Download Awareness of food and health choices

Food in Focus
A Food and Health Improvement Strategy
for Grampian
2003–2006
January 2004
Contents
Page
1. Introduction
4
2. Food and Health
6
2.1 What is a healthy diet?
2.2 How much is enough?
2.3 What influences food choice?
3. The Need for Improvement
3.1 Obesity
3.2 Diet and cardiovascular disease in Grampian
3.3 Diet and cancer in Grampian
3.4 Diet and diabetes in Grampian
3.5 Food safety
4. Setting the Scene
4.1 National context
4.2 The Grampian context
5. Framework for Dietary Health Improvement
5.1 Food and health intelligence
5.2 Develop and implement a strategic framework for food and health
5.2.1 Food and health improvement strategy: Grampian 2003-2006
5.2.2 Related regional strategies
5.2.3 Future / proposed / related strategies and service plans
5.3 Detection, prevention and treatment of obesity
5.3.1 Detection
5.3.2 Prevention
5.3.3 Treatment
5.3.4 Grampian action
5.4 Develop and deliver food and health activity in priority settings
5.5 Protection from food related hazards which impact on health
5.6 Individual, group and population capacity building
5.7 Sector, agency and community capacity building
5.8 Measuring impact and assessing effectiveness
6. Measuring Progress
6.1 Progress toward adult dietary targets for 2005
6.2 Progress towards children and young people’s dietary targets 2005
7. References
Appendices
1.
2.
3.
8.
6
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10
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13
16
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27
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35
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Guide to healthy food choices
Designated areas of deprivation in Grampian
Internationally accepted BMI ranges
Grampian Food and Health Improvement Action Plan
52
2
Executive Summary
Section 1: A healthy diet coupled with an active lifestyle is a necessary component for a long and
healthy life. National and regional action to address food and health improvement culminated in the
national diet action plan and the regional counterpart. In order to review the strategy for Grampian a
regional conference (food in focus) brought together those from each stage of the food chain to inform
this strategy and action plan.
Strategic Vision: People in Grampian enjoy the benefits of consuming a healthy diet
Strategic targets: to promote the consumption of at least 5 portions of fruit and vegetables per day; to
encourage the reduction in the consumption of foods containing fat, in particular saturated fat and to
reduce the amount of total fat in the diet; to ensure action to promote healthy eating encompasses the
promotion of physical activity; to build capacity to enable healthy food choice.
Values: Work collaboratively with those at each stage of the food chain; ensuring all food and health
developmental activity is based on available evidence and innovation where evidence is not available;
ensuring principles of efficiency and cost effectiveness are applied; applying a long-term vision.
Section 2: Clarifying, simplifying and consistently communicating what a healthy diet is, remains a
key aim of this strategy and action plan. The Eating for Health Model (plate model) is a nationally
accepted tool for demonstrating the types and proportions of food in each food group that make up a
well balanced and healthy diet. The dietary targets also outline what amount of food is necessary for a
healthy diet. Awareness, availability, access, acceptability and affordability also influence the ability
to make healthy food choices.
Section 3: What we eat and the social aspect of food preparation and consumption can provide many
positive benefits. However a diet that does not provide the necessary proportions of nutrients has been
identified as a risk factor for a range of diseases and conditions. Obesity, cardiovascular disease,
cancer, diabetes and food safety issues are explored in more detail.
Section 4: Improving the diet of the Scottish population requires co-ordinated action at all levels of
our society and at each link of the food chain. Improving Health in Scotland – The Challenge (2003)
provides national context together with a range of national and local related strategies.
Section 5: Health improvement in Grampian is underpinned by 8 functions, which have, for the
purposes of this strategy, been translated into eight food and health improvement functions.
Section 6: Local data provides an indication of progress towards the dietary targets through trends and
behaviour change indicators.
Action Plan: The following 4 key aims have been identified to enable the implementation of the food
and health improvement strategy in Grampian.




Early Years Aim: To seek to promote healthy eating in the pre-conception, ante and post natal
period in order to maximise the potential for a healthy start for children born in Grampian.
Teenage Transition Aim: To seek to promote healthy eating with young people at key transition
stages, in relation to the key settings of school, home and communities.
Workplace Aim: To seek to provide opportunities and increase awareness for adults of working
age to have access to healthier food choices within the workplace.
Communities Aim: To seek to build individual and community capacity to address food and
health improvement issues and to address food and health inequalities.
3
1.0
Introduction
A healthy diet coupled with an active lifestyle is a necessary component for a long and healthy life.
Conversely a diet high in processed foods, containing high proportions of fat, sugar, and salt and a low
intake of fruit and vegetables together with a sedentary lifestyle increases the risk of a range of noncommunicable, largely preventable diseases in our communities. Diet is a modifiable risk factor for
diseases such as obesity, diabetes, cardiovascular disease, some cancers, osteoporosis and dental
disease.1
This is particularly the case for the Scottish diet, which is habitually low in the consumption of fruit
and vegetables and high in fat, salt and sugar. Accumulating evidence is showing that a diet low in
fruit and vegetable consumption can exacerbate the contribution of other risk factors, such as tobacco
use/exposure to both lung cancer and cardiovascular disease. This has an even greater impact on the
population’s health2. It is therefore crucial that policies to improve the diet of the Scottish population,
in particular measures to increase the consumption of fruit and vegetables be prioritised.
