)

Argyll & Bute Food and Aims to promote health and quality of life through an integrated, Health Strategic Plan comprehensive food and health plan in the local community. The (2007) benefits of increasing the amount and distribution of locally grown food, especially fruit and vegetables encompass many aspects of health including nutritional, environmental, social and cultural with direct and indirect economic benefits for the whole community.

Active Schools Action Local partnership agreements between Sport Scotland and local Plans authorities set out the specific local targets and action plans for promoting physical activity to schools in Highland and Argyll & Bute

Local Health Plan Sets out Highland’s progress against the national and local priorities and targets and the strategy for achieving these. It is NHS Highland’s response to Delivering for Health which sets out the Framework for Service Change in Scotland

29 Local Delivery Plan Describes the implementation and delivery of the Local Health Plan.

Your Choice to Healthy ‘Your Choice to Healthy Living’ has involved NHS Highland and Living The Highland Council in the development of a 40 point plan that covers a wide range of health improvement activities centred on school communities. A significant section of the ‘Your Choice’ plan also embodies the implementation of ‘Hungry for Success’; the Scottish Executive’s national policy on improving school nutrition, and also The School Food and Health Promotion (Scotland) Bill. The implementation of Your Choice is led and monitored by the Health Action Group (HAG) a multi agency steering group.

For Highland’s Children The Highland Council and NHS Highland Plan for integrated children’s 3 services.

Argyll & Bute Integrated Integrated plan for all partners working with children in Argyll & Bute Children’s Services Plan to assist with integration of all services for children and addressing 2009-2012 identified needs, concentrating on services for the most vulnerable children.

The Highland Council Aims to develop a comprehensive access network, including Core Access Strategy 2008- Paths; remove barriers to access, encourage community involvement 2011 and provide opportunities to enjoy the countryside. Also includes specific health related actions that impact on healthy weight.

Argyll & Bute Council This Access Strategy is due to be revised. Argyll & Bute is Access Strategy and implementing actions through the core paths plan that will improve Core Paths Plan access and walking/cycling opportunities.

The Highland Council These Strategies detail the approaches, priorities and plans of the and Argyll & Bute local authorities’ promotion of physical activity and sport to all sectors Council Physical Activity of the community. They include service provision and infrastructure and Sports Strategies development. They are to increase participation in less active groups, tackle issues of inclusion and inequality; whilst also promoting and supporting excellence in sport.

30 5. Membership of the original Healthy Weight Strategy Development Group

Name Job Title Organisation

Dawn Cameron (until 2006) Healthy Weight Project Officer NHS Highland

Anne Campbell Public Health Practitioner, Argyll & Bute NHS Highland CHP

Alan Clark Active Schools Manager, The Highland Council

Fiona Clarke Health Improvement NHS Highland

Pat Dobbie Raigmore Patient Council Representative

Neil Downie Sustainability Manager TEC Services The Highland Council

Jane Groves (Chair) Health Improvement NHS Highland

Suzy Hamilton Active School Co-ordinator The Highland Council

Sandra Harrington Health Promotion Specialist, Child and The Highland Council Family Health

Miles Greenford Public Health Practitioner, North CHP NHS Highland

Sue Menzies Managed Clinical Network for Coronary NHS Highland Heart Disease

Margaret Moss Professional Head Dietetics NHS Highland

Julia Nelson Health Development Officer – Early NHS Highland/The Years, Highland Council

Sheelagh Rodgers/ Clinical Psychologists NHS Highland Katherine Inman

Susan Russel Public Health Practitioner, Mid CHP NHS Highland

Roseanne Urquhart Planning Head of Health Care Strategy NHS Highland

Margaret Walker Locality General Manager, SE CHP NHS Highland

Pat Wells Lay Representative

Mairi Wotherspoon Public Health Dietitian NHS Highland

Current Health Promotion Specialist for Healthy Weight and initial contact for this strategy:

Dan Jenkins,  01463 704855,  [email protected]

31 6. Mapping Exercise - Initiatives relating to healthy weight in NHS Highland area

This section includes a selection of initiatives intended to give the reader a sense of the variety of activity that supports healthy weight, and the breadth of its reach throughout NHS Highland area. It is by no means an exhaustive list, and also includes a few examples of projects that have ended or are in a state of flux due to funding issues. Further details are available from Health Promotion Specialist for Healthy Weight at NHS Highland.

Description of Initiatives:

Active Commuting By Is an example of Cycling Scotland’s work. It has recently produced Bike an updated Cycle Friendly Employer pack. This contains helpful info for companies on how they can promote cycling to work, and can by distributed by Healthy Working Lives (HWL) or www.cyclingscotland.org

Active Nation Mentioned as part of the Scottish Government’s plan for a Legacy from the 2014 Commonwealth Games. It includes any kind of physical activity (walking, gardening, dancing, organised sports) and encourages people to be more active in their daily lives, through personal pledges

Active Schools Network The fundamental aim of the Active Schools Network is to offer school- aged children the motivation and opportunities to adopt active, healthy lifestyles now and into adulthood. These opportunities are available before, during and after school, as well as in the wider community. Around 30 Active Schools co-ordinators promote activity for all within Highland Council schools, and 13 in Argyll & Bute.

Active Scotland Online database set up and maintained by NHS Health Scotland www.activescotland. that lists local physical activity opportunities throughout Scotland. org.uk Searchable by postcode, place name, and type activity, it gives results by expanding radius from a specified location.

Argyll Active GPs, practice nurses, physiotherapists and dieticians follow referral criteria to refer inactive patients to a local and appropriately trained exercise consultant who will support them through a supervised 10 week activity programme. Referral Programme Consultants (RPC) employed by Argyll & Bute Council at various centres in Argyll & Bute.

