19 Apr 2019

Do you agree that a whole system approach could enable change to take place? If not, why? What are the opportunities, risks and barriers to effective leadership?

We agree with a whole systems approach, and support the ideas outlined in LEC 1 and 2, including focusing on early prevention and prioritising & focusing resources where they are most needed. However, we are concerned that there is a lack of detail within the current proposals. We would hope that the Welsh Government will be able to more specifically outline what interventions they would like to see implemented. We mention a range of evidence-based interventions in later questions that could be supported with funding and resource on an “all Wales” basis.

We believe that there needs to be a clear commitment from Welsh Government to ensure that this strategy applies across government, with obesity recognised as a cross-departmental issue. For example, the proposed tier 1 target applies to the NHS, but all public services (education, transport etc.) need to be held accountable with measurable targets and progress in reaching these targets reported to Welsh Government. Action for prevention and early intervention, particularly during the first 1000 days should be included in all Public Service Board Health and Well-being Plans and health board Integrated Medium Term Plans.

Dietitians, as the clinical experts in diet and nutrition, are best placed to lead the development, delivery, implementation and evaluation of programmes to prevent and reduce overweight and obesity. We are concerned that there is no suggestion of additional investment in local health teams in all the proposals. This will be essential to delivering any change in obesity rates in Wales.

Consistent and ongoing evaluation and commitment to continuous improvement is vital if this long-term strategy is to be a success. We welcome the 10-year timescale, but hope that Welsh Government include a clear set of targets, including ambitious overall targets, against which the success of the programme will be judged.  

We particularly welcome the plan to introduce a second measurement as part of the Child Measurement Programme (CMP), which will bring Wales into alignment with the rest of the UK. However, we would recommend that Welsh Government consider going further. There are examples such as the CHAMP scheme[i] in Greater Manchester whereby measurements are taken more regularly to better target those at risk of developing obesity. Interventions are needed for children and families. We would like to see a joined up approach between this programme and targeted interventions for those identified as overweight or with obesity. At present it is purely a surveillance programme which misses an opportunity to intervene at a key life stage

Are you aware of any good practice locally? How can we build upon and maximise existing practice and resources to support population change across Wales?

There are a great many examples of dietitians leading multi-disciplinary approaches to obesity prevention and management. Many of these involve training other health professionals and care staff to provide better nutrition and dietary advice, and know when to refer to specialist dietetic services.    

Much of this work sits under the Nutrition Skills for LifeTM (NSfL) banner, which is now core business for dietitians in the Welsh NHS. NSfL provides health, social care and voluntary workers with the skills to deliver robust, consistent nutrition advice and it supports the development of local health eating initiatives with a standardised approach to delivery and assessment. This was first evaluated in 2009 by Glyndwr University[i].

A range of programmes exist under the NSfL brand including Foodwise in Pregnancy, a six-week programme developed at an all-Wales level between dietitians and midwives to train dietetic or maternity support workers to deliver interventions with all women during pregnancy.

Dietetic services across Wales deliver accredited nutrition training and are working with partners to embed key messages in midwifery, health visiting and the health and social care and child care curriculum.

In addition, dietitians in all health boards in Wales train and support non-NHS specialist staff such as National Exercise on Referral Scheme co-ordinators and leisure service staff to deliver Foodwise for Life, an effective community based, structured weight management programme.

In Cardiff dietitians have introduced a service wide approach to obesity prevention including nutrition, cooking and budgeting training for professionals and families as part of the Flying Start programme. BDA Wales Board believes that Welsh Government needs to take steps to formally embed dietetic services within Flying Start across Wales.

Dietitians have been improving staff and patient health and wellbeing in hospitals such as University Hospital of Wales through achievement of Gold Corporate Health Standard and implement hospital retail standards.

There are also a range of effective, dietetic led weight management programmes developed in NHS Wales health board dietetic services, that support individuals to make lasting dietary changes and can lead to >5% weight loss, which has a clinically significant impact on the development and management of conditions.

Do you agree that the proposals set out in HE1- HE5 would make our food and drink environment healthier? If you agree, how do you think these could be implemented and what support will be required? If not, why?