Action to address food and health issues in Scotland is set within the strategic framework of Eating for
Health: A Diet Action Plan for Scotland3 (1996). The action plan prioritises several stages of the
lifecycle in particular pregnancy, childhood, and young people and encompasses action to address
social inclusion, prioritising the food and health needs of low-income communities. The Diet Action
Plan has been continually endorsed by a range of holistic and disease specific national strategies
including the recent Partnership for Care White Paper4 (2003) and the accompanying Improving
Health in Scotland: The Challenge5 framework for health improvement (part one).
Regional action has been outlined in the Grampian Health Plan (2003/04) 6 which has identified a
priority for NHS Grampian to review the Grampian Diet Action Plan (1998), the existing framework
for the implementation of the Diet Action Plan for Scotland7 within a Grampian context.
This document aims to summarise food and health issues for the general population in Grampian in
order to outline key targets, priority groups, and mechanisms for action, set within a framework for
health improvement for the period 2004 to 2007. This strategy requires a co-ordinated effort and is
therefore applicable to those operating at each stage of the food chain.
In developing this document local and national food and health related information has been collected
in addition to engaging with those at each stage of the food chain in Grampian. This culminated in a
regional conference: ‘Food in Focus – from plough to plate’8 recommendations from which are
incorporated and specified throughout this document having been used to inform this strategy and
action plan. Further consultation on this document will take place to gain consensus and commitment
to support the implementation of measures to improve the diet of people in Grampian.
4
Strategic Vision
The strategic vision for the Grampian food and health improvement activity outlined in this document
is that:
“People in Grampian enjoy the benefits of consuming a healthy diet.”
Strategic targets
The following strategic targets have been set to prioritise areas of activity for maximum health gain:




To promote the consumption of at least five portions of fruit and vegetables per
day.
To encourage the reduction in the consumption of fat in the diet in particular
saturated fat.
To ensure action to promote healthy eating encompasses the promotion of physical
activity.
To build capacity to enable healthy food choices.
Values
We have strived to ensure that the activity outlined in this document is consistent with the
recommendations from the Food In Focus conference and therefore adheres to the following values:





Working collaboratively with all those at each stage of the food chain
Ensuring all food and health developmental activity is based on available evidence
and innovation where evidence is not available.
Ensuring principles of efficiency and cost effectiveness are applied.
Ensuring activity is socially inclusive
Applying a long-term vision.
5
2.0
Food and Health
2.1
What is a healthy diet?
The nutrients we receive from the food we consume are necessary for life. Our bodies require a well
balanced diet to enable us to live healthy active lives. Clarifying, simplifying and consistently
communicating what a healthy diet is remains a key communication aim of this document and
accompanying action plan. In order to facilitate this process the ‘Eating for Health’ model was
adapted by the then Health Education Board for Scotland (now known as NHS Health Scotland), as a
pictorial guide as to the contents of a balanced meal or overall diet (figure 1).
Figure 1: Eating for Health Model,  NHS Health Scotland, used with kind permission.
Eating for Health or the plate model as it has become more commonly known, is the nationally
recognised model, which is used to demonstrate the types and proportions of food in each of the food
groups that make up a well balanced and healthy diet.
The five food groups are:

Bread, cereals and potatoes

Fruit and vegetables

Milk and dairy foods

Meat, fish and alternatives

Foods high in fat, food and drinks high in sugar
The size of each of the segments in the plate model is intended to indicate the approximate proportion
of that food group which should be consumed to ensure a balance diet over the course of a day.
In addition to food consumption we should drink at least 1.5 to 2 litres of fluid per day which equates
to six to eight glasses/cups per day. However, carbonated drinks and other high sugar cordials should
6
be minimised while drinking water should be actively encouraged.
2.2
How much is enough?
The plate model is a useful pictorial reference tool for consumers, caterers, cooks and menu planners
in order to guide the proportions required for a daily balanced healthy diet. However, guidance on
healthy eating can be perceived as complex as it requires individual tailoring, is potentially subjective
to interpretation and is influenced by processing, preparation, cooking, and food safety. To keep
healthy eating messages simple this document intends to place emphasis on the following
recommendations:
FOOD
GROUPS
Bread/cereal/
potato group
DAILY
MEASURES
5-14
include some
wholegrain products
daily
Fruit/vegetable
group
5 or more
include a mixture of
vegetables and fruits
daily
Milk and dairy
group
2-3
choose lower fat
types
Meat, fish* and
alternatives
group
2-3
choose lower fat
types
Fatty and sugary 2-5
foods
(visible fats)
(occasional
foods)
0-2
WHAT COUNTS AS A MEASURE?