Baby Friendly Initiative Raigmore Hospital, Caithness General and Vale of Leven Hospital have been awarded UNICEF Baby Friendly status. All four CHPs have achieved Stage 1 and are working towards Stage 2. The Baby Friendly Initiative revolves around 10 steps, which aim to encourage breastfeeding. It ensures that all staff who care for women throughout pregnancy, labour and the postnatal period are highly trained and meet stringent criteria to ensure best practice at all times.

32 Description of Initiatives:

Behaviour Change NHS Highland Health Improvement Team run a training course in ‘Negotiating Health Behaviour Change’ for professionals who work with individuals, which has evaluated very well. Approximately 48 people per year complete the course. The course covers the psychology of health behaviour, the importance of self-efficacy, brief interventions, and the use of Motivational Interviewing approaches. Motivational Interviewing has been recommended in NICE guidelines as a potentially effective approach. There are plans to deliver Training for Trainers in order to create a network of trainers.

Children’s care The pathway for the management of overweight or obese children in pathway NHS Highland is in development, and includes a needs assessment of the target group. Many health professionals including school nurses, family health nurses and health visitors give individual advice and support. At present paediatricians see overweight children who have been referred by GPs and other health practitioners; they are usually referred on to the paediatric dietetic service. SIGN guidelines for the management of weight in children were published in 2010.

Children’s Meals and The food choices for children and young people in cafes and Menus – eating out restaurants are of concern to many people as they are often based on poor quality foods that are high in fat, sugar and salt and do not reflect the main menu.

Class Moves A resource aimed at primary school children to link a child’s natural tendency to move with daily lessons. The resource contains a calendar with appropriate exercises for different times of the school day. NHS Health Scotland continue to promote this resource, and its use in schools varies.

Clinical Psychology The Clinical Psychology service has a significant role in the secondary/ tertiary treatment of obesity. Referral to the service is via General Practitioner or Consultant. The service provided is very restricted due to limited resources. There was concern over the lack of a standardised care pathway, training and partnership working in this complex area. More training is required in particular areas - binge eating, personality disorders and Cognitive Behavioural Therapy.

Council Leisure The Highland Council and Argyll & Bute Council own and manage Facilities various leisure centres throughout region; they also lease facilities from private contractors. The Highland Council promotes activity through the ‘High Life’ card which offers low cost access for individuals and families in all council/ trust/community owned facilities and to some private centres (e.g. MacDonald Highland Resort in Aviemore.

33 Description of Initiatives:

Counterweight The Counterweight Programme is a peer reviewed, evidenced based Programme weight management programme, commissioned by the Scottish Government as the preferred option for adult weight management in routine Primary Care Counterweight is a novel programme of continuous improvement which involves primary care staff (mainly nurses) participating in a competency based training and mentoring programme. The programme provides a range of options to promote an active weight loss phase supported by a weight (loss) maintenance phase. There is a lot of flexibility in how the programme can be implemented locally, including the type of weight management service preferred and the interventions which are offered. On-going review of outcomes and continuous improvement enables Counterweight to be modified and improved over time. In NHS Highland there are two 0.5wte Counterweight Weight Management Advisors who are recruiting and raining GP practices in the Counterweight approach. These posts are currently funded until August 2010.

Cowal Hungry for An example of a healthy eating and physical activity project involving Health primary school children and families in the Cowal area of Argyll & Bute. Supports healthier and more active lifestyles, promotes sustained knowledge increase and behaviour change

Cycling Scotland Cycling Scotland’s vision is to establish cycling as an acceptable, www.cyclingscotland. attractive and practical lifestyle option. Their goals are to: org • champion high quality public space that encourages active living • highlight the health benefits of regular cycling • establish cycling as a solution that extends choice and improves access for everyone • promote the economic and social benefits of cycling and its infrastructure • encourage cycling as an effective, practical and sustainable transport option.

Eating Disorders Cognitive Behaviour Therapy (CBT) is provided via an out patient Services eating disorders service for binge eating disorders and bulimia. The Eating Disorders Service has been developing the role of primary care nurse therapists (trained in CBT) across Highland – with the emphasis mainly on depression and anxiety disorders.

Emotional Wellbeing The importance of promoting emotional wellbeing when working with individuals who are overweight and obese is stressed by many health professionals who feel that this factor may be overlooked.

34 Description of Initiatives:

Food 1st A pilot programme, bringing together both existing and newly www.pfw.org.uk/ created activities and services which are focused on improving food1st.htm nutritional health, through the funding of a co-ordinated food worker and resource/activity programme. The goal is to increase the accessibility, availability and affordability of healthy food for the residents and communities of Inverness and surrounding areas. This project is managed by Partnerships for Wellbeing and was funded by the Scottish community foundation and Lloyds TSB. At the time of writing, further funding is being sought to continue the project.

Forestry Commission Aims to protect and expand Britain’s forests and woodlands and www.forestry.gov.uk increase their value to society and the environment. They provide information on: • places to go • walking • mountain biking and cycling • horse riding • local events • related news They have employed specific Health Advisor posts to lead and provide support for projects that incorporate health gain from use of outdoor spaces.

General Practice/ Most GPs and practice nurses will raise the issue of weight and its Practice Nurse impact on other medical conditions. Practices develop their own interventions depending on local interest and resources. Obesity is recognised as a separate disease entity in the revised GMS2 contract. Some see the GMS contract as a barrier to implementing weight management in primary care, as it only accrues 8 points for recording BMI. The GMS contract, together with the QOF, is being reviewed and renegotiated. Well North and Counterweight initiatives are increasing capacity of staff in primary care settings

GIRFEC Getting it Right for Every Child: the programme for change that will www.forhighlands build on existing best practice and revolutionise services for children in children.org/htm/ Scotland. girfec/girfec.php

Green Gym Utilising outdoors and in particular gardening projects for increasing physical exercise. Examples are allotment and garden projects - Growing is Fun in Bute (including unemployed adults, people with mental health problems, and families), and BTCV (British Trust of Conservation Volunteers), working to help set up and maintain community environmental volunteer projects.

