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Obesity Strategy

Date: 11th June 2012

Version number: 2

Author: Elizabeth Clark

Review Date: June 2022

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Contents:

Purpose of Strategy...............................................................................2

Introduction............................................................................................2

Background............................................................................................4

National policy drivers...........................................................................11

Obesity Prevention................................................................................14

Energy consumption...................................................................14

Energy expenditure.....................................................................17

Early years..................................................................................19

Workplaces..................................................................................21

Obesity Treatment..................................................................................23

Childhood obesity treatment........................................................23

Adult obesity treatment................................................................27

Key Partners ..........................................................................................31

Action Plan.............................................................................................32

Appendix 1: Estimated Energy Needs....................................................37

Appendix 2: Eatwell Plate.......................................................................38

Appendix 3: Pre- pregnancy Care Pathway for Women with obesity... 40

Appendix 4: Antenatal Care Pathway for Women with obesity...............41

Appendix 5: Example Primary Care Pathway.........................................42

Appendix 6: Management of Women with Obesity in Pregnancy..........44

References.............................................................................................47

Rapid Impact Assessment.....................................................................48

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1. Purpose

The purpose of this strategy is to inform and provide clear actions in order to both

prevent and treat obesity, with an ultimate aim of reducing obesity levels in Shetland.

The strategy also illustrates the many factors that contribute to obesity and how only

a partnership approach will have any impact on reducing obesity levels in Shetland.

It is part of the ten year Health Improvement Plan for Shetland and complements the

newly developed Active Lives and Sports Strategies and previously approved Infant

Feeding Strategy. It replaces the Shetland Healthy Weight Strategy 2008-2011.

2. Introduction

Obesity is a well known term. It is an issue which causes a lot of concern and action

needs to be taken now to reverse the worrying obesity trends. Obesity has a great

financial cost but perhaps more importantly it has a human cost, whether it be

mortality, morbidity or quality of life. This is an update of the Shetland Healthy

Weight Strategy 2008-2011 and many of the actions of the previous strategy

continue to be current. However, evidence gives updated guidance on both

prevention and treatment, which it is essential to adopt locally.

Prevention, as outlined in “Preventing Overweight and Obesity in Scotland” i focuses

on healthy eating, being physically active and reducing sedentary time. An

imbalance between these is the main cause of obesity. However, it is recognised

there are multiple factors surrounding healthy eating and physical activity. A co-

ordinated, cross sector approach, across the life stages is required in order to make

any head way. There is a need to take the global and national picture and translate

it at a local level.

Treatment of obesity mostly takes place through primary and secondary care. The

“SIGN 115 Management of Obesity” ii presents clear recommendations on treatment,

this includes adult and child interventions, the use of medication and bariatric

surgery.

The principles, aim and objectives for tackling obesity remain the same as the

previous strategy, but, in line with the rest of Scotland, we have not made the

progress we would have wanted, so some of what we do in the future must be

different.

We must tackle the stigma and prejudice around overweight and obesity.

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We must tackle the factors which cause and contribute to being overweight

and obese.

We must tackle obesity and overweight problems in individuals and

communities by tackling the physical environment that we live in and

encouraging physical activity making access to healthy eating options easier.

We must work in partnership with community policy makers.

We must work to shift cultural attitudes and social norms around overweight

and obesity.

The emphasis should be strongly on prevention rather than treatment.

Preventative approaches usefully open up the scope for action which is more

holistic, crosses boundaries and extends responsibility. Medicalised attitudes

of obesity and eating disorders as diseases to be cured remove personal

responsibility and confine them to being the business of the NHS.

We must recognise the relationship with and influence of health and social

inequalities on overweight and obesity.

Aim

To increase the number of people of a healthy weight in Shetland

Objectives

To increase the number of people eating healthy diets in Shetland.

To increase physical activity levels in Shetland.

To influence policy makers into creating environments which support healthy

eating and physical activity where local producers, processors,

manufacturers, retailers and caterers promote healthy food.

To have clear referral and treatment pathways for children and adults who are

overweight or obese.

To tackle the stigma around obesity and talk about it in ways that mean

people can acknowledge the problem and ask for help to tackle it at both a

personal and social level.

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3. Background

3.1 What causes obesity?

Obesity is a term used to describe an excess accumulation of body fat. Obesity

results when energy intake from food and drink (including alcohol) exceeds energy

expenditure. Energy expenditure includes the energy required to keep the body

functioning as well as the extent to which the individual is active or sedentary, once

the scales tip towards excess energy intake the result is overweight, which may lead

to obesity. i

Charts illustrating average daily energy needs for 11- 18 year olds are presented in

appendix 1.

3.2 How is overweight and obesity measured?

The most widely used clinical definition of obesity in adults is body mass index (BMI)

this is measured as follows:

BMI = body weight (Kg)

(height (m) 2

Classification of overweight and obesity in adultsiii

BMI range (kg/m2) Classification

< 18.5 Underweight

18.5-24.9 Healthy weight

25.0-29.9 Overweight

30-34.9 Mildly obese

35-39.9 Moderately obese

40+ Morbidly obese

Energy intake Energy expenditure

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In adults waist circumference indicates total body fat at least equally as well as BMI.

It is also the best measure for predicting the fat surrounding organs. Women with a

waist circumference of 80 cm or more and men with a waist circumference of 94 cm

or more (90cm or more for Asian men) are at increased risk of obesity-related health

problems. BMI and waist circumference can be used together to refine assessment

of risk of obesity- related co-morbidities.ii

Obesity in children is measured by comparing BMI with age- and sex-specific centile

charts. Cut-offs help identify whether or not a child is overweight or obese.

Classifications for overweight and obesity in children (For clinical use)ii

BMI Centile Classification

≥91st centile Overweight

≥98th centile Obese

≥ 99.6th centile Severely obese

>3.5 SD above mean of UK 1990 reference chart for age and sex

Very severely obese

>4 SD above mean of UK 1990 reference chart for age and sex

Extremely obese

3.3 Is there an obesity epidemic? – a look at the statistics

Obesity rates across the world continue to grow. Scotland has one of the highest

levels of obesity in Organisation for Economic Co-operation and Development

(OECD) countries; third only to Mexico and the USA.iii It is predicted that by 2030

adult obesity in Scotland could reach over 40%.i Data shows that in 2010 in Scotland

27% of adults and 15% of children were obese.i However, it is important to realise

that therefore 73% of adults and 85% of children were not obese and this is the

positive view point from where actions must move forward.

Between 1995 and 2010 in Scotland, the proportion of adults aged 16-64 who were

overweight or obese (as opposed to be just obese) increased by 10.9% to 63.3%.

This equates to 66.1% of men, and 60.3% of women being overweight or obese.

The increase mostly occurred between 1995 and 2008 with the greatest increase

being in the number of men and women that are obese or morbidly obese. From

2008 to 2010 figures have remained around the same. iv

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Prevalence of overweight and obese in adults 1995-2010 (16-64), 2003-2010 (16+)iv

By applying the UK Faculty of Public Health adult obesity ready reckoner v to

Shetland population statistics levels of obesity in Shetland adults can be estimated.

These estimates are presented in the table below and can be used as a basis for

setting future targets for preventing and treating obesity.

Population BMI >30

Age Male Female Male Female

16-24 1245 1037 112 125

25-34 1283 1193 269 215

35-44 1563 1568 391 376

45-54 1709 1642 479 443

55-64 1622 1458 535 437

65-74 1059 1078 328 377

75 plus 658 999 119 270

SUB-TOTAL 9139 8975 2233 2243

TOTAL 18114 4476

In Scotland 29.9% of children (31.1% of boys and 28.5% of girls) were overweight or

obese in 2010. Between 1998 and 2008 the proportion of girls who were

overweight/obese, did not vary significantly. Over the same time period the

proportion of boys in these categories has fluctuated reaching a peak in 2008, before

declining in 2009 then increasing slightly in 2010. iv

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All children in Shetland are routinely weighed and have their height measured during

their first year at school, when they are aged 5-6. (This is the ‘P1’ check). The graph

below shows the % of children that were overweight in Shetland at these checks as

compared to the overall Scottish %.

