A Healthier Future – Action and Ambitions on Diet, Activity and Healthy Weight
23rd January 2018
Statement submitted from Prof Bob Steele and Prof Annie S. Anderson, Co-directors of the SCPN
The Scottish Cancer Prevention Network (SCPN) is focused on moving evidence on cancer risk reduction into everyday life, practice and policy (https://www.cancerpreventionscotland.org.uk/). Whilst it is recognised that governments do much to support changing behaviours we also recognise that there is a need to increase capacity around cancer prevention and screening, and there is much more that agencies and government work streams can do to help to accelerate change. As an advocacy group we raise the profile of cancer prevention and screening research and action through a range of communication channels (newsletter, conference, workshops, social media and web-based activities) and support ongoing work in reducing the prevalence of cancer risk factors. The SCPN is funded by the Scottish Cancer Foundation charity (SCO28300).
The evidence base for actions to reduce cancer incidence and improve prognosis is provided by the WHO International Agency for Research in Cancer (IARC) who have also developed the European Code Against Cancer (https://cancer-code-europe.iarc.fr/index.php/en/about-code). It is estimated that 4 in 10 cancers can be prevented largely through lifestyle changes. Lifestyle plays an even greater role in the prevention of bowel cancer (47%) and breast cancer (38%) https://www.wcrf-uk.org/uk/preventing-cancer/cancer-preventability-statistics. The public remain generally unaware of major risk factors (e.g. obesity) and have little access to services to support behaviour change even although evidence shows that lifestyle alterations after the age of 50 (age screening for breast and bowel cancer commences) is associated with reduced risk of these cancers and other chronic diseases including diabetes and cardiovascular disease.
Are there any other types of price promotion that should be considered in addition to those listed above? (listed as: foods high in fat, sugar and salt, including multi-buys and temporary price promotions)
Our food environment tempts us at every turn to eat more and more of the food and drinks that we should be eating less and less of. The SCPN welcomes restrictions on all types of price and non-monetary promotions of foods and drinks that are high in fat and sugar and those which fail to meet the updated OFCOM nutrient profile model.
We are mindful that restrictions should include
- Price marked promotions (price printed on packaging to attract attention).
- Meal deals which include confectionery.
- Product placement: prominence of chocolate and other discretionary foods in shops.
It is important that promotions in the catering sector (not only retail sector) are included. These have particular significance for workplace and commuter health (2).
How do we most efficiently and effectively define the types of food and drink that we will target with these measures?
The OFCOM nutrient profile model (3) provides guidance on foods and drinks acceptable for promotion (i.e. price, quantity, and special offers). This is an evidence based approach (soon to be updated) that should be applied to all promotion products and allows promotion of healthier options.
Previous aspirations of Scottish Government to develop a Publicly Available Specification (PAS) for the marketing of food and drink should be reconsidered (4).
Use of traffic light cut-offs (as per NHS healthy retail initiative) is a half-hearted attempt to address the worst promotions – we need to do better than this. Many foods permitted to be promoted under the healthy retail scheme would fail the nutrient profile model.
To what extent do you agree with the actions we propose on non-broadcast advertising of products high in fat, salt and sugar?
We agree that the OFCOM nutrient profile model provides excellent guidance for directing non-broadcast advertising; to use any other definition would lead to mixed messages and this would undermine current nutrient profile modelling.
It is important that advertising limits extend to public transport given current evidence on commuter health (5).
Advertising needs to extend beyond adverts targeted at children because:
- This implies that children are making choices about their food habits (while influential, they do not control the finances in the household).
- Adults are the ones creating the obesogenic environment for the children.
- 65% of Scottish adults are overweight or obese. Therefore, more attention should be paid to advertising targeted at adults (in addition to children).
- Ban inappropriate sponsorship of prestigious events, e.g. sporting events, and festivals. This glamorises and promotes unhealthy behaviour.
Do you think any further or different action is required for the out of home sector?