35 Description of Initiatives:

Green Tree Café The Green Tree Café in Rothesay is part of a community project to www.butehealthy improve diet in people of all ages, and is complemented on Bute living.org.uk/ by lunch clubs and basic cookery courses to make healthy eating as TheGreenTreeCafe.php simple, affordable and enjoyable as possible.

Health For All Children Hall 4 recommends the collection of BMI data as a surveillance (Hall 4) measure, on an annual basis for all primary school children at P1 www.healthforall and less frequently for P4 and P7. This is not a screening tool as it children.co.uk is inappropriate to use BMI for population screening until there is a consensus as to what intervention programmes might be effective, and a commitment to provide the necessary resources. However, population trends in BMI might be useful for monitoring the impact of public health interventions, and BMI is included in the proposed care public health dataset.

Health Promoting “A health promoting school is one in which all members of the school Schools community work together to provide pupils with integrated and positive experiences and structures, which promote and protect their health. This includes both the formal and the informal curriculum in health, the creation of a safe and healthy school environment, the provision of appropriate health services and the involvement of the family and wider community in efforts to promote health.”

The Health Promoting Schools initiative in Highland is delivering in partnership between Local Authority Education Services and NHS Highland Health Promotion Department, who have designed and developed criteria for achieving health promoting school awards. All schools in The Highland Council and Argyll & Bute Council areas have been awarded Health Promoting status since 2007.

Health Visitor Work/ Tomatin Tummy Tamers (Healthy Living Group) was an example of a Tomatin Tummy local health visitor group. It was born out of a local needs assessment Tamers which indicated the call for healthy living advice and support within the local area. The service was open to all; ran weekly in the local hall; facilitated by the community’s health visitor and district nurses. Individuals received a tailored health plan with goals.

An audit of the service suggested that the drop-in clinic supported individuals to lead healthier lives. Funding for the project was secured from many sources including; the community council, fundraising by the local community and the Badenoch and Strathspey health improvement fund. It ran successfully for a few years and may be a model that is repeatable with additional consideration around sustainability.

Health Walks in Argyll Walking for health projects have been established in Argyll & Bute for and Bute the past 6 years. Seven organised walking groups are currently active in Dunoon, Lochgilphead (x2), Oban, Islay, Helensburgh and Bute. All of the walks follow the health walk model, although some will offer longer detours for more active members. Further development and co-ordination across the region is in progress.

36 Description of Initiatives:

Healthy Start Healthy Start was introduced in November 2006 and replaced the Welfare Food Scheme. All pregnant women under 18 years of age and those on low incomes will receive vouchers that can be exchanged for liquid cow’s milk, fresh fruit, fresh vegetables and cow’s based infant formula suitable from birth. The Healthy Start voucher is worth £3.10 per week, per beneficiary, or £6.20 for each baby under 1 year, and £3.10 for each child aged over 1 and under 4. (Values as at August 2010) Free Vitamin supplements are also available for eligible pregnant and breastfeeding mothers, and children under 4. The challenges for NHS Highland area include access to healthy food in exchange for the vouchers, particularly in the more rural areas; maximising opportunities for brief intervention advice on breastfeeding and diet; providing community initiatives to support the scheme. Logistics of distributing vitamin supplements is also challenging.

Healthy Working Lives Healthy Working Lives aims to improve the health of working-aged (HWL) people in Scotland, and seeks employers’ support in the national www.healthyworkinglives. effort to improve our competitiveness as a nation, through action com to improve health and reduce health inequalities. In Highland there are 3.5 wte HWL Advisers.

HITRANS HITRANS is the Highlands and Islands Transport Partnership in www.hitrans.org.uk Scotland. As a statutory body its remit covers all forms of public transport in the Highlands and Islands of Scotland including ferry, road transport, rail, air travel, cycling and walking.

Highland’s Information The information trail covers pre-conception to five years and covers Trail – Developing information from a national and local perspective, and signposts Integrated Children’s parents and professionals through to related support services and Services resources. The information trail has been developed to support the implementation of Hall 4. This exercise has highlighted the limited range of information on nutrition, physical activity and maintaining a healthy weight.

Ideal W8 Club Ideal W8 club is an example of a privately run club (currently at Bannatynes in Inverness) offering diet and nutritional advice, with weekly weight, waist measurement and body composition. Run by two fitness consultants who had previously expressed frustration in joint working and difficulty in getting advice from health professionals. They feel there is a need to target youth groups, particularly 16 – 18 age group.

37 Description of Initiatives:

Infant Feeding NHS Highland appointed two Infant Feeding Advisors in 2007 (1 WTE). Advisors Their remit is to implement and support the UNICEF Baby Friendly Initiative hospital and community awards throughout NHS Highland. It also has a role developing strategy and training around pre-conception, pregnancy, maternal nutrition, artificial feeding, neonatal growth and appropriately timed weaning. The post manages a caseload of women who require specialist breastfeeding support, and has developed peer support networks of skilled breastfeeding supporters trained to UNICEF standards; and has developed age-specific school education which sits within Curriculum for Excellence.

Infant Feeding Breastfeeding - The Strategic Framework 2010-2013 NHS Highland has been Framework developed. Aims to provide an evidence based and practical approach with guidance on food and health for all stages of the early years: pre-conception, maternal nutrition, breastfeeding, artificial feeding, growth, weaning, under 5 nutrition and food hygiene. Implementation will be supported through a training and action plan.