The table below shows the overweight, obese and severely obese figures for

Shetland Primary 1 school children for the school years 08/09, 09/10 and 10/11.

School Year

08/09 number 09/10 number 10/11 number

NHS Shetland

Number of children measured

244

239

235

% Overweight (includes obese and severely obese) 19.3 47 22.6 54 21.7 51

% Obese (includes severely obese) 9.0 22 12.6 30 7.2 17

% Severely Obese 4.1 10 7.9 19 3.8 9

If we apply the figures from the last three years, and assume similar rates of severely

obese in other years (age 3 – 18) we can estimate that there are around 200

severely obese children and young people in Shetland today. Given the evidence

we have of the harm (social and emotional as well as health-related) caused by

being severely obese, we have to use this information to identify these children early,

and take action to help prevent them growing up into obese adults. This has to be

done sensitively and without victimising the child, and generally has to involve the

whole family.

08/09 09/10 10/11

Shetland 19.3 22.6 21.7

Scotland 20.8 21.5 21.4

-

5.0

10.0

15.0

20.0

25.0

Per

cen

tage

P1 BMI Checks - Overweight Children

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3.4 Why do anything about obesity?

Obesity is not a disease in its own right but a warning sign that the risk of disease

has increased. At extremes it is a disabling condition that prevents people leading

active lives and feeling well. The higher the person’s BMI the greater the risk of

disease or ill-health. This is why it is important for both adults and children to keep

body weight within healthy limits. The limits of a healthy weight are quite broad.

While it is good to be the correct weight for height, overweight people can benefit

from even modest weight losses, if these are sustained. iiii

As well as the human cost of obesity there is also the monetary cost much of which

is avoidable. It is estimated that the total cost to Scottish society of obesity in 2007/8

was over £457 million and this is probably an underestimate. Of this over £175

million of the cost is direct NHS costs, which equates to 2% of NHS Scotland's

revenue budget. However, it is estimated that health care costs are minor in

comparison to the wider costs on society in terms of reduced work productivity

through increased sickness absence from school or work and premature death.

There are also costs in terms of mental wellbeing as well as housing, transport and

social support. People with extreme obesity e.g. BMI > 50 are increasing in numbers

most rapidly and present much greater costs, to housing, transport, social support as

well as healthcare. If obesity levels in Scotland continue to rise in line with predicted

figures it is estimated that the direct costs to NHS Scotland will almost double by

2030 and the estimates for total cost to Scottish society range from £0.9 billion - £3

billion. i

3.5 Deprivation and Obesity

There are many factors that contribute towards obesity and people who are living in

deprivation are less well equipped to deal with these.iii In general terms obesity and

overweight is higher in the most disadvantaged groups. The Scottish Household

Survey (SHS) data shows that there is a correlation between women who are

overweight and obese and their education level and socio-economic status. The

picture for men, however, is more mixed.iv In 2008 the SHS showed a clear

relationship between increasing obesity levels in women and increasing levels of

deprivation. This pattern is not seen in men where there are higher levels of obesity

regardless of the deprivation quintile, although it is predicted that a link between

deprivation and men will become more obvious over time.vi Never the less it could be

argued that any lack of links between obesity and socio-economic status in adults in

Scotland, could illustrate the reach of the epidemic in that all members of society are

similarly affected by adulthood. iii

In terms of children in Scotland, socio economic status does not significantly

correspond with being overweight. However, boys in lower income households are

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more likely to be obese than those in other income groups.vi Furthermore, area

deprivation is significantly associated with childhood obesity and families with one

obese parent are more likely to have an obese child.

The following diagram shows the additional challenges facing those living in social

deprivation in relation to factors that can cause or compound obesity. The contents

of the diagram highlight the need to focus on external factors in order to reduce

obesity levels rather than individual lifestyle choice which is restricted amongst

people who are socially deprived. iii

DOMAIN Physical Economic Legislative Sociocultural

Factor/driver High neighbourhood disorder.

Tendency to opt for lowest cost per calorie.

Lower social groups less able to campaign for their interests

Immediate gratification often a coping strategy.

Leads to...

Effect of deprivation re obesity

Reduced opportunity/ inclination for activity.

Increased consumption of energy dense foods.

Tendency towards making do with poor options/local facilities.

Longer term consequences of behaviour not considered

Counteract with...

Potential mitigation

Improved safe/green space provision

Subsidised healthier foods; restrict bulk promotions of High Fat and High Sugar foods.

Facilitated community development/activity events

Improvements to circumstances = Reduced comfort seeking behaviours

It is now understood, locally and nationally, that the best way to tackle poverty and

social exclusion in a rural area, such as Shetland, where it is dispersed, is to provide

an individual, out-come focused approach, and this will underpin all actions within

this strategy. Those individuals who are particularly vulnerable continue to be:

young people whose parents are not able to ensure they are able to access opportunities and grow up feeling a part of the community within which they live;

adults of any age who have low self-esteem and/or poor mental health, often due to situations which have developed as a result of negative experiences in

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the past and can result in homelessness and substance misuse. This is particularly acute if their situation is not understood by the community within which they live;

those who are physically disabled or with a long-term illness and their carers, when they do not receive adequate support and understanding;

those looking after a young family without access to their own transport, particularly those living in remote areas of Shetland;

older people unable to access opportunities that would enable them to feel a part of the community.

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4. National Policy Drivers

4.1 Policy impacting on Obesity

Since the establishment of a Scottish Parliament there have been a number of

policies produced to support work on tackling overweight and obesity. In 2003 Let’s

Make Scotland More Activevii was published, setting clear actions to increase

physical activity levels in Scotland. The strategy was reviewed in 2009 and it was

recommended that actions should continue to be implemented.viii The national food

and drink policy (2009) “Recipe for Success”, focused on economic growth of the

food and drink industry whilst also addressing health and wellbeing. ix More recently

“Improving Maternal and Infant Nutrition a framework for action”, published in 2011,

sets out a plan for changing infant feeding practices in Scotland with an emphasis on

partnership working. It is anticipated that this will help establish life-long healthy

eating habits. x

Looking at the wider picture there have been a range of policies and actions which

indirectly contribute to preventing obesity. Education policies have taken this into

account, in particular through the health and wellbeing outcomes of the Curriculum

for Excellence. Environmental policies have helped to focus on active travel and

climate change. Also through planning policy inroads are being made to take into

account the health impact of infrastructure, housing and industry development. i

4.2 Obesity Policy

Policies that directly impact on obesity include “Healthy Eating Active Living Action

plan 2008-2011”, which recommended targeted healthy living initiatives to improve

diet, increase activity and tackle obesity.xi In addition there have been a number of

briefing papers that have been produced emphasising the essential nature of

tackling obesity. These include a paper produced for elected members; “The obesity

Time Bomb: Why it’s everyone’s business,” which outlines the economic

consequences of obesity for councils. This includes both the costs of long-term care

as a result of major health problems associated with obesity and the costs of staff

obesity, which is linked to higher levels of employee sickness and absence, resulting

in reduced productivity.xii

In February 2010 “Preventing overweight and obesity in Scotland: a route map

towards healthy weight was published.” The ‘route map’ outlines how the

Government will work across a range of departments so that making healthy choices

is easier at an individual level and thereby tackle obesity.i The Route Map is the

main obesity prevention policy for Scotland and is based on the recommendations of

the Foresight report on Tackling Obesity which identifies a range of social and

biological factors that contribute to obesity. These are presented under seven main

themes iii

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1. Biology: an individual’s starting point survival advantage of an appetite which

exceeds immediate need, the influence of genetics and ill-health on fat

accumulation.

2. Activity Environment: the influence of the environment on an individual’s activity behaviour.

3. Physical activity: the type, frequency and intensity of activities an individual carries out.

4. Societal influences: the impact of society

5. Individual psychology: for example a person’s individual psychological drive for particular foods and consumption patterns, or physical activity patterns or preferences.