We welcome all the proposals made in HE1 – HE5, and would have the following recommendations regarding their implementation and what support would be required.

  • HE1 – Offering businesses specific tools to help reformulate products and make a point of highlighting good practice will help make this a reality. We already know that within categories some manufacturers already manage to have much lower sugar, salt and saturated fat content for the same sort of products.  
  • HE2 – We welcome these proposals, which reflect similar measures elsewhere in the UK. It is important that Welsh Government is comprehensive in its approach, considering online shopping and non-retail promotion. We believe that Welsh Government should use its considerable purchasing power to encourage companies to limit the advertising or promotion of products in public places. We would also encourage Welsh Government to support, or if necessary create, campaigns which positively promote healthy options (akin to the successful VegPower initiative[i]) to counteract unhealthy promotion.
  • HE3 – We would encourage Welsh Government to move quickly to implement restrictions on price promotion and discounting practices, to ensure that Wales does not fall behind the rest of the UK. We would encourage Welsh Government to provide online tools to help smaller businesses to implement the restrictions, in particular if the restrictions utilise the Nutrient Profiling Model. Again, while unhealthy foods should be made more expensive and harder to promote, steps should be taken to encourage people to eat more healthily by supporting the provision of cheaper healthy foods.
  • HE4 – We would encourage the Welsh Government to set clear rules as to any mandatory out of home calorie labelling, and provide online tools to support smaller businesses. Clarity regarding how measures are to be taken and how calories have to be displayed would ensure consistency and avoid confusion.
  • HE5 – We believe energy drinks sales should be banned from the age of 18, which will be easier to enforce as it is in line with alcohol and cigarettes. We would encourage Welsh Government to go further and accompany any ban with a clear public health campaign to highlight the reasons behind the ban.  We would welcome Wales becoming a “refill nation” and a nation of water drinkers but with initiatives embedded to reduce plastic waste.

We believe that the Welsh Government could go further with regard to restriction on public promotion of unhealthy products. We would be keen to see further consideration given to sponsorship of sports and other events in Wales, as we know these have a significant impact and large influence on key target audiences.

We welcome the commitment to consider how changes to front of pack labelling might be made after the UK’s exit from the EU. However, we are concerned that the language used is quite woolly and we would like to see a stronger commitment to address this with repatriated powers following Brexit.

We would like to see a commitment to use funds from the Soft Drink Industry Levy to support efforts to prevent childhood obesity, which is the approach taken elsewhere in the UK.

: Do you agree that the proposals set out in HE6-HE7 would provide an environment with more opportunities to be active? If you agree, how do you think these could be implemented and what support will be required? If not, why?

We agree that the Planning Process should be considered as part of efforts to promote an active environment. However, this same process should also be used to create healthier food environments, considering steps such as reducing the number of fast food takeaways on high streets or specifically near schools. CRUK research has shown that fast food outlets have multiplied rapidly across Wales and that the public support such a policy[i].

A truly comprehensive and whole system approach would go further and recognise that the wider determinants of health, such as employment, housing and poverty, all have a role to play in someone’s risk of developing obesity. All infrastructure and economic developments need to consider these issues and provide for the environments that are active, with access to good homes, good food options and jobs which allow people to eat well and exercise.

Do you agree with the proposals for the following settings?

  • Early Years (HS1)
  • Schools (HS2)
  • Higher/ Further Education (HS3)
  • Workplace (HS4)
  • NHS (HS5)
  • Public Sector (HS6)

We welcome the comprehensive nature of the proposals at every life stage, and hope that Welsh Government can ensure that sufficient resource, both in terms of funding and staffing can be secured to make them all a reality. We would also recommend a “Once for Wales” approach, with appropriate local flexibility, to ensure that all health board areas/local councils/schools implement these programmes consistently. We know that many existing programmes are not delivered in this way due to insufficient resources and a lack of prioritisation by some local authorities.

HS1 – There is a clear training need in early years settings and expert dietetic support could ensure standards are effectively implemented. Responsibility for monitoring and evaluation of settings and the extent to which they are meeting and continue to meet these standards needs to be made clear.