Living Streets Living Streets aims to investigate ways of overcoming barriers to walking by www. working with communities, organisations and local authorities. The approach livingstreets. is mindful of the social inclusion agenda and is particularly directed at the co.uk needs of people with disabilities, older people, children and those who do not have access to a car. Living Streets runs: • A campaign to highlight the importance of public areas for community life and to raise awareness of barriers such as traffic volume and speed, quality of maintenance and personal safety. • A series of Community Street Audits which assess public spaces from the perspective of local people and identify potential improvements to specific routes and neighbourhoods. • Workshops and briefings in order to influence professionals engaged in street design and maintenance.

Local Paths Argyll & Bute Council and The Highland Council have developed Core Network/Core Paths Plans to satisfy the requirements in the Land Reform (Scotland) Path Network Act 2003. They aim to improve the provision of path networks including Plan connecting and new routes, and to involve communities in the planning and development process to best meet local needs and priorities

Lochaber Larder No longer running, this was a group of representatives from a wide range www. of food related organisations involved in the development of a local food lochaberlarder. initiative. The main purpose of the group was to encourage healthy eating, co.uk increase local food production, improve the distribution of fruit and vegetables and to educate people about the quality and standards of produce available throughout Lochaber. The mission statement for Lochaber Larders was: ‘…. to facilitate Lochaber to grow locally, buy locally and eat healthily’. Discussions are in progress at a regional level to identify the best way to support local food producers.

38 Description of Initiatives:

Making Recognising that some people taking medication for mental health conditions Changes Group experience weight gain the aim of this group is to provide a multi-disciplinary approach to helping people with significant mental illness to look after their physical well being particularly in relation to body weight and BMI. The group includes information on fitness, diet and lifestyle, as well as motivation and support to make lifestyle changes. The group is based on the Lily “Healthy Living” pack, which is successfully used for groups throughout the UK.

Men’s Health Men’s Health Highland deliver Lifestyle Health checks engaging with hard Project to reach men. The project is funded by the Scottish Executive and aims to www.mens- go where men are, offer health checks and promote the concept of healthy health- living. Men’s Health Nurses have covered areas such as Eastgate Shopping highland.org.uk Centre Inverness, Social Clubs, the Dingwall Mart, sporting events and work places. They also run a regular series of free public talks on a range of health topics. The success of the project is well documented. It has had a positive affect by delivering good advice, easy to understand test results and an integrated approach to signposting men to specific services if needed. Engaging with the project has prompted behaviour change in men who live in remote and rural Highland. ‘One man had a really poor lifestyle. He drank too much, ate all the wrong foods, did no exercise and was not surprisingly extremely overweight. Since having his MOT he has completely changed his lifestyle. He has lost weight, curbed his drinking, takes regular exercise and revisited the project a couple of stones lighter and a much happier man.’

Monitoring Adult Self reported weights and heights have been collected in the Highland Adult Lifestyle Survey between 1996 and 2001. National data from the Scottish Health Survey has taken only small samples from Highland and therefore it has been difficult to monitor or detect any trends in Highland BMI. However, this survey is under review and sample size may be increased to provide Highland with adequate data to monitor trends. Body composition data is usually only taken in dietetics, ‘Men’s Health MOT’s’ and some private gyms. Children Since April 2007, NHS Highland has participated in the national Child Health Surveillance System, through which the BMI of all primary 1 children is collected. This will provide us with trend data. Fitness levels of children in The Highland Council area are collected annually by Highland Active Schools Co-ordinators. A baseline of P1 and P7 children was taken to assist planning of the HEAT 3 target response.

39 Description of Initiatives:

Nutrition and Dieticians provide individual tailored advice for individuals who are trying Dietetic Services to lose weight but referral patterns and levels of service vary throughout the region. The majority of overweight and obese patients are seen in hospital and community outpatient clinics with limited health improvement, training and mentoring interventions.

Draft adult healthy weight pathways are being developed.

Planning The Scottish Executive published a consultation paper, ‘Towards a Healthy Weight Action Plan for Scotland’ in 2006. Particular discussion was had surrounding the issue of the Local Authority and the Built Environment as it has an impact on a community’s physical activity and weight. Nationally there is a growing interest in planning for a healthy environment, and this includes access to the natural environment. This has been followed up in 2010 with the COSLA Route Map for preventing obesity which outlines the role of all aspects of local authority planning and service provision to support healthy weight. The Highland Council has developed supplementary guidance for Open Space within all new residential developments (including play areas, greenspace and allotment provision).

Play@home Play@home helps to strengthen parent and child communication through fun, play activities that contribute to muscular development, co-ordination, speech and language skills. Start to Play trainers have guidance on how Start to Play sessions link with play@home

Pre-school Pre-school follow healthy eating guidance and it is part of the 3 - 5s curriculum.

Private Leisure Various health and fitness clubs exist within Highland including facilities based in hotels. Subscription fees are usually a standard rate and therefore their value for money depends on usage, however they tend to be prohibitively expensive for a large section of the population.

Private Weight Organisations such as Weight Watchers and Scottish Slimmers and Slimmers loss Clubs World offer weight loss clubs with a weekly weigh in and diet/exercise plans and motivational talks for groups.

Rain Starts Play All pre-school settings within The Highland Council area are issued with full- coverage waterproof suits and wellies for every child, to encourage outdoor play in most weathers.

Ready Steady These are a substantial resources for pregnant women and families of very Baby!/Toddler young children. Ready Steady Baby! is distributed to women at their midwife booking appointment, and Ready Steady Toddler is given out later by Health Visitors. Both contain information on balanced eating and healthy choices.