(1 oz = 30 g)
 3 tbsp. breakfast cereal
 small bowl porridge
 slice of bread/toast
 ½ bread bun/roll
 3 - 4 crackers
 2 tbsp. cooked rice/pasta/noodles
 1 medium sized potato
 2 tbsp. vegetables (fresh, frozen or
tinned)
 small salad
 piece of fresh fruit
 2 tbsp. cooked/tinned fruit
 small glass (100 ml) fruit juice
 1/3 pint/200 ml of milk
 small pot of yoghurt, fromage frais
 1 1/2 oz/40g cheese (small matchbox
size)
 2 small tubs cottage cheese
 2-3 oz lean meat, poultry without skin,
oil-rich fish
 4-5 oz white fish (not fried)
 2 eggs (up to 6 per week)
 3 tbsp. baked beans, lentils, dahl
 1 1/2 oz/40g cheese (small matchbox
size)
 2 tbsp. nuts, nut products
 1 tsp. butter, margarine
 2 tsp. low fat spread
 1 tsp. oil, lard, dripping, ghee
 1 tsp. mayonnaise, oily salad dressing
 1 packet of crisps
 1 small pie/sausage roll
 1 chocolate/2 plain biscuits
 ½ slice cake
7
 small bar chocolate (2 oz)
* Ideally fish should be eaten twice a week, one of the portions should be an oil-rich variety
The exact amounts required by individuals will vary depending on age, sex and activity level.
2.3
What influences food choice?
Providing information on what a healthy diet is will not by itself be sufficient to facilitate changes to
our eating habits.
Healthy food choice is not solely due to lack of information about what constitutes a healthy diet.
Research has shown that people on low incomes can describe a healthy diet as well as those on higher
incomes9. We therefore need to look at food consumption within the context of individual’s daily
lives and enabling people to make those choices means that improving knowledge alone is ineffective
in improving people’s diets10. In terms of food choice, people on low incomes have a tendency to eat
lower amounts of fruit and vegetables despite spending proportionately more of their disposable
incomes on food 11. Those living with limited budgets report finding household expenditure that is
being allocated to provide food for the family, susceptible to squeezing to meet other demands.
Nutritional vulnerability, disadvantage, and deprivation exist in areas of Grampian. Scottish Office
Deprivation Indicators have shown that Grampian has 5 areas identified within the worst 10% in
Scotland and a further 12 areas identified within the worst 20% in Scotland (appendix 1). Issues of
rurality can also contribute to disadvantage amongst our remote and rural communities12.
Food choice is not only affected by our ability to afford or be aware of healthy choices. Increasingly
in relation to our busy lifestyles, food is now more likely to be consumed ‘on the run’ and less likely to
be purchased, prepared, or eaten in the context of family meals. In terms of where we buy our food,
large retail outlets, which can provide choice and lower cost, can often be physically inaccessible to
those without private transport. Smaller urban outlets can be equally inaccessible in areas of
deprivation because of lack of transport, or practicalities of transporting food, which can be heavy or
requiring proper storage.
People living in rural areas of Grampian also face significant barriers to healthy food choice. Prices
tend to be higher and the availability of a range of healthier foods is considerably limited.13 This is
further exacerbated by limited access to private or public transport. A local survey undertaken in
Grampian has shown that healthy foods cost more in local, small convenience shops and that the range
of food on sale is often limited and of variable quality.
8
The range of influences to our food and drink consumption can be summarised under the
following headings:
Awareness of food and health choices
 Consumers need to be aware of and have clear consistent information on what a healthy diet
consists of and the benefits that eating and drinking healthily can have for their health and
wellbeing.
 The need to ensure messages are interpreted to meet the needs of special populations such as
children and older people is required.
 How this message is communicated and interpreted will impact on choice.
 Messages should be consistently based on the ‘Eating for health model’ and incorporate food
safety, food skills and food labelling information.
Access and availability of appropriate food choices
 To encourage and enable individuals to make healthy food and drink choices they must be
accessible and readily available to all.
 There is a need for sufficient availability of healthy choices in all areas where individuals are
buying or consuming food and drink.
 Experimentation and variety should be encouraged to increase the range of healthy food choices
that are made available in our communities and workplaces.
Acceptability of food choices
 Attitudes to food consumption such as, taste, time needed to prepare, like and dislikes of family
members and lack of confidence in cooking impact on food choice.
 Individual preference and tastes should be encouraged.
 Well cooked, well presented healthy food choices being sensitive to cultural and specific individual
and community needs, beliefs and values should be encouraged.
Affordability
 A barrier to the purchasing of healthy food is often cost. Every effort should be made to reduce the
cost of healthy foods to eradicate this barrier.
Access to healthy food is a cross cutting issue and forms a key part of many policy agendas. Delivery
on these issues will require the strengthening of links between and action by all sectors of the food
chain from ‘plough to plate’.
Local authority, health and voluntary sector agencies working together through the community
planning process and regeneration initiatives has the potential to address these barriers offering
practical solutions to local needs. In particular planners should take specific account of retail provision
in disadvantaged areas. Communities need to be supported to increase confidence, independence, and
capacity. To make an impact on these issues health, economic and environmental policies need to be
integrated with an emphasis on food issues.
9
3. The Need For Improvement
What we eat and the social aspect of food preparation and consumption can provide many positive
benefits in terms of confidence, interaction, self-esteem, general well being and providing some
structure to the day. However a diet that does not provide the necessary proportions of nutrients
necessary for living has been identified as a risk factor for a range of diseases both with physical and
psychological conditions. In general Scottish people of all ages are disadvantaged by a diet low in
cereals, fruit and vegetables and high in processed foods, confectionery, salty snacks, sugary drinks,
meat and dairy products with a high saturated fat content and increasing alcohol consumption
levels14,15.