6. Food environment: the influence of the food environment on an individual’s food choices.

7. Food consumption: the quality, including energy density, quantity (portion sizes) and frequency of consuming food.

Foresight recommends 4 key areas for action, based on the 7 themes, which will

have the greatest impact on obesity prevention. The Scottish Obesity Route map

adopts these key areas as these have the strongest links between weight gain,

behaviour and environmental exposure (Scottish Government 2010).

1. Energy Consumption

Controlling exposure to, demand for and consumption of excessive quantities

of high calorific foods and drinks

2. Energy Expenditure

Increasing opportunities for uptake of walking, cycling and other physical

activity in our daily lives and minimising sedentary behaviour

3. Early Years

Establishing life-long habits and skills in the early years, for positive health

behaviour, through early life interventions

4. Workplaces

Increasing responsibility of organisations for the health and wellbeing of their

employees

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To have an impact on all these areas partnership working across, public, private and

the third sector is required. Decisions must be made on priority areas and actions

put in place to tackle them. The Route Map recommendations form the basis for the

prevention section of this Obesity Strategy.

4.3 Targets

4.4 Treatment Guidelines

In terms of obesity treatment the SIGN Management of Obesity: a national clinical

guideline 115 (2010) provides evidence based recommendations on the prevention

and treatment of obesity within a clinical setting. It covers children, young people and

adults. ii

The Obesity Treatment Best Practice Statement (May 2012) produced by the

Scottish Government, gives guidance on the following areas:

1. The patient pathway from specialist weight management services into assessment for bariatric surgery. 2. Surgical procedures. 3. Assessment of patients who do not fulfil the criteria for surgery. 4. Clinical outcomes, what data should be collected and how. 5. Follow up protocols following surgery. xiii

These 2 guidelines form the basis of the treatment section of this strategy.

The Scottish Government gives us specific Health Improvement Targets that provide

focus for action on obesity. These are as follows

Cardiovascular health – Achieve agreed number of inequalities-targeted cardiovascular

health checks during 2011/12.

Child healthy weight – Achieve agreed completion rates for child healthy weight

intervention programme over the three years ending March 2014.

The single outcome agreement outlines both national outcomes and local priorities. In

Shetland the indicators that are relevant to obesity are as follows:

NI 14: Reduce the rate of increase in the proportion of children with their Body Mass

Index outwith a healthy range by 2018:

NI 16: Increase healthy life expectancy at birth in the most deprived areas.

NI 21: Reduce mortality from coronary heart disease among the under 75s in Shetland.

II25: Increase the percentage of the local population taking part in sport and leisure

activities.

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5. Prevention

5.1 Energy Consumption

The relatively lower prices of foods high in calories and the reduction in the real price

of food are key drivers of the current obesity epidemic with more people eating more

high energy and high sugar foods worldwide. Studies have shown an association

between the increased consumption of these foods and weight gain.iii

5.1.1 Making accessing healthier options easier – eating out and on the move

Scotland’s food and drink policy “Recipe for Success” brings together three formerly

disparate policy areas, sustainability, business and health.ix Joint action needs to be

taken in all these areas in order to tackle obesity. It must be possible to make

healthy food choices easier where access to healthier, less energy dense food and

drink and smaller portion sizes becomes the norm. It is vital that all actions argue

the business case for change, whilst simultaneously creating the demand for

healthier options lifestyle change.

Nationally the aim is to work with the Scottish Retailers’ Forum to reduce the amount

of energy dense food and drinks to lower energy options stocked by supermarkets

and convenience stores so that it fits better with the healthy balanced diet. Locally

an effort needs to be made to tie in with this. Work needs to take place alongside

the local retailers association or equivalent to see what changes can feasibly be

made in Shetland. Shops will be encouraged to set up their own healthy schemes or

to sign up to the Healthy Living Neighbourhood shop project, with a focus on product

placement and marketing of healthy choices. We are already working with shops to

set up fruit and vegetable pre-order box schemes but this work needs to be

expanded.

On Commercial Street we will encourage businesses to provide more healthier

options especially for children and young people and for employees. Efforts should

also concentrate on youth clubs and with places that have vending machines to

make healthy eating choices easier. Within all these areas we will use an Eat Well

plate as a guide. The plate is clearly set out in five sections for the five food groups,

each section is of a different size in accordance with the ratio a person should eat

over a day. A copy and explanation of the Eat Well plate is presented in appendix 2.

Nationally the aim is to work with Small to Medium Enterprises (SMEs) who produce

food to use healthier products as a marketing tool. This may involve the

reformulation of certain products, however, the highest priority should be given to

everyday basics which are at the more affordable end of the market. In Shetland this

will involve work with the producers of such products to maintain their healthier

options or help work towards healthier options. Work has recently been done with 3

producers to create health messages that complemented their produce which was

displayed at the local food festival.

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Nationally work is to be carried out with producers, retailers and caterers to ensure

that portion sizes served or suggested are in line with energy needs. Locally this will

be done through producers, retailers and caterers being educated on portion size

and portioning in line with the Eat well plate. We must also encourage these

outlets to make calorie content obvious as part of the daily requirements. These

outlets could also adopt the nutritional requirements in food and drink in schools

(Scotland) regulations 2008.xiv

5.1.2 Making accessing healthier options easier – for employees

Nationally the intention is to work with consumer focus Scotland to extend the

Healthy Living Award to all public sector organisations and to the high street. The

Healthy Living Award encourages caterers to make healthy eating choices easier, by

cooking more healthily, promoting healthy options and placing healthy options more

prominently. In Shetland we will encourage and support food outlets on Commercial

Street and in the Toll Clock Shopping centre to work towards the Healthy Living

Award. There also needs to be an emphasis on workplaces that provide in-house

catering to achieve the Healthy Living Award.

Work should also be done across the public sector to promote and support the

procurement of lower energy-dense products and to adopt nutritional guidance that

is similar to the school nutrition regulations for retail outlets, public and staff catering

facilities. Public sector should be setting the example for all and any publically

funded organisations should become a condition of funding.

5.1.3 Making accessing healthier options easier – in schools

In schools nationally the drive is to continue with the health promotion and nutrition

act 2007. In Shetland there is a high uptake of school meals including free meals we

need to maintain this. We need to encourage local producers to deliver reformulated

options to comply with the nutrition regulations. We also need to establish the

extent to which children are accessing inappropriate meals and goods from

businesses near schools and take action where required to work with outlets to

promote appealing less energy dense options for pupils who leave school for lunch.

Within Shetland schools there tends to be pack lunch trends which ebb and flow.

Pack lunches are also eaten by a range of people. There needs to be a co-ordinated

approach to promoting healthy lunchbox and snack messages to parents/ carers,

young people and employees.

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5.1.4 Education on the healthy choices and making the healthy choice more

obvious

We need to work with local producers to make the nutritional content of their foods

more obvious, in particular, and, where appropriate, adopting the Food Standard

Agency’s (FSA’s) recommendation for front of pack labelling. We will aim for simple

methods for communicating energy density to be used (such as how far you have to

walk to burn off a product) and will present these in the Shetland context.

Work should be undertaken to ensure that the people of Shetland have a good

understanding of food and diet, through schools and work with communities and

workplaces. Messages should not only relate to the Eatwell plate but also to energy

density of food and portion size. Everyone should have access to opportunities to

learn how to shop and cook from scratch affordably. We need to build up a co-

ordinated approach to life skill courses where there are parent/ carer and child

classes this needs to include those who are corporate responsibility guardians. In

schools learning about healthy eating and healthy weight should tie in with the

curriculum for excellence but it should also be at the heart of school activity. Schools

are a crucial setting in which to equip children and young people with skills to pick,

buy and prepare less energy dense meals and snacks. In the early years effort

should be made to broaden tastes.