40 Description of Initiatives:

REAL Food Project: Inverness High School’s enterprise project in the form of a market stall htttp://real-ihs. selling a wide range of fresh produce. It has a permanent site in Eastgate blogspot.com Shopping Centre, a mobile stall sited at several businesses on different days of the week, and a bespoke veg box delivery scheme. A farm plot at the school grows some of the featured items, and others are sourced as locally as possible. Pupils are involved in various stages of the business and it extends several areas of the curriculum.

Safe Routes to Safe Routes to Schools continues to combine practical and educational Schools measures to give children more travel options and help them develop good travel habits for the future. The Safe Routes to Schools programme enables children to walk or cycle to school, promoting their health and fitness.

Schools Eco Work An Eco friendly school which has been awarded a green flag, is a school which displays a strong commitment to preserving the environment. They will have a steering group, regular meetings, ongoing activities and strong awareness of the ‘Eco Code’. There are links to be made in, for example, promoting active transport and growing vegetables. All schools in Highland and Argyll & Bute are registered for the award, and a significant number have been awarded Green Flag status.

Scottish Healthy The Healthy Living Award is run by the Scottish Executive and aims Living Award to reward businesses for offering healthy food choices in a healthy www.healthy environment. Around 50 awards have been achieved in NHS Highland livingaward.co.uk area, including hospitals, schools, colleges, private businesses, leisure facilities, and public cafes.

Scottish Natural Work to secure the conservation and enhancement of Scotland’s unique Heritage and precious natural heritage - the wildlife, the habitats and the landscapes www.snh.gov.uk which have evolved in Scotland through the long partnership between people and nature. Their work also includes access, education, landscape, casework, renewables and green space.

Sports Directory The Sports Directory lists contact details of all sports and activity clubs in Highland and is published by the Sports Council. Local Sports Councils are involved in encouraging and promoting participation in sport and physical recreation throughout the Inverness area. They receive funding from The Highland Council and other local bodies (e.g. Inverness and Nairn Enterprise).

Start to Play Staff around NHS Highland area have been trained on the Start to Play course: mainly Active School Co-ordinators and some early years practitioners. They will be responsible for training other staff within their area.

Step It Up Step It Up Highland is an initiative developed through joint working Highland with Partnerships for Wellbeing, NHS Highland and Paths for All. Trained www.stepitup volunteers support and encourage individuals who are keen to take part in highland.org.uk led walks. There are currently 25 active walk groups spread across Highland with the exception of Caithness and Sutherland. Groups vary in size and are led by one or more of their 105 trained volunteer walk leaders. They currently have around 800 walkers registered. Walks are low level, short, and paced to suit the least able participants. 41 Description of Initiatives:

Surgery The North of Scotland Planning Group is reviewing the access to and provision of bariatric surgery. There is currently very limited availability in Aberdeen for North NHS Highland patients, and in Glasgow for Argyll and Bute.

Sustrans Sustrans is the UK’s leading sustainable transport charity which provides www.sustrans. creative, imaginative solutions to transport, environmental and health co.uk challenges. Their projects include: Active Travel Scotland, The National Cycle Network, Liveable Neighbourhoods

Weight There is a rising trend of overweight and obese women presenting in management Obstetrics and Gynaecology, and this impacts on the number of women before, during and suffering from polycystic ovary syndrome and/or infertility. There are after pregnancy also increased pregnancy risks in obese women, which includes a greater anaesthetic risk, pre-eclampsia, gestational diabetes, foetal abnormalities, still births, neonatal deaths and lower breastfeeding rates. NHS Highland’s approach to supporting women to enter pregnancy and childbirth in the best possible nutritional state is contained within the Maternal and Child Nutrition Best Practice Guidance.

Weight Reducing Orlistat is the only prescription and over the counter drug clinically proven Drug Therapy to aid weight loss management (used in conjunction with dietary therapy). Manufacturers produce guidelines and additional patient support. The ‘Highland Joint Formulary’ includes recommendations on the use of drug therapy to support weight management and this will link into the weight management pathway.

X-programme NHS Highland’s response to the Scottish Government HEAT 3 target (2008-2011) has developed a family-based, health behaviour change, motivational programme of sessions to support confidence, feeling good and healthy positive lifestyle choices, to assist children, young people and families in making and maintaining changes that will improve diet and physical activity levels. Targetting 5-15 year olds and their families throughout the region.

Your Choice to ‘Your Choice to Healthy Living’ has involved NHS Highland and The Healthy Living Highland Council in the development of a 40 point plan that covers a wide range of health improvement activities including Health Promoting Schools and Active Schools. A significant section of the ‘Your Choice’ plan also embodies the implementation of the Schools (Health Promotion and Nutrition) (Scotland) Act 2007. The implementation of Your Choice is led and monitored by the Health Action Group (HAG) a multi agency steering group.

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7. An analysis of NHS Highland Healthy Weight Strategy links to Argyll and Bute Single Outcome Agreement

Providing evidence of links between strategic documents is a key process in the efficient development and management of services to the population of Argyll & Bute.

The SOA is clear on the priority given to “Partnership Working – the key to successful delivery”, thus highlighting the importance of co-ordinating these strategic approaches.

The Fairer Argyll & Bute Plan asserts a “strategic focus on tackling health inequalities and preventative action”. It specifically details, under “vulnerable individuals and groups are supported to access services appropriate to their needs”, that a key action is to “provide health improvement opportunities to influence lifestyle behaviour changes and reduce health inequalities”: which is fundamental to the objectives of the Healthy Weight Strategy.

The following summary outlines the areas where the Healthy Weight Strategy is integral to the delivery of the SOA, and also the areas where there is a supporting connection that furthers the aims of both. This table should be viewed alongside the SOA for cross referencing.