3.1
Obesity
The prevalence of individuals recorded as obese or overweight is steadily increasing. In Scotland it is
estimated that between 40-50% of the adult population are either overweight or obese16. There is a
difference between the genders with 44% of men being overweight compared to 32% of women. The
prevalence of obesity is higher in women at 17% compared with 14% in men. Obesity is a major
challenge as it is a risk factor for cardiovascular disease, diabetes, hypertension and premature death 10.
Obesity also has an impact on the quality of individual lives and their general mental health and
wellbeing.
The rate of childhood obesity is rising. For the 2001-2002 school year, 33% of Scottish 12 year olds
were overweight, 18% were obese, and 10-11% were severely obese17. The picture for pre-school
children is similar; of children born in 1998, 21.3% were overweight by the time they reach 3.5 years
old, 8.8% were obese and 4.5% were severely obese. Most children are obese not because of any
underlying medical condition but rather as a result of their lifestyle such as lack of physical activity
and consuming a diet high in processed foods and confectionery16. Obesity in childhood increases the
likelihood of exhibiting risk factors for coronary artery disease and atherosclerosis and increases the
risk of other serious health problems such as high blood pressure, diabetes and psychological stress.
The SIGN guidelines for the management of Obesity in children and young people indicate that
parental obesity should be recognised as a risk factors for childhood obesity to continue into
adulthood18.
3.1.1 Defining obesity
Adults
In adults overweight and obesity is identified by using the body mass index (BMI) calculation, which
allows for differences in weights for adults of differing heights.
BMI is calculated by
BMI =
Weight (kg)
---------------Height (m2)
The internationally accepted ranges of BMI are outlined in table 1.
10
Table 1: The internationally accepted ranges of BMI.
Categories
Underweight
Normal
Overweight
Obesity
Extreme obesity
Measurement of waist circumference is also used
excess of intra-abdominal fat.
Range
<18.5
<18.5-24.9
25.0-29.9
30.0-39.9
≥ 40
for identifying patients with increased risk due to
Table 2 Measurement of waist circumference assessing increased risk due to excess of intraabdominal fat.
The following table provides sex-specific relative risk.
Men
Women
Increased risk
≥94cm (≈37inches)
≥80cm (≈32inches)
Substantial Risk
≥102cm (≈40inches)
≥88cm (≈35inches)
Reference: Table 1&2 Obesity in Scotland: Integrating Prevention and Weight Management. SIGN 8
(pilot 1996).
Children
In the UK a paediatric BMI centile chart is required to interpret children’s BMI. The International
Obesity Task Force (IOTF) has proposed paediatric cut-offs for obesity and overweight that
correspond with adult cut-offs. Measurement of childhood obesity is more complex in relation to
childhood development and therefore guidance on the diagnosis of childhood obesity is provided in the
Management of Obesity in Children and Young People, SIGN Guideline (69) (2003) 16.
3.1.2 Obesity in Grampian
In line with the Scottish trend, the prevalence of overweight and obesity in adults and children has
increased in Grampian in recent decades. The introduction of the national pre-school information
system in Grampian will enable a more comprehensive monitoring of children under the age of three
years.
Results from the 1994 and the 1998 Grampian Adult Lifestyle Survey* have shown there to be a
marked increase in the overall percentage of Grampian adults reporting as overweight (31.2 % to
33.2%) and obese (9.8% to 11.6%) 19,20.
*Adult and Youth Lifestyle Surveys are carried out every 3-4 years on a sample of the Grampian population. The
respondents self report and are not measured so the data needs to be carefully interpreted. Self reported food intake is
highly unlikely to be accurate.
11
In terms of gender 48% of men and 41% of females were calculated as obese or overweight in the
1998 Lifestyle Survey representing a 3% (45%) and a 4% (37%) increase from the 1994 results.
Generally being overweight or obese was most commonly found in male respondents but for both
sexes was most common in older age groups.
3.2
Diet and cardiovascular disease in Grampian
In Grampian, 6.3% of men and 4.6% of women aged 16-74 years have coronary heart disease or have
suffered a stroke. This means about 5,000 people under the age of 60 and a further 8,500 in older age
groups have symptoms of heart disease.
Although mortality from coronary heart disease has fallen over the last few years, as treatment
improves and our population gets older, the number of people living with a diagnosis of coronary heart
disease is forecast to increase substantially in the next 5 years6.
Close links have been identified between certain nutritional factors and the risk of major
cardiovascular diseases1. Diet and physical activity are therefore key modifiable risk factors in the
prevention of coronary heart disease and play a fundamental role in the development of the disease
through consumption of saturated fat and its relationship to blood cholesterol levels.
3.3
Diet and cancer in Grampian
Currently 1 out of every 4 deaths in Grampian is due to cancer. Although diet may not play a role in
the development of all cancers, it is estimated that around one third of cancers are related to poor diet6.
In particular diet has been recognised as contributing to the development of cancers of the colon,
rectum, stomach, lung and prostrate.