Locally we will adopt the “take life on” campaign to increase consumer awareness of

the benefits of healthy eating and encourage healthier food choices. The on-line

Shetland food guide should be adapted to put a focus on healthy eating.

5.1.5 Alcohol and energy intake

When looking at prevention of obesity it is also important to consider alcohol as it is

highly calorific and lacks nutritional value. Recommended limits for alcohol are 2-3

units per day for women and 3-4 units per day for men with two alcohol free days per

week. One unit of alcohol is equivalent to 70 kcal. This means that a standard glass

of wine (175ml and 13%abv) equals 159 kcals and one pint of beer (5% abv) equals

199 kcals. xv There has been a drive nationally for local areas NHS Boards across

Scotland to deliver brief advice to help people who are assessed to have issues with

alcohol. xvi This coupled with the local Drink Better campaign which is working to

change alcohol culture in Shetland will help to address alcohol issues in Shetland

and thereby contribute to helping reduce obesity levels.

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5.2 Energy Expenditure

Due to the levels of obesity in Scotland many adults may need to do 60 minutes of

physical activity daily to reach a healthy weight. iThe realistic way to do this is to

build it into people’s daily routines with a focus on active travel – moving away where

possible from motorised vehicles to cycling and walking.

To support active travel we need to make changes made to the physical and cultural

environments. This includes making cycling and walking accessible, safe and

appealing so that it automatically becomes the way that people travel for short, local

journeys. Policies at a local and national level need to support active travel.

5.2.1 Transport policy

It should be ensured that active travel is covered in both the national and local

transport strategies. Locally work should also be done to deliver on the cycle action

plan for Scotland which proposes that 10% of all journeys are made by bicycle by

2020. There is an opportunity to encourage active travel particularly in and around

Lerwick.

Sustrans is a national organisation which helps to support sustainable transport

development Scotland wide. It is important that this work continues. Locally we

should create incentives for active travel rather than incentives for personal car use

for short and local journeys.

5.2.2 Planning policy and design and placemaking

Locally there is a need to maximise the opportunities from the National Planning

Framework for Scotland so that development plans have a positive impact on active

living and healthy weight.

In priority order, the preference for active personal travel should be walking, cycling,

then public transport followed by car and other means of motorised vehicles. This

needs to be reflected in the work of Shetland’s transport strategy.

Design should consider the provision of open space and physical activity

opportunities, encouraged through ongoing training and promotion. Design should

also encourage a range of ways to reduce car dependency, increase active travel

and increase, where relevant accessible open spaces for recreation through the

Scottish Sustainable Communities Initiative.

Nationally, work is planned with architecture and Design Scotland to investigate the

potential to improve standard practice in the design of new and refurbished buildings

such as bike storage and shower facilities. We should consider the implications of

this locally.

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5.2.3 Supporting Behaviour Change

We need to take action to ensure that people feel safe and comfortable being

outdoors in their communities. One way is to divert people away from crime and

disorder by getting people involved in alternative activities.

Work also needs to be done to respond to concerns about the safety and

convenience of active travel. We need to work with communities to reduce the fear of

road safety and concentrate on making the roads feel safer. This will involve tackling

public perceptions of walking and cycling on the roads – Shetland is actually a very

safe place to walk or cycle.

5.2.4 Sports and recreation

Actions on sports and recreation in terms of preventing and tackling obesity are

being addressed through the local Active Lives and Sport Strategies. In summary,

these involve the following actions:

Maintaining physical activity levels of those who are already active and

targeting the least active as getting the most inactive active will have the

greatest benefits.

Maintaining, creating and providing environments that encourage and support

physical activity Shetland-wide, making best use of the many assets that we

have.

Improve monitoring of physical activity levels and evaluation of physical

activity programmes

Improve Partnership Working on Physical Activity and creating joined up ways

of letting people know when, how and where they can get involved in physical

activity and the most up to date activity advice.

Focusing on all these areas will help to improve pathways to and participation in

sport and thereby help support people, where possible, to become healthily active.

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5.3 Early Years

The early years offer the best opportunity to establish positive behaviour toward

healthy eating and physical activity.i

5.3.1 Before and during pregnancy

Early years includes before and during pregnancy. The number of women who are

obese during pregnancy is increasing. This can not only have short term affects on

mother and infant health but also long term affects on infant health right through to

adulthood. Required actions include letting women of child bearing age pre-

conception know about the relationship between maternal obesity and issues in

pregnancy. In Shetland there are pre-pregnancy programmes running focusing on

adopting healthy lifestyles. A pre-pregnancy plan for obese women and a pre-

pregnancy care pathway have been developed copies of which are presented in

Appendix 3 and 4 respectively.

5.3.2 Infant feeding

There is evidence that breastfed babies show slower growth rates which may

contribute to a reduced risk of obesity in later life; also that infants are more likely to

be overweight later in childhood if they gain weight rapidly in the first 2 years or are

weaned onto solid foods earlyxvii. Work needs to continue to ensure that more babies

are breastfed for longer. Work also needs to be done to help pregnant women and

new mothers to develop healthy lifestyle behaviours, through, for example, parenting

programmes and community capacity building in the Early Years Framework. In

Shetland breastfeeding rates are already good but work continues to maintain and

improve the breastfeeding rates.

Locally there is a need to influence, planning, regeneration and transport policies to

promote health enhancing environments for children and families. We need to

ensure that parents have knowledge about how they feed themselves and their

babies, in particular when babies go on to solid foods. An education programme for

those who work with parents and families should be made available, to provide best

quality information on feeding all family members. There is a national maternal and

infant nutrition framework and locally an action plan has been created to meet the

outcomes of this framework. In addition, we plan to audit the support that currently

obese Primary 1 children have received to establish whether further support could

have been offered at any stage.

5.3.3 Increased access to healthy eating options and physical activity

We need to ensure that nutritional guidance for the early years is being implemented

across all services for children between one and five years, regardless of providers

of those services. We need to ensure that nurseries and other childcare facilities

20

minimise sedentary activity during playtime and give regular chances for enjoyable

active play and structured physical activity sessions.

The third sector needs to be supported to increase chances for promoting play, this

including the national go play programme. Currently Shetland Pre-School Play do a

range of activities to promote healthy eating and physical activity in the early years,

including Adventures in Foodland, promoting play including the play van, resources

to promote active play and healthy eating. Shetland Pre-School Play need to be

supported in rolling out and evaluating this work.

Finally the roll out and implementation of Getting It Right For Every Child (GIRFEC)

must continue so as to help identify the range of factors that may contribute to a child

being overweight and put in place actions to prevent or tackle this.

We will continue to train and support relevant key workers e.g. nursery staff, health

visitors, to have the confidence to raise the issue of weight with a child’s parent or

carer, and to use motivational skills in supporting that child and family to reach a

healthier weight.

21

5.4 Workplaces

A healthy workforce is needed to help Scotland increase sustainable economic

growth. Evidence suggests that physically active employees take 27% fewer sick

days than non-active employees. On-site fitness programme can reduce staff

turnover by 8%- 15%.i

5.4.1 The business case

Increasing obesity levels will lead to increased sickness absence and therefore it is

in the interest of employers to help support employees to prevent or tackle obesity.

As people spend so much time at work there is a real opportunity to actively promote

obesity prevention in the workplace. However, the limitations of workplaces in doing

this must also be taken into account. More workplaces are now aware that a healthy

workforce is more productive and many help support employees to keep healthy.

However, work needs to be done to let businesses understand the cost of obesity to

them and the benefits of policies and practices of preventing and tackling obesity,

along with cheap and practical way of supporting employees to be healthier.

5.4.2 Healthy Working Lives

In Shetland all the major employers are engaged with the Healthy Working Lives

(HWL) initiative, but we need to engage a more diverse range of businesses.

Healthy Working Lives provides a range of services free to help support employers

to support the health of their staff through health related training, health and safety

advice, or help with writing health related policies.

We will work to influence the national agenda so that obesity prevention is part of the

national strategy for HWL.