Local authorities through planning regulations could alter the number of catering outlets available to the public. The growth in cafes, fast food restaurants (FFR) and take away outlets is dependent upon local authority policies. Without regulation, new food and drink outlets and businesses will continue to grow and encourage out of home eating. Average energy intake from eating out was 240 kcal per person per day in 2015 accounting for 11 per cent of total energy (6). Even with the proposed action on out of home establishments the density of outlets makes a major contribution to our obesogenic environment and continued consumption of excess energy.
There is a need to re-visit the criterion used for the Healthy Living Award which looks weak compared to nutrient profiling and other schemes for defining healthier options.
It would be timely to include vending sales and promotions as part of the retail environment – notably in local authority settings.
We recommend the use of our Healthy Meeting scorecard to guide meeting organisers (private, public and third sector) in order to highlight key issues of food and beverage hospitality and physical activity (BOTH of which should be considered for reducing obesity reduction). The Healthy Meetings Scorecard can be found at the following link: https://www.cancerpreventionscotland.org.uk/what-we-do/healthy-meetings/scorecard/.
Do you think current labelling arrangements could be strengthened?
Please explain your answer.
All written nutrient information on packaging should be clearly laid out (e.g. large font, specific position) on all packages. It is notable that, in the 65 to 74 age group, 73% of Scottish adults are overweight and 32% are obese (7). Significant numbers of people in this age group having reading problems and would find current information on the weight of food within a package hard to read. In addition, current estimates suggest that sight loss affects around 188,000 people in Scotland and this figure is set to double by 2031 as a result of the ageing population, and because of the increase in health conditions associated with visual impairment—such as obesity and diabetes (8). Traffic light information helps considerably but quantitative information must be in a readable format. Ideally, information on the nutrient profile score should also be available given evidence from Australia which suggests that a “composite score” which provides a summary of overall nutrition rating scheme is more effective at directing consumers towards healthier choices (9).
What specific support do Scottish food and drink SMEs need most to reformulate and innovate to make their products healthier?
Do you think any further or different action is required to support a healthy weight from birth to adulthood?
Please explain your answer.
Early life nutrition has a major impact on growth trajectories throughout childhood and adolescence which in turn impact on cancer risk in later life (10). The promotion of breast feeding, appropriate introduction of complementary foods, diet in the first years of life and early growth patterns set the scene for cancer risk reduction. But the role of diet and body weight in cancer development does not stop in childhood.
Midwives, Health Visitors and other community based health professionals are key in supporting healthy living for mothers and families. There is a need to ensure that “front line staff” are not only trained, but also supported and monitored, for fidelity of the interventions provided and that evidence of advice given is noted on client databases.
How do you think a supported weight management service should be implemented for people with, or at risk of developing, Type 2 Diabetes – in particular the referral route to treatment?
We agree that supported weight management services should be implemented for people with (or at high risk of) diabetes, but we need to look beyond traditional health service delivery programmes to develop community based support with third sector involvement. The ActWELL programme (11) http://actwellstudy.org/ is a good example of this type of approach.
Within the health service, funding GP surgeries to have ‘health champions’ for overweight and obesity would be a useful and visible consideration.
It is also important to note that obese people who are diagnosed with breast, colon and other obesity related cancers fare worse than the non-obese (12). Oncologists and other health professionals recognise this challenge and also note the lack of access to support obese cancer patients. Therefore, we recommend that greater priority should be given to provide weight management services to obese cancer patients (or those at higher risk of cancer) as well as those with diabetes.
It should also be noted that many patients at higher risk for cancer are also at higher risk of diabetes, as demonstrated in the BeWEL study (13), and targeted weight management can offer significant health gain.
Do you think any further or different action on healthy living interventions is required?
Please explain your answer.
The European Cancer Code has developed the recommendation that we take action to be a healthy body weight throughout adult life. The phrasing is important:
- Adult weight gain is the starting path towards excess body fat.
- In our obesogenic environment everyone is at risk of weight gain.
- Excess body fat is related to 13 different types of cancer.
- Weight gain (irrespective of starting weight) in adult life is related to increased breast cancer risk.
It is undesirable to stress that all people should achieve a healthy weight – this goal is unachievable for many – but avoiding weight gain and weight loss (in the overweight) are messages applicable to all – taking action is the key message.