Present evidence indicates that increased consumption of saturated fat, and also red meat is associated
with an increased risk of colo-rectal and potentially prostate cancer. Obesity, particularly central
obesity, where body fat is deposited around the waist and abdomen, increases the risk of developing
postmenopausal breast cancer and being overweight or obese increases the risk of developing
endometrial cancer21. The table below provides an indication of the incidence and rates of these
cancers in Grampian.
Table 1: Cases and rates of site-specific diet related cancers in Grampian for 1999.
Cancer
site
Breast
Uterus
Prostate
Gender
Total Cases
Mortality
Registration
Cases
Total Mortality
Rates per 10,000
per annum
standardised rate
Registration rates
per 10,000 per
annum,
standardised rates
Male
Female
Female
Female
Male
99
86
95
10
83
182
160
324
50
222
1.9
1.7
1.9
0.2
1.6
3.5
3.2
6.4
1.0
4.4
Source: Health Intelligence, NHS Grampian.
12
While various carcinogens have been identified in smoked and barbecued food these appear to
contribute only slightly to the overall impact of diet on cancer risk.
Dietary recommendations to reduce the risk of developing cancer are in line with those for healthy
eating and explained in section 2.2. Evidence is now available on the protective effects of food and
certain cancers, for example there is a strong association between intakes of fruit and vegetables and
cancers of the colon, rectum, stomach, oesophagus, mouth, pharynx, larynx and urinary tract 22.
The good news is that
 high consumption of fruit and vegetables are associated with a reduced risk of a number of
forms of cancer. 2,23
 increase in fruit and vegetable consumption is regarded as the second most important strategy
for cancer prevention after reducing tobacco use.24
 the benefits of fruit and vegetable consumption are greatest for those cancers where there is an
established environmental carcinogen, such as tobacco, rather than those cancers where factors
such as genetic make up are involved.2
3.4
Diet and Diabetes risk in Grampian
The prevalence of diabetes in Grampian is between 2-3%, which equates to approximately 15,000
people living in Grampian with the condition 6. The incidence can increase with age and therefore in
the 60 years age group and over the incidence is as high as 6%. It is anticipated that as a result of an
ageing population and improvements in detecting and diagnosing the condition the incidence will
increase.
There are two types of diabetes, with type 2 being strongly linked with behavioural and environmental
factors such as being overweight and lack of, physical activity. 25,26 The impact of increasing
prevalence of childhood obesity presents a public health challenge in relation to the prevalence of type
2 diabetes in children, made more pronounced in the presence of other risk factors such as ethnic
grouping and family history. 27
Diabetes has a physical, psychological and an economic impact on individuals, families and
communities in terms of the burden of ill health, detriment to quality of life and premature death.
Evidence has shown that preventative action and lifestyle changes such as healthy eating and physical
activity can reduce the risk of progression to diabetes by 58% over 4 years.28
Weight management is the main goal of treatment for individuals with type 2 diabetes. A weight loss
of 10% leads to a reduction in the risk of several cardiovascular risk factors such as blood pressure
management and blood lipid levels in addition to a reduction in diabetes related death by more than
30%. 29 At least 80% of people newly diagnosed with type 2 diabetes are overweight.
Diabetes UK, formerly the British Diabetic Association, made the first UK position statement on diet
and diabetes care in the 1980’s. These guidelines promoted a diet that is much more in line with
healthy eating recommendations for the general population. A significant aspect of the guideline is
that dietary advice is linked to reducing the risk of cardiovascular disease, the main complication of
type 2 diabetes. These recommendations have been updated over the last 20 years but a diet high in
starchy carbohydrate and low in fat remains the cornerstone of the prevention and treatment of type 2
diabetes. 30,31
13
3.5
Food safety
Good food preparation, handling, storage, and cooking practices in the home and food premises
minimise the risk of foodborne diseases, which may impact on our health and wellbeing. Our
communities are increasingly aware, through the media and other sources of issues such as intensive
farming and fishing, animal feeding practices and the presence of genetically modified products and
question the evidence in relation to the impact on health. High profile outbreaks of illness associated
with food or water in the UK and elsewhere have impacted on consumer confidence. The provision of
information and improving the quality of food produce is a priority to enable the consumer to make
informed choices about the food available in our communities.
Food safety is therefore a key issue for farmers, fishing industry, producers, manufacturers, caterers
and retailers. Consistency of information is paramount to aid consumer decision-making, and rebuild
consumer confidence. The public concern around the increase in cases of foodborne diseases as
outlined in the Richmond Committee report, contributed to the establishment of the Food Standards
Agency (FSA). 32,33 The FSA as part of its strategy on foodborne disease, has set a target for the
reduction of foodborne disease in the UK by 20% over a 5 year period (2000-2005). 33 In particular
the strategy focuses on the five major foodborne diseases outlined below to monitor trends in
foodborne disease across the UK. Good food hygiene can reduce risk of infection expected to have an
impact on all types of foodborne diseases across the UK.
FSA Foodborne Disease Strategy:
Identifies the 5 major foodborne bacteria:
 Salmonella
 Campylobacter
 E. Coli 0157
 Liseteria monocytogenes
 Clostridium perfringens
The FSA strategy has identified key priority areas of action.