Action to implement health promotion action in hospital settings – under CEL 01

(2012) Health Promoting Health Service – Action in Acute Care Settings will

continue. This includes work on alcohol, smoking breastfeeding, healthy eating and

healthy working lives.

Public sector organisations need to be encouraged to set an example to other

landowners by taking action on their estate to help support activity, for instance sign

posted walks or better walking paths.

Paths for all is a national organisation that helps promote and encourage walking.

Locally we will promote this organisation with the aim of increasing the number of

workplaces signed up to their workplace walking programme. Workplaces will also

be encouraged to identify their own walking programmes.

22

Businesses should be encouraged to support their staff to be more active, this

includes participating in active nation promotions to tie in with the promotion of

activity as part of the build up to the 2014 Commonwealth games.

5.4.3 Healthy Living Award

The Healthy Living Award encourages caterers to make healthy eating choices

easier, by cooking more healthily, promoting healthy options and placing these

healthy options more prominently. All public sector employers who provide catering

to staff should work towards achieving this award before progressing to the Healthy

Living Award Plus1.

5.4.4 Weight management programmes

NHS Boards need to work with businesses to assess the need for and put in place

workplace weight management programmes. Currently Counterweight is offered to

workplaces locally.

1 http://www.healthylivingaward.co.uk/caterers/the-plus-award/

23

6. Obesity Treatment

6.1 Childhood obesity – how is it treated?

SIGN 115 lays out guidance on childhood obesity treatment it is important that all

practitioners follow this guidance and updates to it.

Treatment of childhood obesity needs to be family based. It needs to focus on

changes to diet (decreasing overall dietary energy intake), increasing physical

activity and reducing sedentary behaviours, often including screen time. The use of

behaviour change tools has also been shown to be effective. In children and

adolescents lifestyle interventions are shown to have significant reductions in

overweight and obesity when compared to standard care and self-help.

Interventions on the whole have been found to be most effective if they are both

intensive and long-lasting, of at least 6 months duration.

Behavioural modifications included in treatment should involve goal setting, stimulus

control, self-monitoring, rewards for reaching goals and problem solving. Giving

praise and encouraging parents/carers to role model desired behaviours are also

recommended.

All staff involved in the management of childhood obesity should undertake training

on the necessary lifestyle changes and the use of behavioural modification

techniques.

Before any obesity programme commences with children it first must be ascertained

that the child has no underlying medical cause. Programmes should only be offered

to those who are ready and willing to make lifestyle changes. There is a need locally

to develop a pathway for referral to child healthy weight interventions. This pathway

must take into consideration the link between obesity and malnutrition, refusal to

engage with services and child protection (an example pathway is presented in

Appendix 5).

For most obese children (BMI≥98th centile) weight maintenance is an acceptable

treatment goal. For children with a BMI ≥99.6th centile a gradual weight loss to a

maximum of 0.5-1.0kg per month is acceptable. In overweight children (BMI centile

91st to <98th) weight maintenance is an acceptable goal. In the case of the latter it

may be appropriate to do annual BMI monitoring thereby reinforcing weight

maintenance and reducing the chances of overweight children becoming obese. By

charting weight over time on the BMI centile charts the benefits of weight

maintenance or modest weight loss in older children can be demonstrated to the

family.

The Child Healthy Weight HEAT target gives each Health Board in Scotland a

number of child healthy weight interventions to complete by the end of March 2014

with children aged between 2-15 years, with a BMI ≥91st centile. The target also

24

involves taking health inequalities into account. The target comes along with

guidance which encourages boards to take a 3 tiered approach to childhood obesity

prevention and management as illustrated in the diagram below: xviii

In local terms tier 1 work is outlined in the prevention section of this strategy. Tier 2

work is delivered locally through a school based programme. This consists of 6

lessons over at least 6 weeks delivered to whole classes and focuses on education

on healthy eating, physical activity and reducing sedentary time. Children are given a

take home chart, which they complete with their family. It is run in partnership by

NHS Shetland public health nurse trainee and health improvement staff and

Shetland Island Council active school and teaching staff. Over the next year,

teaching staff will be trained to deliver these sessions themselves with support from

NHS staff.

Tier 3: Specialist assessment/care for children/young

people ≥99.6th centile with obesity-related co-morbidity

or suspected underlying medical cause of obesity.

Tier 2: Overweight and obesity management

interventions for children/ young people ≥91st centile.

Individual or group, school or community-based,

delivered by appropriately trained child healthy weight

specialists from a range of professional backgrounds.

May be delivered to children <91st centile at same time

e.g. as part of a class group

Tier 1: Obesity prevention / health improvement / intervention

work to tackle wider influencers and structural determinants of

child unhealthy weight, reaching the whole child population.

Indirectly supports raising the issue and stimulates

contemplation of behaviour change amongst overweight/obese

children and their families.

25

In terms of tier 2 there are currently four family based child healthy weight

programmes available, namely SCOTT, SCOTTlite, Building Physical Activity and

Healthy Eating into daily life and Counterweight Families.

The SCOTT programme is a family centred weight management programme to help

promote childhood healthy weight. It consists of 9 family based one-one sessions

with a health professional over 6 months for children and adolescents aged 5-15

years. The programme does not focus on dieting but instead helps the whole family

establish long-term lifestyle changes to diet as well as increasing physical activity

and reducing sedentary time in order to promote healthier weight. It takes a

behaviour change approach which involves goal setting, monitoring and reward for

achieving goals. To qualify for this programme the child must have a BMI ≥91st

centile and must have an assessment to ensure there are no other underlying

medical causes and that the family are ready to engage.

SCOTTlite works on the same principles as SCOTT except that it is geared towards

2-15 year olds and those with special needs. The practitioner works with the parent

to address the child’s need rather than directly with the child although the child will

be present at appointments. Overall it consists of 6 one-one sessions.

The Counterweight families programme is a structured family programme which

consists of 10 sessions over one year. The sessions cover the following preparing

to change, implementing planned changes, setting boundaries, family working

together to achieve changes, family shopping, rewarding success, family being

active, getting enough sleep, family meals (the benefits of eating together) and

making changes part of everyday life. In order to qualify for this programme the

family must have at least one parent/carer with a BMI≥30 and a child or children with

BMI/s ≥91st centile. It is for primary school aged children only.

Building Physical Activity and Healthy Eating into daily life focuses on giving advice

on healthy eating, physical activity and reducing screen time and other sedentary

time in line with identified individual need. The aim is to help the client to adopt and

maintain a healthy lifestyle and work towards a healthy weight. This is a family

centred weight management programme to help promote child/young person healthy

weight. It consists of 8 sessions with a health professional and child/young person

taking place over 1 year involving at least one parent/carer, focusing on children and

young people aged 5-18 years. The programme is designed to offer an alternative

for those not wanting to participate in other available programmes but still seeking

support and guidance.

Currently in Shetland all these programmes are predominantly delivered by one

practitioner, there is a need to train more staff that work directly with children within

the 2-15 years age group to build the delivery of these programmes into their work.

26

However, if we assume that the primary 1 figures are indicative of the rest of the

population, we still have a long way to go to meeting the needs of these children.

We need to set year on year targets in line with the estimated need, including the

use of GIRFEC to identify and refer children.

Raising the issue of children being overweight can be difficult. However, there is no

reason that this cannot be done by a range of professionals who work with children

on a regular basis. Raising the issue training has been created by Health Scotland

and can be delivered to staff locally to increase their confidence and skills in this

area. This coupled with an understanding of how to refer children on for help once

the issue of weight has been raised will help to increase the number accessing

healthy weight programmes.

Analysis of available local childhood overweight and obese data is planned and

treatment and prevention targets set for the next 10 years in order to reduce

childhood obesity levels with an aim to have no children who are severely obese

within ten years.