Primary health care provides opportunities to promote and support guidance on diet and avoidance of weight gain throughout adult life. However, there are also many teachable moments within a health promoting health service when healthy lifestyles could be discussed, including cancer screening settings. The BeWEL study (14) demonstrated successful weight loss in adults (predominantly men) over 50 diagnosed with colorectal adenomas with equal effects on people from lower and higher deprivation (15).
The Scottish Government funded ActWELL trial using the setting of breast screening is a further example of offering weight management support within routine screening. There are other screening settings to explore including aortic aneurysm screening for men aged 65 (who rarely access diet and obesity advice despite having the highest rates of obesity of any adult sub group).
In ActWELL it is notable that Breast Cancer Now volunteers have been trained to deliver the weight management intervention. This model deserves further examination because it increases capacity for supporting weight loss but also impacts on the health of trained volunteers. This model also has the potential to be more cost effective than reliance on the limited available NHS personnel who are trained to deal with obesity.
How can our work to encourage physical activity contribute most effectively to tackling obesity?
In addition to weight management, the European cancer code (1) recommends that people are active in everyday life.
This recommendation translates as active at home, at work and in transport.
Active travel should be safe, affordable and convenient. This could be achieved through: bike libraries, bike racks, cycle lanes, safe walking paths (well lit, good pavement surface). Consideration needs to be given to:
- Those living in rural areas where the only route of transport may be by car. Park and ride facilities with walking options should be explored and supported by local authorities.
- Older people who are home based (and do not wish to or cannot) attend group based activity sessions
While the daily mile is a good start in schools it would be good to see this supported across the wider community including workplaces and NHS sites; there is a need for more action in this vein; regular interval breaks for physical activity should be encouraged by employers to break up sedentary behaviour which is associated with increased colon cancer (16). We need to think well beyond children and develop a portfolio of techniques for engaging adults that are not based on “sports and exercise”.
The SCPN would like to see pedometers given on prescription to all people at risk of obesity with guidance on personalised goal setting (17). This approach can act as a first and universal approach to many people who are too inactive to support any increase in energy expenditure.
What do you think about the action we propose for making obesity a priority for everyone?
Collectively, we need to create weight management as a desirable goal which may mean not focussing on health aspects. For example, Football Fans in Training used the draw of football clubs to attract participants. There are many other reasons for wanting to manage weight … playing with grandchildren, doing main stream shopping, looking good. It is timely to explore cultural reasons for why obesity stops us leading the full and varied life that many people could aspire to.
Within the NHS, the Health Promoting Health Service (HPHS) initiative needs to achieve greater commitment from health boards and clearer outcomes relating to healthy eating, active living AND support for weight management.
How can we build a whole nation movement?
A whole nation is the sum of the parts. Each of us individually and collectively have a part to play. The SCPN would like to see a pledge from multiple organisations to take key specific actions in our everyday lives, worksites and communities. Let’s be ambitious!
What further steps, if any, should be taken to monitor change?
At a population level the magnitude of obesity in Scotland is already monitored by The Scottish Health Survey and should remain the key indicator of change in this epidemic.
At an individual level, self-monitoring of body weight has been shown to be effective in regulating weight gain (18). Avoiding weight gain in adult life is the first step towards weight management. The average annual weight gain in adults is around 400g (19). Many people don’t start to monitor body weight until after excess fat has accumulated. Encouragement and support for avoidance of weight gain during adulthood from health professionals should be provided as part of an overall health care strategy. Weight gain in adult life is also associated with an increased risk of breast cancer independent of body fat stores (20).
Do you have any other comments about any of the issues raised in this consultation?
There is a strong focus placed on children’s behaviour.
- Please note: it is adults who create an obesogenic environment for children: this should be the focus of our attention. Children have little choice or agency in this.
- As the report highlights, 70% of child weight gain is achieved by age 5. Children under age 5 have little choice with regards to what they eat and are heavily influenced by role models.
WE need to take a long hard look at the cultural norms around consumption and consider how we, as a society, can tip the balance forward to lower calorie intakes e.g.
- Many of the places we used to smoke in we now eat in (e.g. transport, cinemas).
- We now see consumption of food and drink in classrooms (from schools to Universities).