1. Reduce microbial contamination of foods (particularly poultry and red meat)
2. Promote better food safety management and practice
3. Promote hygienic preparation of food commercially and in the home. Such as;
A food hygiene campaign that promotes the 4 c’s:
Cleanliness
Cook food thoroughly
Chill foor thoroughly
Avoid Cross contamination
 National Food Safety Week, targeting key sectors such as catering , schools and colleges and
population based media messages at key times of the year such as Christmas and bar-b-ques have
been implemented.
 Consumer campaigns have focused on the key messages of clean your fridge and wash your
hands.
14
3.4.1 Food Safety in Grampian
The Local Authorities have responsibility for the enforcement of Food Safety legislation and
implementing measures to control foodborne disease. NHS Grampian and Aberdeen City,
Aberdeenshire and the Moray Councils work closely together to monitor, investigate and control all
gastrointestinal disease that may be food or waterborne. An outbreak control team headed by the
Consultant in Public Health leads and co-ordinates the investigation and control of any outbreak
working within nationally and locally agreed guidance.
Grampian recorded the following cases of gastrointestinal disease in 2000-2003
Disease
Campylobacter
Salmonella
E Coli O157
Listeria
Clostridium perfringens
2000
987
225
69
0
0
2001
861
231
61
3
0
2002
819
162
69
2
0
2003
592
174
31
1
0
Source: Public Health, NHS Grampian.
Campylobacter is the most commonly identified cause of foodborne disease. It has been found mainly
in poultry, red meat, unpasteurised milk and untreated water. Although it doesn't grow in food it
spreads easily, so only a few bacteria in a piece of undercooked chicken could cause illness.
Salmonella is the second most common cause of food poisoning, after campylobacter. It has been
found in unpasteurised milk, eggs and raw egg products, meat and poultry. It can survive if food is not
cooked properly
E coli O157 - the commonest risk factor for E coli O157 in Grampian is environmental exposure to
animal faeces, but it can be foodborne.
Listeria monocytogenes is a rare cause of foodborne illness and presents as septicaemia or meningitis.
Illness has been associated with eating contaminated foods e.g. unpasteurised soft cheese, pate and
unwashed salads.
Clostridium perfringens - contaminated food that is not properly cooked, stored or reheated can cause
outbreaks of foodborne illness attributed to Clostridium perfringens
15
4.
Setting the Scene
Improving the diet of the Scottish population requires co-ordinated action at all levels of Scottish
society.
4.1
National Context
4.1.1 Background
‘The Scottish Diet’ report (1993), provided, for the first time, clear information on the relationship
between diet in Scotland and the magnitude of the related health challenges 14. The report also set out
a number of dietary targets for Scotland to the year 2005 to measure progress, which is explored in
more detail in section 6.14
In 1996 the Scottish Office published a comprehensive national food and health improvement strategy
‘Eating for Health: A Diet Action Plan for Scotland’ which was developed to provide a framework for
action over a 10 year period to tackle Scotland’s diet and support action to measure performance
towards the dietary targets7.
The Diet Action Plan for Scotland incorporates the 2005 targets and highlights the role of producers,
processors, caterers, and retailers in the supply and provision of food. Guidelines for the public sector
provision and action for the NHS and local authorities are also identified. A national award scheme
(Scottish Healthy Choices Award) for catering outlets, including workplaces in both private and public
sectors was also encouraged.
A key focus of the Diet Action Plan for Scotland is addressing issues of health inequalities and
prioritising the challenges faced by our most disadvantaged communities to accessing a healthy diet.
As a consequence the Scottish Community Diet Project (SCDP) was established to support community
food initiatives in Scotland. The SCDP continues to play a crucial part in supporting and tackling food
and health initiatives in communities.
4.1.2 Current position
The Diet Action Plan for Scotland has been cross referenced into most subsequent national health
improvement strategies where improvement in the diet is implicated, such as the Cancer plan34, Our
National Health: A Plan for Action a Plan for Change35, Coronary Heart Disease and Stroke
Strategy36.
The White Paper: Partnership for Care (2003) and its accompanying Improving Health In Scotland:
The Challenge provides the main strategic framework for food and health improvement activity to
support the further implementation of the Diet Action Plan for Scotland. The Challenge outlines key
health topics, including promoting the increased consumption of fruit and vegetables, addressing
obesity and increasing physical activity in addition to identifying key themes which are: early years,
teenage transition, communities, and workplace. The priority diet related actions are outlined below:
16
Diet related health improvement challenge actions:
Targets
 Increase the consumption of fruit and vegetables
 Decrease the consumption of saturated fat
Concepts
 Increase the demand for healthy food
 Supply the demand for healthy food
 Provide support, education, and skills development to allow people to act on this information to
make healthy choices
Strategic plan
1. Promote the consumption of a healthy diet and food choices;
2. Promote the preparation and provision of meals offering a balanced diet;
3. Increase access to healthier food choices particularly in low-income and rural areas;
4. Work with food manufacturing, processing, catering and retailing industries to further develop
healthier food choices;
5. Ensure the Agricultural and Fisheries interests contribute fully to the achievement of the Scottish
dietary targets.
Food Health Improvement activity within the themes:
Early years:
 Improve childhood diet and oral health.
 Encourage breastfeeding for a minimum of the first six weeks of life
 Ensure well-nourished, well-balanced and healthy children who are well prepared to benefit from
education.