27

6.2.1 Adult obesity - how is it treated?

SIGN 115 lays out guidance on adult obesity treatment. It is important that all

practitioners follow this guidance and updates to it. ii

There are a number of health benefits of losing weight and keeping it off. Healthcare

professionals should make people aware of these as follows:

Improved lipid profiles

Reduced osteoarthritis-related disability

Lowered all-cause, cancer and diabetes mortality in some patient groups

Reduced blood pressure

Improved glycaemic control

Reduction in risk of type 2 diabetes

Potential for improved lung function in patients with asthma

Assessment of patients with obesity should include assessment of:

Co-morbidities

Co-existent risk factors

Liver function tests

Weight cycling

Binge eating disorder

Willingness to change and set targets against willingness

Weight management programmes should include physical activity, reduced

sedentary behaviour, dietary change and behavioural components. Practitioners

delivering such programmes should be appropriately trained. Dietary interventions

for weight loss should be calculated so that there is a 600 kcal energy deficit per day.

Individual or group based psychological interventions should be included in weight

management programmes; these should be tailored to individuals and their

circumstances.

Orlistat is a drug which reduces the absorption of dietary fat. It should only be used

where appropriate and where diet, physical activity and behavioural changes are

supported. Patients with a BMI ≥28kg/m2 with co-morbidities or BMI ≥ 30 kg/ m2

should be considered for Orlistat on an individual basis following assessment for risk

and benefit.

There are certain factors associated with the risk of overweight and obesity. Giving

up smoking leads to increased chances of putting on weight over the first years and

health care professionals should offer weight management interventions to those

who are planning to quit. Certain medications can also cause people to put on

weight and weight management measures should be discussed with people

prescribed such medication.

28

In Shetland we will work to embed assessment of physical activity as part of routine

clinical practice, as per equivalent risk factors like smoking and alcohol. A single

question assessment and script for brief advice/ assessment is being finalised by

NHS Health Scotland and we will support the implementation of this for Allied Health

Professionals and for primary care.

Alcohol is also highly calorific and lacks nutritional value and must be taken into

account when assessing and treating obesity. Recommended limits for alcohol are

2-3 units per day for women and 3-4 units per day for men with 2 alcohol free days

per week. One unit of alcohol is equivalent to 70 kcal. This means that a standard

glass of wine (175ml and 13%abv) equals 159 kcals and one pint of beer (5% abv)

equals 199 kcals. xv

Alcohol can also lower inhibitions as well as being an appetite stimulant meaning

that people may overindulge in foods they are trying to avoid. For patients with

weight control difficulties, alcohol consumption should be limited.

SIGN Guidelines suggest that Health Boards should develop explicit care pathways

offering a range of weight management interventions which may be targeted at the

various subgroups of the population. The evidence for obesity treatment is growing

and currently suggests that a tiered service is the most effective for population

planning. xiii The tiers are usually described as 1 to 4 as follows:

Tier 4: Specialist surgical service

Bariatric surgery, gastric bands. Specialist

follow up.

Tier 3: Specialist Weight Management

Access to multi-disciplinary team e.g. dietetic led

programme, psychological expertise, physiotherapy.

Tier 2: Primary Care

NHS Healthy Weight programmes, Lifestyle Adviser, Community

Dietetic. Drug therapy if appropriate supported by local clinical

guidance.

Tier 1: Population-wide health improvement work

Community interventions including active referral, walking groups, leisure club classes,

cooking classes. Links to Obesity Route Map.

www.scotland.gov.uk/Publications/2010/02/17140721/0

29

The links between BMI levels, the tiers of the previous diagram and local service

provision and gaps are illustrated in the following diagram.

BMI ≥ 35 Surgery (relates to tier 4)

18 – 44 years with a BMI between 35 and 40 and <5 years of type 2 diabetes. Need to have completed Tier 3 intervention for at least 6 months and maintained weight or lost 5kg.

18 – 44 years with a BMI between 40 and 50 and <5 years of type 2 diabetes. Need to have completed Tier 3 intervention for at least 6 months and maintained weight or lost 5kg. Those who fall out with these groups but would still like surgery will have their case heard by locally elected board which needs to include all relevant professionals i.e. die titian, physiologist, surgeon. As this guidance is very new a panel is yet to be set-up locally but this will be done as a matter of priority.

A

.

BMI ≥35 or ≥ 30 with co-morbidities (relates to tier 3) – Currently this is a gap in provision in Shetland where referral to a specialist programme is required led by dietetics with input from mental health and physiotherapist services as relevant. (this may or may not include use of low calorie liquid diet or pharmacological interventions). Development of this service is required.

BMI ≥ 28 with co-morbidities or BMI ≥30 (relates to tier 2) – In Shetland the Counterweight programme is available through primary care in most areas. This is a fully evaluated, structured 3 month programme aiming for a 5 to 10% weight loss and maintenance. This is achieved through dietary changes either involving a goal setting approach or estimated 500 calorie deficit diet and increased physical activity and reduced sedentary time. The participants are followed up 3 monthly for the first year and then annually thereafter. Ongoing training will be delivered so that it is available Shetland-wide. However, there needs to be updated referral guidance for Counterweight, in particular, for those who attend but are not fully engaged. There are also programmes available through the community, and it is an individual’s personal choice to attend these. However, more research is needed locally on these programmes and there needs to be guidance to aid individuals in making such choices.

BMI ≥25 - BMI<30 (relates to tier 2). Currently this is a gap in terms of delivery in Shetland. A structured intervention needs to be put in place focusing on increasing physical activity, reducing sedentary time and healthy eating involving participants attending sessions where they do physical activities and hands-on learning about healthy eating.

BMI < 25 (relates to tier 1) Primary prevention approaches using population

based strategies and resources as detailed in prevention section of strategy.

30

There is also currently a gap in provision of healthy weight programmes for the 16-

18 years age bracket and further work needs to be done to develop a suitable

solution to this. There is a need overall to develop an adult healthy weight referral

and treatment pathway taking into account all four tiers.

Analysis of available local adult overweight and obese data needs to done and

treatment and prevention targets set for the next 10 years in order to reduce

overweight and obesity in adults.

6.2.2 Management of women with obesity in pregnancy

Maternal obesity has become the most commonly occurring risk factor in obstetric

practice. This is usually defined as a Body Mass Index (BMI) ≥30kg/m² or more at

the first antenatal appointment. NHS Shetland maternity department have created a

management protocol with clear actions in relation to this area. The protocol is

presented in appendix 6.

31

7. Key Partners and reporting lines

Community Planning Partnership yearly updates on delegated actions

Community Health Partnership Committee 6 monthly update on delegated actions

Health Action Team 6 monthly update on delegated actions

DPH

Department Managers

Cross departmental

NHS staff

Exec director: Children

Services/Deve-lopmental Services

HODs

Cross departmental

SIC staff

SRT General Manager

Health and Fitness

Manager

SRT staff

Zet Trans General

Manager

Lead Officer

Zet Trans Staff

Voluntary Action

Shetland Executive

Officer

VISP

Third Sector Staff

32

Year 1 Action Plan

Outcomes Indicators Action Time scale Lead

Prevention

More people in Shetland eating healthily

Report produced ready for circulation

1. Produce report on business case for producing healthier food (applying social marketing approach)

March 2013

Health Improvement And Economic Development (SIC)

Guidance document drawn up and support offered

2. Guidance and support for shops to set up fruit and vegetable box schemes

March 2013

Health Improvement

Report produced and action plan in place

3. Audit of contents of vending machines across SIC and SRT estate and 5 year plan to stock and promote healthy eating options

November 2012

Health Improvement

Report and action plan in place on healthy eating and tuc shops

4. Audit of tuck shops in youth clubs and 5 year plan to stock and promote healthy eating options

December 2012

Health Improvement, Oral health promotion and youth services

5. Audit of school tuck shops and 2 year plan to stock and promote healthy eating options

September 2012

Oral Health Promotion

Increased activity levels in the population of Shetland

Increased awareness of safety and active travel People feel safer when travelling by bicycle or on foot

6. Work with communities to reduce the fear of road safety and concentrate on making the roads feel safer, consult with communities and put action in place.