HS2 – We would like to see the Welsh Healthy Schools programme strengthened and believe that healthy eating needs to be given greater priority, as focus is too often on physical activity when it is clear that both are needed. We would recommend dietetic expertise is sought to ensure a whole school approach to food and nutrition.

We agree that the Healthy Eating in Schools Regulations and Healthy Eating in Schools Measure need to be updated and expanded. Dietetic-led training for school-based staff through Nutrition Skills for LifeTM should be expanded, to include catering staff, school nurses and others. Dietitians support the nutrition education component of School Holiday Enrichment Programme (SHEP) in local authorities and for this scheme to continue to grow we need increased capacity in line with the number of school settings joining the scheme.

HS3 – Dietitians could again play a critical role in helping young people to improve their practical nutrition knowledge and cooking skills by working with universities and colleges. This would require increased capacity.

HS4 – We welcome the commitment from Welsh Government to use their significant purchasing power through the Economic Contract, but believe they should go further than “encouraging” employers to support the health and wellbeing of their staff. This should be an expectation or even a prerequisite. We would recommend the BDA Work Ready Programme as an ideal model for improving nutrition and hydration in workplace settings - https://www.bdaworkready.co.uk/

HS5 – We completely agree that health boards and trusts must be exemplars and NHS staff need to be supported to eat healthily and exercise more. As NHS staff, dietitians are ideally placed to offer weight management services such as Foodwise for Life for colleagues. For example, Powys THB is in the process of implementing a healthy menu for staff and are in the very early stages of developing a sustainable programme of weight management services for staff by training volunteers from occupational health and the Wellbeing at Work group to deliver Foodwise for Life.

A Hospital Retail Standard is long overdue. External food outlets in hospitals should be mandated to provide healthier food choices and building on any positive work on this within Wales is needed. Contracts would need to be scrutinised and health impact assessments made at every level where decision making takes place to ensure that all food served, sold and promoted to staff and visitors on hospital sites promote a healthy balanced diet.

It will be important that staff are given the time and working conditions necessary for these programmes to be effective. Getting the environment right is only part of the solution – NHS staff have to have the appropriate time and support to look after their physical and mental health, and that includes reducing stress, protecting meal times etc. 

HS6 – If NHS settings should be exemplars it is equally important that other areas of the public sector do the same. Detailed guidance on how public sector procurement can improve the food offer in leisure centres, youth and community settings would be welcome. Dietetic services can provide expertise in nutritional composition for food and food products and provide training for key members of the workforce to promote and embed the guidance. In all settings there should be increased emphasis on workers being healthy lifestyle advocates and role models with this built into recruitment and induction processes.

Do you agree that proposals HP1 – HP2 will support behavioural change and increase conversations about healthy weight through front line services? If you agree, how do you think these could be implemented and what support will be required? If not, wh

Inclusion of strengthening opportunities to develop and reinforce the knowledge and skills of staff working across a range of roles and the roll-out of high impact behaviour change programmes is welcome. However, both of these points are vague and it is not clear how these would be delivered effectively. Resources and funding, clearly identified for these programmes, will be needed.

Implementing MECC more widely should be a key starting point, but we believe we need to go further. It is important that the limitations of MECC are recognised. We are aware that School Nurses for example who have undertaken MECC training do not feel confident to raise the issue of weight. Therefore, training needs to include how to raise the issue of weight and implement other brief interventions. Welsh Government could be more ambitious in the scope for who and where MECC and further training could be applied.

We would be pleased to highlight to Welsh Government existing behaviour change programmes based on the evidence of what is effective for specific groups, as action is needed urgently and without delay. A “Once for Wales” approach to the provision of programmes, with of course flexibility over local delivery, would seem most appropriate.

There is an opportunity to expand the all Wales Nutrition Skills for LifeTM model of training, and professional support provided by registered dietitians in NHS Wales and to incorporate this training into undergraduate HCP curriculum. Nutrition and healthy weight messages have been incorporated into undergraduate midwifery training and Specialist Community Public Health Nursing training in Cardiff, Swansea, University of South Wales and Glyndwr/Bangor Universities. This provides a standardised, consistent, evidence based ‘Once for Wales’ approach.