National Supporting local outcome / indicator / action Outcome

1 OE2 / SD3 – outdoor + environmental activity impact on healthy weight; OE4 – accessibility of opportunities and services; VC5 – housing planned appropriately for health improvement; VC6 - services and facilities impact on healthy weight

2 OE2 / SD3 - as above; OE3/SD10b – high quality food also available and affordable for local people; OE4, VC5, VC6 – as above; FL5 – SD14 – develop rural dialogue to boost social economy, leading to local behavioural norms that support healthy weight

3 VC6, FL5 – as above

4 VC6, FL5 – as above

5 VC1 – healthy weight impact of HEAT targets H3 & H7; VC5 – applying health improvement principles to homeless applications; VC6 - services and facilities that support children and young people developing healthy weight

6 All local outcomes impacted, especially: VC1 – Scottish Government HEAT Targets integral to healthy weight H1, H3, H7; VC5 – as above; VC6 / T6 – obesity related conditions reduced, HT2 + HT3 – active travel impact on healthy weight

7 OE4 – as above; VC1 / H1, H3, H7 – as above; VC5, VC6 / T6 + HT3 – as above

8 VC1 / H7 as above; VC5, VC6 – as above

9 VC6 – SPT5, HT2 opportunities to encourage active travel

10 There is a need to highlight the impact of environment design and access to amenities on people’s ability to achieve and maintain healthy weight: OE4, VC5 – as above; VC6 – HT2, HT3 – active travel; FL4 - SPT5

43 National Supporting local outcome / indicator / action Outcome

11 OE4, VC5, VC6, FL5/SD14 – as above

12 There is a need to highlight the impact of built and natural environments on people’s ability to achieve and maintain healthy weight: OE2/SD3 – as above; VC5,VC6 – as above; FL4/HT2 – active travel

13 No specific healthy weight links

14 OE1 / SPT2 – walking, cycling and public transport impact on healthy weight; OE2/ SD3 – as above

15 OE4, VC5, VC6 – as above; FL4/SPT5, FL5 – as above

The Healthy Weight Strategy also specifically links to National Indicators and Targets numbers 14, 36, 37, 44 (through well developed healthy weight treatment pathways and support); and is related to numbers 16, 21 and 33.

44 8. An analysis of NHS Highland Healthy Weight Strategy links to The Highland Council Single Outcome Agreement – updated 2010

Providing evidence of links between strategic documents is a key process in the efficient development and management of services to the population of Highland. The SOA is clear on the priority given to Partnership Working, in that “each party to this Agreement is corporately committed to the agreed outcomes for the Highlands and its people”; and the Healthy Weight Strategy is an integral component to supporting the delivery of some of the agreed outcomes contained in the SOA. Several connected issues are highlighted in The Highland Council SOA(2): Aging population reflects increasing importance to avoid health conditions often associated with later life, for which obesity is a major contributor. Health inequalities highlighted relate to factors that contribute to an obesogenic environment. Often these are exaggerated in rural communities with regard to access to healthy affordable food and varied leisure opportunities. There are also clear links between oral health indicators and quality of diet consumed. Whilst Smarter Highland reflects NHS focus towards anticipatory care, many outcomes in the aims to foster a Healthy Highland depend on reversing the upwards trend of obesity and the environmental factors that advance this trend. Green/active travel and the increase of locally grown food are key outcomes in this varied and often dispersed region The following summary outlines the areas where the Healthy Weight Strategy is linked to the delivery of the SOA, and provides a supporting connection that furthers the aims of both. This table should be viewed alongside the SOA for cross referencing.

National Outcome Supporting local outcome / indicator / action

1: We live in a 1.A – access to services includes healthy affordable food and varied Scotland that is leisure and physical activity opportunities the most attractive 1.E – protecting and enhancing our natural heritage relates to the place to do increasing evidence base of the positive health impact of enjoying business in Europe open/green spaces – for which Highland has a great opportunity to maximise 1.I – access to health enhancing housing environments and promotion of active transport options has significant impact on healthy weight

2: We realise our full It is essential to consider the impact of unhealthy weight in terms economic potential of sickness, absence, long-term conditions leading to long-term with more and unemployment and the resultant economic/employment costs, which better employment are well documented. opportunities for Supporting more people into employment - our people 2.J – includes supporting people into healthy employment, and keeping them healthy whilst employed. With an increase in sedentary work environments, healthy weight needs to be on the agenda of all employers in Highland if full economic potential is to be achieved 45

National Outcome Supporting local outcome / indicator / action

3: We are better Local Outcomes 3.A and 3.J impacted as described above; educated, more with physical, mental and social health all contributing to high skilled and more achievement in this broad outcome. Following the philosophy of successful, renowned healthy at any and every weight improves motivation and self- for our research and esteem, and increases achievement levels across this outcome. innovation

4: Our young people are Though not specified directly in the SOA, the adoption of Curriculum successful learners, for Excellence throughout schools is embedding a healthy ethos, and confident individuals, impacting directly on support around healthy weight. effective contributors There may also be important informational links to the Lifestyle and responsible Survey carried out by the Council, to contribute to healthy weight citizens support. 4.C – reflects leadership opportunities around varied, enjoyable and easily integrated physical activity, and supports the outcomes of the Council’s Physical Activity and Sport Strategy (PASS). 4.M – the healthy weight implications of alcohol also need recognition.

5: Our children have the 5.O Breastfeeding links to healthy weight of children. Parenting best start in life and skills and confidence are increasingly highlighted in supporting are ready to succeed family behaviours that support healthy weight.