January 2013

Shetland Island Council Health Improvement

As per Active Lives Strategy

7. Year one actions from the Active Lives Strategy

As per Active Lives Strategy

New developments have designs

8. Design to continue to consider active travel as part of new

Shetland Island Council

33

that support active travel

developments Planning

Increased adoption of healthy eating and physical activity habits in the early years

Decrease in women who are obese pre and during pregnancy

9. Continue with the management of obesity pre and during pregnancy

March 2012

Midwifery

As per infant feeding strategy

10. Implement Infant Strategy Actions

2011 – March 2012

Infant Feeding Strategy Group

Increased usage of GIRFEC by professionals from all sectors

11. Continued roll out of GIRFEC and information circulated to all relevant people in order to gain an understanding of this within the context of child healthy weight

December 2012

Reduced obesity levels in working age population

Obesity become part of Healthy Working Lives nationally

12. Produce briefing report and use this to lobby for obesity to be part of the National Healthy Working Lives strategy

September 2012

Health Improvement

Treatment

Reduction in obesity levels in Shetland

Increased referral to weight management programmes/ services

1. Create and implement child healthy weight referral pathway

November 2012

Child Health

2. Create and implement adult healthy weight referral pathway

March 2013

Dietetics

3. Relevant staff trained in raising the issue of child healthy weight

March 2013

Health Improvement

Increased number of healthy weight sessions delivered in schools

4. Teaching staff to be trained to deliver school based healthy weight sessions

October 2012

Health Improvement

Greater range of weight management programmes on offer Improved

5. Research weight management programmes for the 16- 18 years age group and put in place programme

March 2013

Dietetics and Health Improvement

6. Research and put in March Dietetics and

34

access to weight management programmes

place specialist weight management programme for those in tier 3

2013 Health Improvement

7. Research programmes available for those with a BMI ≥ 25 < 30 and take action based on recommendations

March 2013

Dietetics and Health Improvement

8. Establish panel for assessment for bariatric surgery for those outwith guidance criteria

September 2012

Dietetics and Health Improvement

Clear targets set and a practical plan for prevention and treatment in place

9. Analyse available data and set targets for reducing obesity of the population of Shetland through prevention and treatment

December 2012

Health Improvement

35

Year 2 Action Plan

Outcomes Indicator Action Timescale lead

Prevention

More people in Shetland eating healthily

Increased numbers of healthy eating options available at tuck shops, vending machines and shops

1. Implement action plans for year 1 actions 1-5 Prevention section

As per plans Health Improvement

Report produced and action plan in place

2. Audit of food purchasing patterns of young people who choose to eat outside school

October 2013

Health Improvement and SIC education

Decrease in lunch box usage in schools And improved lunch boxes in wider population

3. Healthy Lunch box and snack messages promotions

November 2013

Health Improvement and SIC education

Report produced and action plan in place

4. Identify areas where there is the greatest need for cookery classes and put these in place

October 2013

Health Improvement

Increased activity levels in the population of Shetland

Report produced and action plan in place

5. Research in the Shetland context if people feel safe being outdoors and the impact this may be having on being active

January 2014

Health Improvement SIC community safety

Increase in numbers of people walking to or throughout the working day

6. Paths for all promotions across workplaces

January 2014

Health Improvement

7. Through consultation with a range of workplaces create a pack to help them encourage staff to be more active

January 2014

Health Improvement SIC economic development

36

Actions Year 3- 10

Implement actions 2,4,5,9 of year 2 plan

Consult with supermarkets and convenience stores and look into ways to

reduce the amount of energy dense food and drinks stocked.

Evaluation of all healthy weight programmes, review effectiveness and take

action in line with findings

Implement Year 3-10 actions of the Active Lives Strategy

Board work with workplaces to assess need for weight management

programmes and take action to address the need

Work alongside the local retailers association to take a co-ordinated approach

to identifying need for and improving access to healthy eating options

Shops encouraged to set-up their own healthy schemes or sign up to the

Healthy Living Neighbourhood shop scheme

Promotion of and encouragement of eating outlets and caterers to sign up to

the Healthy Living Award, in particular workplace caterers.

Work with local producers to make the nutritional content of their food more

obvious

Assess use of the public sector estate and where appropriate take action to

help support people to be more active.

Increased adoption healthy eating and physical activity habits in the early years

System put in place

8. System put in place for setting up and monitoring nutritional guidance compliance across all services for children between 1 and 5 years.

March 2015 SIC education VAS

Report produced and action plan put in place

9. Audit of sedentary activity in early years settings

March 2015 SIC education VAS

Treatment Reduce obesity levels in Shetland

1. 6 monthly monitoring meeting of set targets with regards to child and adult obesity

March 2015 Health Improvement

37

Appendix 1: Estimated Energy Needsxix

The following are examples of varying energy (calorie) needs for teenage boys and

girls of different ages and activity levels.

38

Appendix 2: Eatwell Plate xx

39

Eatwell key messages

1. Base your meals on starchy foods

2. Eat lots of fruit and vegetables

3. Eat more fish – including a portion of oily fish each week

4. Cut down on saturated fat and sugar

5. Try to eat less salt – no more than 6g a day for adults

6. Get active and try to be a healthy weight

7. Drink plenty of water

8. Don’t skip breakfast

40

Appendix 3: Pre-pregnancy Care Pathway for women with obesity

Pre – pregnancy care of all women with a BMI≥30

Give information and advice about risks of obesity and pregnancy to include

Miscarriage

Gestational Diabetes

Pre-eclampsia

Venous thrombosis

Induced labour

Caesarean section

Anaesthetic complications

Wound infection

Breastfeeding

Stillbirth

Congenital abnormalities

Prematurity

Macrosomia

Neonatal death

Childhood obesity

Metabolic disorders of childhood

Place of delivery Support women to lose weight and refer to counterweight programme. Commence Folic Acid 5mgs daily at least one month prior to conception.

41

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42

Appendix: 5

Example primary care pathway for children and young people with overweight and

obesity

Assessment of weight/ BMI in children and young people if ≥ 91st centile overweight, ≥

98th centile obese

Yes

NO

Child and Family willing to change?

Yes

YES

Recommend healthy eating, physical activity, brief behavioural advice. Manage co- morbidity/ underlying cause if appropriate. See SIGN guideline section 20 for resource suggestions OR Refer to local obesity service (if child meets local criteria)

Progress/ BMI centile decreased?

Yes

Maintenance and local support options.

Raise the issue of weight

Previous literature provided? Review as appropriate

Provide lifestyle advice targeted to

individual family. See SIGN guideline

section 20 for resource suggestions.

Discuss the value of managing

weight; provide contact for more

help/ support.

Offer further discussion and future

support if/ when required

Re- evaluate if family/ child willing to change.

Repeat previous option for management

OR

Refer to local child obesity service for further

support (if meet local criteria)

OR

If appropriate and available, consider referral

to paediatric endocrinologist for assessment

of underlying cause and/ or comorbidities.

43

Assessment

Eating habits, physical activity patterns, sedentary behaviours, eg TV

viewing

BMI- plot on centile chart

Emotional/ psychological issues

Social and school history

Level of family support

Stature of close family relatives (for genetic and environment information)

Family history, eg obesity/ diabetes

Non- medical symptoms, eg exercise intolerance, discomfort from clothes,

sweating

Mental health

Acanthosis nigricans

Consider

Associated comorbidity- consider: metabolic syndrome, respiratory

problems, hip and knee problems, diabetes, CHD, sleep apnoea, high blood

pressure

Underlying cause- consider: hypothyroidism, Cushing’s syndrome, growth

hormone deficiency, Prader- Willi syndrome

44

Appendix 6: Management of Women with Obesity in Pregnancy

Purpose

Maternal obesity has become the most commonly occurring risk factor in obstetric practice.

Usually defined as a Body Mass Index (BMI) ≥30kg/m² or more at the first antenatal

appointment.