Do you agree that proposals HP3 – HP4 will enable children and families to support a healthy weight? If you agree, how do you think these could be implemented and what support will be required? If not, why?

We agree that the plans outlined for both a Children and Families programme and a 10 Steps to Healthy Weight programme could support families to maintain healthy weight, although both are lacking in detail, especially the C&F programme. We welcome the recognition that the approach has to start before birth and include important elements such as breastfeeding support, although effectively addressing low breastfeeding rates needs to involve a comprehensive approach beyond the healthcare sector to ensure the whole environment is supportive of breastfeeding.

Funding and resources behind these programmes, especially with more vulnerable or hard to reach communities will be essential. It would not be enough to expect existing NHS or public health services to deliver these programmes from existing budgets and staffing.

Consideration does need to be given to the existing Healthy Start scheme and how this could be improved given recent statistics showing below optimum uptake levels across local authority areas with a significant number of eligible families not taking up the scheme. The Healthy Start scheme is promoted through all dietetic training programmes to promote uptake.

Successful and proven programmes already exist that can support elements of both the C&F and 10 Steps programmes, such as Nutrition Skills for LifeTM. However, we know that there is inequity of access across Wales and a “Once for Wales” approach to both these programmes to ensure equality of access would be a real positive.

Do you agree that proposal HP5 will develop a clinical pathway to ensure those who are overweight or obese can access the right kind of support? If you agree, how do you think these could be implemented and what support will be required? If not, why?

We are very disappointed and concerned that the consultation document only commits to a review of the All Wales Obesity Pathway. This pathway has been in place for almost 10 years, but has still not been rolled out in full across Wales, largely due to inadequate resources and a lack of motivation for already hard-pressed health boards. Services are patchy at all levels of the pathway, and people in some parts of Wales have no access to services for their age group or at their level at all.  It is most concerning that very few services are in place to support overweight and obese children.

A clinical obesity pathway has to come with the funding to ensure it becomes a reality or it will continue to be funded in a piecemeal manner and any change will be slow or non-existent. The review process need input from the multi-disciplinary team involved, particularly clinical specialists include psychology. A level 3 service will require highly specialised staff and reallocation of funding/ workloads will not be sufficient to achieve this. Consideration would also need to be given to how working environments such as clinic rooms and community halls and equipment would be funded.

As it stands, only one health board has a fully comprehensive tier three service for children for example. Even at tier one, for programmes such as Nutrition Skills for LifeTM, which is a core part of all dietetic services in each health board, lack of resource means some areas are not able to deliver these services at sufficient scale.

Level 3 services are an essential and critical stage in the Obesity Pathway, representing a threshold between community-based, predominately preventative action, and surgical intervention. Level 3 services provide a step up from Level 2 when community interventions have not been effective, and is a vital bridge to Level 4 pre- and post-operative surgery. Anecdotal evidence received by OAC members suggest that where a Level 3 service is operational, consultants report increasing numbers of complex referrals from clinical colleagues outside their Local Health Board. Conversely, Level 4 surgical services in Swansea are reported to be underused as surgeons are unable to accept referrals without a patient first receiving Level 3 intervention. It is imperative that patients have the psychological support offered by Level 3 services prior to being considered for surgery. The absence of comprehensive Level 3 services in some parts of Wales means that the majority of obese people cannot access bariatric surgery.

Access to treatment for overweight and obesity should be part of the suite of measures for Wales to reduce obesity. However, the consultation document does not give this area enough attention and, as a result, there is a significant risk that the pathway, or a renewed version of it, may not be in place for a number of years. This must be urgently addressed.

We support plans to review current delivery and implementation barriers, set minimum standards at each level and agree a minimum national dataset to help monitor impact, these are all clearly needed. However, no time should be wasted to determine whether the pathway “meets current standards” – we know it doesn’t.

Delivery of targeted services for children needs to be addressed as a matter of urgency.


Consultation Document