Teenage Transition:
 Encourage young people to undertake regular physical activity and to eat a healthy diet.
Workplace:
 Support development of healthier workplaces through the implementation of the Scottish Healthy
Choices Award Scheme, Scotland’s Health at Work Award Scheme and workplace policies
prioritising small and medium enterprise. Support the NHS as an employer to provide and support
healthy eating in the workplace.
Communities:
 Increase the demand for healthy food.
 Support the implementation of the communications plan for Healthy Living.
Clinical Priorities:
 National review of obesity services to report by the end of December 2003.
 Support the development of chronic disease management systems for diabetes
 Improve the management of high blood pressure to prevent strokes
 Implement therapeutic and behavioural interventions for adults with established heart disease to
decrease the risk of further cardiac event.
Reference: The Health Improvement Challenge (2003) SEHD.
17
4.1.3 Current National activity/agencies
To support the implementation of the Diet Action Plan for Scotland a Food and Health Co-coordinator was appointed to oversee the further development, monitoring, and implementation of the
Diet Action Plan.
Other recent or forthcoming national policy and research initiatives to specifically support food and
health improvement activity include:
Early years:
 Healthy Start Proposal (consultation Dec 2002). Healthy Start is the consultation to
reform the UK Welfare Food Scheme. The reformed policy will be introduced by
200437.
 Free Fruit in Schools initiative for primary 1 and 2 pupils (2003) 38
 Hungry for Success including Scottish Nutrient Standards for School Lunches
(2003) 39
Teenage Transition
 Hungry for Success including Scottish Nutrients Standards for School Lunches
(2003)
 FSA commissioned research on the Promotion of Foods to Children Research, report
expected summer 2003.
Workplace:
 European Council Drinking Water Directive. Following consultation the Directive is
expected in 2004. The directive provides guidance on the review of water supplies in
public buildings40
 Healthy Working Lives. A short-life working group representing departments and
stakeholders will be established in 2003 to bring together SHAW, SHCAS and health
living to promote a new and effective set of interventions which will promote healthier
workplaces.
Communities:
 Management of obesity in children and young people. SIGN 69 (2003) 18
 Food Standards Agency Scotland (FSAS) Draft Diet and Nutrition Strategy Scotland
(consultation) 41.
 FSAS & SEHD are developing measures to monitor performance against food targets.
18
4.2
The Grampian Context
4.2.1 Background
In 1997 Grampian Health Board formed the Food Strategy Group in order to implement the Diet
Action Plan for Scotland in Grampian. Eating for Health: A Diet Action Plan for Grampian (DAPG)
was subsequently developed and approved by the then Grampian Health Board for implementation in
1998 to 2003. In order to support the further implementation of the document within the Local
Authority setting a guidance document was produced by the Food Standards Agency for Local
Authorities.42
4.2.2 Current Position
The NHS Grampian Health Plan 2002/03 has prioritised the review and further development of the
Food and Health Improvement Strategy and Action Plan for Grampian. This regional strategic review
mirrors the current review of ‘Eating for Health: A Diet Action Plan for Scotland’. This document is
designed to be the main strategic plan in Grampian, providing a clear framework and direction for food
and health work for all agencies with a role to play in supporting food and health improvement. The
Grampian Health Plan also called for a Food Access Action Plan. For the purposes of this document
and the planning of food and health work, a food access action plan is fully integrated as a key, interrelated part of the overall food and health framework.
4.2.1 Food and Health in partnership with others.
As the major providers of local services that affect the determinants of health, Local Authorities have a
critical role to play in promoting health and reducing health inequalities. It is therefore vital that the
health impact of Local Authority planning and policies takes into account support for our communities
to access a healthy diet. In particular, the Community Planning process, the development of Joint
Health Improvement plans and through the implementation of Agenda 21 to support the development
of sustainable communities, Local Authorities and their partners, including the NHS have a key role in
factors affecting food choice and consumption. These policies should directly address measures to
enable our existing and future citizens to make healthy food choices.
Local authorities have a long history of public health protection. Environmental Health Services
enforce the Food Safety Act 1990 and associated legislation. In addition Local Authorities are also
food providers either directly or via catering contractors to large numbers of people across all age
groups. For example under 5s in nurseries and playgroups, school age children, young people in care,
older citizens, people with mental or physical impairments and those using local authority run
premises such as sports and recreation facilities. Providing healthy nutritious food, prepared, cooked
and served in an appealing manner has the potential to improve customer satisfaction in addition to
having positive benefits for health and wellbeing.
In addition to the provision of food, the three Local Authorities in Grampian, along with NHS
Grampian, have also been supportive of a whole school approach to health incorporating the ethos of
the whole school through the formal and informal curriculum operating in the school and the wider
community. To support the school community in adopting a whole school approach to healthy eating,
the Health Promoting School – Food and Health programme, incorporating staff training and a
resource pack have been developed and implemented across Grampian. Related Health Promoting
School topics such as oral health, mental health, and physical activity are also supportive of food and
19
health improvement issues and have been/continue to be implemented across Grampian.
Local Authorities are also responsible for local community access to food in both a physical and
economic sense. Physical infrastructure, including safe food premises, public transport and the siting
of food outlets can have a key impact on our community’s ability to access healthy food choices.