6: We live longer, Healthy Weight is highlighted as a long standing challenge, and it is healthier lives recognised is that levels of unhealthy weight for Scotland are second only to the USA, among OECD countries, with all the associated risk factors for numerous serious diseases. The importance of 6.E and 6.J have been covered above. 6.K – directly addresses healthy weight through completion rates for child healthy weight programme, and cardiovascular fitness of children (linking again to PASS). 6.L – maximising the health and independence of older people also relies on addressing healthy weight and it’s contribution to chronic conditions in later life, falls prevention, and appropriate/supported physical activity opportunities (also specified in PASS).

7: We have tackled the Improving equalities outcomes; interventions need to be wider than significant inequalities changing individual behaviours and include broader economic and in Scottish society structural change in how society operates – this is a highly synergistic approach to the Healthy Weight Strategy (i.e. the need for support at policy, structural and all levels to enable people to achieve and maintain healthy weight and healthy lifestyle. 7.A and 7.J – impacted as described above. 7.K – physical activity and leisure opportunities (through High Life) are key to healthy weight; and unhealthy weight is a major contributor to coronary heart disease.

46 National Outcome Supporting local outcome / indicator / action

8: We have improved the life No additional specific healthy weight links noted. chances for children, young people and families at risk

9: We live our lives safe from No additional specific healthy weight links noted. crime, disorder and danger

10: We live in well-designed, Healthy weight will be greatly influenced by plans to ensure sustainable places where better access to services and amenities, and higher standards we are able to access the of design in our residential, commercial and industrial areas. amenities and services we 10.A – the impact of attractive, useable open/green spaces need on how residents view their neighbourhood or community 10.E – health benefits of natural heritage described above 10.F – carbon emissions reduced by active travel plans (which also support healthy weight) 10.I – the Council’s Open Space residential planning requirements support healthy weight and would benefit from a Brief Link. Also within this section it would be beneficial to specify investment in cycling and walking as transport.

11: We have strong, 11.C – supporting volunteers, for example in sports resilient and supportive leadership and other physical activity opportunities communities where people links to the goals of both the Healthy Weight Strategy take responsibility for their and the Council’s PASS. Also potential for supporting own actions and how they healthy weight strategy aims around local community affect others food projects / co-ops, etc. Community capacity and supportive norms of behaviour have great influence in reducing the impact of the wider obesogenic environment.

12: We value and enjoy 12.E – as described above; and also increased participation our built and natural in ranger guided walks and events is an excellent environment and protect motivator for people to enjoy the outdoor it and enhance it for future environment independently and encourage others to generations do so. This also presents the opportunity to maximise benefits of core path plans and outdoor education.

13: We take pride in a strong, No additional specific healthy weight links noted. fair and inclusive national identity

14: We reduce the local and 14.F – as above – the opportunity to reduce carbon emissions global environmental im- through active travel; thus also contributing to healthy pact of our consumption weight. and production

15: Our public services are high 15.D – public rating of the Council, and satisfaction levels in- quality, continually improv- clude leisure facilities, walking routes, allotment policy, ing, efficient and responsive public parks and open spaces, etc: which contribute to to local people’s needs healthy weight.

Extending the joint governance and scrutiny agreements will become necessary following the implementation of the COSLA Route Map Towards Healthy Weight. 47 9. References

British Market Research Bureau for the Children’s Play Council (2006) Playday 2006 Survey Reports Carrel A, MD; Bernhardt D, MD (2004) Exercise Prescription for the Prevention of Obesity in Adolescents; American College of Sports Medicine Cedergren M (2006) Effects of gestation weight gain and body mass index on obstetric outcome in Sweden. International Journal of Gynaecology and Obstetrics 93(3): 269-74 CEMACH ( 2007). The Confidential Enquiry into Maternal and Child Health Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer 2003-2005. London. CEMACH The Counterweight Project Team (2004); A new evidence based model for weight management in primary care: the Counterweight Programme, Journal of Human Nutrition and Dietetics 2004, 17 191-208 Crombie, I. K, Irvine, L., Elliott, L., Wallace, H. (2005). Tackling the obesity epidemic: policies in 14 developed countries. Report No2: Review Group on International Public Health Policy. Curhan G. C. et al. (1996) Birth weight and adult hypertension and obesity in women. Circulation; 94:1310- 15s Department of Health; (2002); ‘Healthy Start: Proposals for reform of the welfare Food Scheme’; Oct; London. Dobson, R.(2005), Smoking May Increase Abdominal Obesity, Obesity Research; 13:1466-75 Erermis S, Centin N, Tarmar M, Bukusoglu N, et al (2004); Is obesity a risk factor for psychopathology among adolescents? Pediatrics International 2004, 46, 296-301 Government Office for Science (2007); Foresight: Tackling obesities: future choices – Project report.. Galtiere-Dereure.F et al. (2000); Obesity and pregnancy: complications and costs. American Journal of Clinical Nutrition 71 (suppl):1242S-8S Gruer L. (2006) Towards a healthy weight action plan for Scotland; NHS Health Scotland Harder T et al (2005); Duration of Breastfeeding and Risk of Overweight: A Meta-Analysis, American Journal of Epidemiology 162: 397-403 Johnston E, Johnston S, McLeod P, Johnston M, (2004) The relation of body mass index to depressive symptoms Canadian Journal of Public Health 2004, 95, 179-183 Lester, S. and Maudsley, M (2006) Play Naturally: A review of children’s natural play, (commissioned by Children’s Play Council) McCormick B, Stone I & Corporate Analytical Team (2007). Economic cost of obesity and the case for government intervention. Obesity Reviews 8 (Supplement 1): 161-4 NHS Health Scotland (2005): Health Promoting Health Service NHS Health Scotland (2008) - Managing for Shared Outcomes – Towards Achieving a Healthier Scotland, Health Improvement Performance Management Review, NHS Highland (2005) Highland Diabetes Guideline 5.1: Diabetes and Obesity, NHS Highland (2010)Maternal and Child Nutrition Best Practice Guidance NHS Quality Improvement Scotland (2003): Food, Fluid and Nutritional Care in Hospitals, Department of Health (2004), National Service Framework for Children, Young People and Maternity Services National Audit Office (2001); Tackling Obesity in England, report by the Controller and Auditor General; London National Institute for Clinical Excellence (2006) NICE public health guidance 2: Four Commonly used Methods to Increase Physical Activity: brief interventions in primary care, exercise referral schemes, pedometers and community based exercise programmes for walking and cycling National Institute for Health and Clinical Excellence (2006) NICE public health guidance 43: Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children