- Hospitality equals food – does it always need to?
- Bigger is value (but not in health terms).
- Choice and variety (known to increase caloric intake) are viewed as fundamental.
Who are the champions who can help us move towards a healthier weight (beyond Jamie Oliver)? What about health professionals, celebrity chefs, sportspeople, politicians, and community representatives?
There is no mention of alcohol in this strategy. We know that alcohol has a key role to play in rising obesity levels and believe it should be highlighted in this report.
- Department for Environment Food & Rural Affairs (2015). Family Food 2015 [online]. Available at:https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/597667/Family_Food_2015-09mar17.pdf [Accessed 15 Jan 2018]
- Scottish Government (2017). Scottish Health Survey: Main Report [online]. Available at: http://www.gov.scot/Publications/2017/10/2970/downloads [Accessed 15 Jan 2018]
- Boswell K, Kail A (2016). Visual Impairment in Scotland. A Guide for Funders [online]. Available at: http://www.thinknpc.org/wp-content/uploads/2016/05/Visual-Impairment-in-Scotland-a-guide-for-funders.pdf) [Accessed 15 Jan 2018]
- Talati Z, Norman R, Pettigrew S et al (2017). The impact of interpretive and reductive front-of-pack labels on food choice and willingness to pay. Int J Behav Nutr Phys Act 14(1):171 doi: 10.1186/s12966-017-0628-2.
- Scientific Advisory Committee on Nutrition (2011). The influence of maternal, fetal and child nutrition on the development of chronic disease in later life [online]. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/339325/SACN_Early_Life_Nutrition_Report.pdf [Accessed 15 Jan 2018]
- University of Dundee (2017). ActWell Study [online]. Available at: http://actwellstudy.org/ [Accessed 15 Jan 2018]
- National Cancer Policy Forum; Board on Health Care Services; Institute of Medicine (2012). The Role of Obesity in Cancer Survival and Recurrence: Workshop Summary. Washington (DC): National Academies Press (US) [online]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK201004/ doi: 10.17226/13348 [Accessed 15 Jan 2018]
- Steele RJ, Anderson AS, Macleod M et al (2015). Colorectal adenomas and diabetes: implications for disease prevention. Colorectal Dis 17(7):589-94 doi: 10.1111/codi.12895
- Anderson AS, Craigie AM, Caswell S et al (2014). The impact of a bodyweight and physical activity intervention (BeWEL) initiated through a national colorectal screening programme: randomised controlled trial. BMJ 348:g1823 doi: 10.1136/bmj.g1823
- Fisher A, Craigie AM, Macleod M, Steele RJC, Anderson AS (2017). The impact of social deprivation on the response to a randomised controlled trial of a weight management intervention (BeWEL) for people at increased risk of colorectal cancer. J Hum Nutr Diet doi: 10.1111/jhn.12524. [Epub ahead of print]
- Cong YJ, Gan Y, Sun HL et al (2014). Association of sedentary behaviour with colon and rectal cancer: a meta-analysis of observational studies. Br J Cancer 110(3):817-26 doi: 10.1038/bjc.2013.709. Epub 2013 Nov 21
- Scottish Cancer Prevention Network (2014). Newsletter Vol 5. Issue 3 [online]. Available at: https://www.cancerpreventionscotland.org.uk/docs/newsletter/Volume_5_Issue_3.pdf [Accessed 15 Jan 2018]
- Shieh C, Knisely MR, Clark D, Carpenter JS (2016). Self-weighing in weight management interventions: A systematic review of literature. Obes Res Clin Pract 493-519 doi: 10.1016/j.orcp.2016.01.004. Epub 2016 Feb 17
- The American Journal of Clinical Nutrition (2010). Mediterranean dietary patterns and prospective weight change in participants of the EPIC-PANACEA project [online]. Available at: http://ajcn.nutrition.org/content/92/4/912.long [Accessed 15 Jan 2018]
- World Cancer Research Fund (2017). Continuous Update Project. Analysing research on cancer prevention and survival [online]. Available at: https://www.wcrf.org/sites/default/files/Breast-Cancer-2017-Report.pdf [Accessed 15 Jan 2018]