Pre-pregnancy care

Women of childbearing age with a BMI ≥ 30 should receive information and advice about

the risks of obesity during pregnancy and childbirth and should include the risk of

miscarriage, gestational diabetes, pre-eclampsia, venous thrombosis, induced labour,

caesarean section, anaesthetic complications, wound infection, breastfeeding, stillbirth,

congenital abnormalities, prematurity, macrosomia, neonatal death, childhood obesity,

metabolic disorders of childhood.

Be supported to lose weight before conception and refer to counterweight programme.

Advice on weight and lifestyle should be given during family planning consultations.

Women should be advised to take 5mg folic acid daily , starting at least one month before

conception and continue during the first trimester.

Antenatal Care

Women with a BMI≥30 will be advised to take folic acid 5mgs daily during the first trimester.

All pregnant women will have their BMI calculated at booking and documented in maternity

notes. Re weigh at 36 weeks enable appropriate plans to be made for labour and delivery.

All pregnant women with a booking BMI≥30 will be provided with accurate and accessible

information about risks associated with obesity in pregnancy and given the opportunity to

discuss this information with referral to appropriately trained professional for dietery

advice.

Women with a BMI≥40 will have a review by a consultant anaesthetist at or around the time

of booking so that they can be alerted early in pregnancy to the specific anaesthetic hazards

of obesity, anaesthesia and delivery. They will be strongly advised to opt for delivery in

Aberdeen. Anaesthetic consultants will also see and advise women with BMI between 30

and 40 if other risk factors are present.

Women with BMI≥40 will require a documented assessment to determine manual handling

requirements and tissue viability.

45

Women with a BMI 30 will be assessed at booking appointment and throughout their

pregnancy for the risk thromboembolism. Antenatal and postnatal thromboprophylaxis

should be considered in accordance with RCOG Clinical Guideline No. 37.

Appropriate size of arm cuff should be used for blood pressure measurements. The cuff size

should be documented in the maternity records.

Women with a BMI≥35 have increased risk of pre-eclampsia and should have antenatal care

in accordance with the Pre-eclampsia Community Guideline (PRECOG) 2004.

Women with a BMI≥35 with at least one additional risk factor should have an early

referral in pregnancy for GP/OB review and referral to Consultant at Aberdeen

Maternity Hospital.

Women with a BMI≥35 with no additional risk factor can have community

monitoring with a minimum of 3 weekly visits between 24 and 32 weeks and 2

weekly visits from 32weeks until delivery.

Women with BMI≥30 will be offered a glucose tolerance test between 24-28 weeks as

recommended by NICE Clinical Guideline No 63 (Diabetes in Pregnancy, July 2008)

Planning Labour and Delivery

Women with BMI ≥30 will have an informed discussion antenatally about possible

intrapartum complications associated with high BMI and how these will be managed. This

will be documented in antenatal records.

Women with BMI ≥30 considering VBAC (vaginal birth after caesarean) should have an

individual decision following an informed discussion about all relevant clinical factors.

Women with BMI ≥35 should deliver in a consultant led obstetric unit with access to

neonatal services as recommended by NICE Clinical Guideline No 55 (Intrapartum Care, Sept

2007). If women decline delivery in Aberdeen Maternity Unit a risk assessment will be

carried out and documented in maternity records. Any woman with BMI 40 insisting on

delivery in Shetland will see an anaesthetist after 36 weeks in order that the risks of delivery

and potential anaesthesia can be discussed and documented. This assessment will include

but not be limited to airway, venous access, potential difficulties with regional anaesthesia

for operative deliveries and risk of venous thromboembolism. They will be advised to opt

for delivery in Aberdeen.

Women with BMI ≥30 require individual assessment for induction of labour and local

guideline should be adhered to.

Anaesthetist and GP/OB to be informed when a Woman with BMI ≥35 is admitted in labour

and documented in maternity records.

46

Women with BMI ≥40 should have IV access early in labour.

Theatre staff should be notified if woman weight exceeds 120kg prior to transfer to theatre.

GP/OB to attend the deliveries of women with BMI≥35.

All women with BMI≥30 should be recommended to have active management of the third

stage and discussion documented in notes.

Women with BMI ≥30 should receive prophylactic antibiotics at the time of a caesarean

section as recommended by NICE Guideline No 13 (Caesarean Section, April 2004)

Women undergoing caesarean section who have more than 2cm subcutaneous fat should

have suturing of the subcutaneous tissue space to reduce the risk of wound infection as

recommended by NICE Guideline No 13 (Caesarean Section, April 2004)

Postnatal care and follow-up after pregnancy

Women with a BMI≥30 will receive support and specialist advice postnatally regarding

benefits, initiation and maintenance of breast feeding.

Women with a BMI≥30 should be offered advice about weight reduction and referred to

counterweight programme.

Women with a BMI≥30 who have been diagnosed as gestational diabetic would be offered

glucose tolerance test 6 weeks after delivery.

If glucose tolerance test is normal regular follow up by GP to screen for development

of type 2 diabetes

Annual screening for cardio-metabolic risk factors and offered life style and weight

management advice.

Obe

Management of Women with Obesity in Pregnancy: References

1. CMACE/RCOG Joint Guideline: Management of Women with Obesity in Pregnancy March

2010

2. RCOG Green Top Guideline No 37: Reducing the risk of thrombosis and embolism during

pregnancy and puerperium 2009

3. The Pre-eclampsia Community Guideline (PRECOG) 2004. Action on pre-eclampsia

4. NICE Clinical Guideline No 13: Caesarean Section, April 2004

5. NICE Clinical Guideline No 55: Intrapartum Care, Sept 2007

6. NICE Clinical Guideline No 63: Diabetes in Pregnancy, July 2008

47

Obesity Strategy References

i Scottish Government (2010) Preventing Overweight and Obesity in Scotland – A

Route Map Towards Healthy Weight

ii SIGN (2010) 115 Management of Obesity – A national clinical guideline

iii Scottish Collaboration for Public Health Research (2011) Policy interventions to

Tackle to Obesogenic Environment – focusing on adults of working age in Scotland

iv Scottish Government (2011) The Scottish Health Survey

v UK Faculty of Public Health (2010) Adult’s Obesity Ready Reckoner Available at:

http://www.fhp.org.uk/adult%27s_obesity_ready_reckoner (Accessed 12th June

2012)

vi Scottish Government (2010) The Scottish Health Survey

vii Scottish Executive (2003) Let’s make Scotland More Active

viii Scottish Government (2009) Five Year Review of Let’s Make Scotland More

Active

ix Scottish Government (2009) The national food and drink policy Recipe for

Success

x Scottish Government (2011) Improving Maternal and Infant Nutrition a Framework

for Action

xi Scottish Government (2008) Healthy Eating, Active Living: An action plan to

improve diet, increase physical activity and tackle obesity (2008-2011)

xii NHS Health Scotland, The Improvement Service, Scottish Government and

COSLA (2011) Elected Member Briefing Note no. 9 The Obesity Time Bomb – Why

it’s everyone’s business

xiii NHS Scotland (short-term working group) (2012) Obesity Treatment Best Practice

Statement

xiv Scottish Government (2008) The nutritional requirements in food and drink in

schools (Scotland) regulations

xv Counterweight (2006) Weight Management in Primary Care Training Manual

xvi Scottish Government (2007). Guidance on HEAT targets issued to NHS Boards.

December 2007

48

xvii Scottish Government (2010) Preventing Overweight and Obesity in Scotland – A

Route Map Towards Healthy Weight

xviii Scottish Government (2011) Guidance for delivery of HEAT Target: Child

Healthy Weight Interventions 2011 – 2014

xix The Caroline Walker Trust (2010) Eating Well for 12-18 year olds Practical Guide

xx Food Standards Agency, NHS Health Scotland, Scottish Government (2012) Your

guide to the Eatwell plate - helping you to eat a healthier diet Available at

www.eatwellscotland.org (Accessed 12th June 2012)