48 National Institute for Health and Clinical Excellence (2008) NICE public health guidance 8: Physical activity and the environment : promoting and creating built or natural environments that encourage and support physical activity National Institute for Health and Clinical Excellence (2009) NICE public health guidance 17: Promoting physical activity for children and young people Promoting physical activity, active play and sport for pre-school and school- age children and young people in family, pre-school, school and community settings Ramussen M and Yaktine A (2009) Weight gain during pregnancy: re-examining the guidelines; Institute of Medicine Robinson H. E., O’Connell C. M., Joseph K. S, and. McLeod N. L (2005) Maternal Outcomes in Pregnancies Complicated by Obesity Obstet. Gynecol. December 1, 2005; 106(6): 1357 - 1364 Royal College of Obstetricians and Gynaecologists (2004) Confidential Inquiry into maternal and child health (2000-2002), Why mothers die Ruxton, C; (2004) Tackling overweight and obesity; Tayside Healthy Weight Scottish Executive. (2003) Let’s Make Scotland More Active: A strategy for physical activity . Scottish Executive (2006); Scottish Planning Policy SPP11: physical activity and open space consultation draft Scottish Executive; (2006); ‘Nutritional Guidance for Early Years: food choices for children aged 1-5 in early education and childcare settings’; Edinburgh. Scottish Executive; (2006), Infant Feeding Strategy for Scotland, A Consultation Paper, January. Scottish Government (2007); Schools (Health Promotion and Nutrition)(Scotland) Act; Edinburgh Scottish Executive (2007) Delivering a Healthy Future: An Action Framework for Children and Young People’s Health in Scotland Scottish Executive (2008), Scottish Health Survey, 2008; Edinburgh Scottish Government (2008); Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008-2011); Edinburgh Scottish Government and Consortium of Scottish Local Authorities (2008) Early Years Framework; Edinburgh Scottish Government (2010) Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight Scottish Office (1998). New Community School Prospectus SIGN (1996) National Clinical Guideline 8, Obesity in Scotland: Integrating Prevention with Weight Management SIGN (2003) National Clinical Guideline 69, Management of Obesity in Children and Young People, Strategy; SIGN (2010) National Clinical Guideline 115, Management of Obesity Som, R (2009); Maternal Obesity: A Growing Problem; RCM Journal June/July 2009 p32-33 Sukalich, S et al. (2006); Obstetric outcomes in overweight and obese adolescents. American Journal of Obstetrics and Gynaecology, 195:851-5 Summerbell C. D, et al. (2005). Interventions for preventing obesity in children. The Cochrane Database of Systematic Reviews, Issue 3. Sustain, (2001), TV Dinners – What’s being served up by the advertisers?, Sustain: The alliance for better food and farming, London. Suter P (2005) Is alcohol consumption a risk factor for weight gain and obesity? Critical Reviews in Clinical Laboratory Sciences 42(3):197-227 Tayside Health Board (2005); Tayside Healthy Weight Strategy: Tackling Overweight and Obesity, The Highland Council (2008); The Highland Council Access Strategy 2008-2011

49 Timperio, A., Salmon, J., Telford, A. and Crawford, D. (2005). Perceptions of local neighbourhood environments and their relationship to childhood overweight and obesity. International Journal of Obesity, 29(2), 170-175. Wannamethee, S. G., Shaper, A. G. (2003). Alcohol, body weight gain in middle aged men. American Journal of Clinical Nutrition 77 (5) 1312-1317 WHO (1998); Obesity: preventing and managing the global epidemic : report of a WHO Consultation on Obesity, Geneva WHO (2002) Obesity Prevention: the case for action. Geneva WHO (2004) World Health Assembly Global Strategy on Diet, Physical Activity and Health. Geneva WHO Growth Standards www.who.int/nutrition/media_page/en/.

50 10. Acronyms

A&BC Argyll and Bute Council ABADP Argyll and Bute Alcohol and Drug Partnership ABICSP Argyll and Bute Integrated Children’s Services Plan BMI Body Mass Index CBT Cognitive Behavioural Therapy CEL Chief Executive’s Letter CEMACH Confidential Enquiry into Maternal and Child Health CfE Curriculum for Excellence CHP Community Health Partnership COSLA Convention of Scottish Local Authorities FHC3 For Highland’s Children 3 GIRFEC Getting It Right For Every Child HADP Highland Alcohol and Drug Partnership HALL4 Health for All Children 4 HC The Highland Council HWL Healthy Working Lives JHIP Joint Health Improvement Plan NICE National Institute for Clinical Excellence NOSPHN North of Scotland Public Health Network NVQ National Vocational Qualification QIS Quality Improvement Scotland (NHS quality improvement specialists) QOF Quality and Outcomes Framework SIGN Scottish Intercollegiate Guidance Network SOA Single Outcome Agreement TOP Training on Play WHO World Health Organisation YCIP Your Choice Implementation Plan

51 Published by: Public Health Department NHS Highland Assynt House, Beechwood Park Inverness IV2 3BW

January 2011

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