Within Grampian many voluntary and community organisations (CIFNE, Cyrenians, private nurseries,
church groups, older peoples groups) are involved in community food initiatives aiming to tackle the
barriers preventing communities and individuals from accessing an acceptable and appropriate diet.
These projects are funded through a wide range of sources. There is a close working relationship
between the voluntary and community organisations and the health and Local Authority providers. It
is anticipated that through this strategy further partnership working will be developed through the
development of collective based local food and health working groups.
20
5.0
Framework for Dietary Health Improvement.
Health improvement in Grampian is underpinned by eight functions as identified by the World Health
Organisation43 and endorsed by the Grampian Health Plan.
The eight functions are:
1. Assessment and understanding the health needs of the Grampian population and variations within
the area
2. Developing healthy public policy.
3. Detecting and preventing disease and disability.
4. Maximising the health impact of services.
5. Protecting the population from hazards which damage their health.
6. Supporting the development of personal skills necessary for health and wellbeing.
7. Strengthening community action for health.
8. Carrying out research to develop health improvement
This strategy will therefore consider the development of health improvement activity in relation to
food under these functions indicating evidence to support activity in this area and outline some
progress to date. The functions have been translated into headings relevant to food and health by the
Scottish Executive as part of the self-assessment component of the health improvement performance
assessment framework (PAF) and have been adapted below for the purposes of this strategy.
Food and health improvement functions:
1. Food and health intelligence
2. Develop and implement a strategic framework for food and health
3. Detection, prevention and treatment of clinical priorities
4. Develop and deliver food and health activity in priority settings
5. Protection from food related hazards which impact on health
6. Individual, group and population capacity building
7. Sector, agency and community capacity building
8. Measuring impact and assessing effectiveness.
21
5.1
FOOD AND HEALTH INTELLIGENCE
Identification of systems to collect, analyse, interpret and disseminate data to enable the
assessment and understanding of the food and health needs of the Grampian Population.
5.1.1 The National Context
National surveys assist in identifying national trends in relation to the diet of the UK and or Scottish
populations. The surveys identified general trends in relation to food consumption and/or resulting
morbidity and mortality. Through regional analysis of national surveys we can monitor Grampian
progress in comparison to regional and national trends.
These include:
National Diet and Nutrition Survey Programme is now under the remit of the FSA. Surveys have been
completed for the following44:
 Older adults (aged 65 years and over) 1998
 Pre school children (aged 1 ½ to 4 ½ years) 1995
 Young people (aged 4 to 18 years) 2000
 Adults (aged 19-64 years) 2002
The Scottish Health Survey (SHS), administrated every 3 years was last completed in 1998 with the
findings being published in 200015. The SHS samples those living in private residences (excluding
those living in institutions) aged 2 to 74 years. Data is aggregated to 7 regions to permit regional
comparisons; Grampian data is aggregated with Tayside. The data is not available in a rigorous
manner to interpret the information for Grampian residents although there is potential for some general
comparisons to be made across the regions. Analysis of social class, regional and national variations
in eating habits are also undertaken.
5.1.2 The Local Context
The Grampian Adult and Youth Lifestyle Surveys19,20,45,46 are undertaken every 4 years to enable the
monitoring self reported trends in lifestyle issues, including diet, physical activity, and the mental
health and well-being of the Grampian population from the ages of 11 to 75.
The dietary targets for Scotland were developed following the development of the Lifestyle Surveys
and therefore it is not possible to measure trend locally, and would be difficult to do so without
significant resource. In addition during the ten years the surveys have been administrated in Grampian
the format of the food and health questions have altered which has meant that the survey data may not
provide an exact measure of progress against the national targets (outlined in more detail in section 6).
The Surveys are however a useful tool to measure dietary behaviours of the young and adult Grampian
population and to measure self reported willingness to change and barriers to inform planning.
The surveys are highly publicised in local media to the wider Grampian community. The results of the
surveys are provided in report format on all electronic systems, published, disseminated and
incorporated in all related health improvement activity.
22
5.1.2.4 Needs Assessment & additional local surveys
In line with the principles of good practice, needs assessment and the local surveys have supported all
innovative or developmental work in relation to food and health in Grampian. These are detailed or
proposed in the action plan that supports the implementation of this document.
In addition wider community health needs assessments and other health improvement activity have
indicated areas of developmental work required in order to promote healthy eating.
23
5.2
DEVELOP AND IMPLEMENT A STRATEGIC FRAMEWORK FOR FOOD AND HEALTH
Develop, implement, and monitor the Grampian framework for the implementation of Eating
for Health: A Diet Action Plan for Scotland.
5.2.1 A Food and Health Improvement Strategy for Grampian 2003-2006:
In late October 2002 a Grampian conference - Food In Focus – from Plough to Plate, supported by
the Scottish Community Diet Project was held to engage with those at each stage of the food chain, to
debate and agree the focus for the food and health improvement activity in Grampian. The report from
the conference has been widely requested, disseminated and endorsed8.
The conclusions and recommendations have been distilled into the following broad categories.
Communities
 Listen to the ideas and concerns of communities
 Target specific groups (young people, older people, excluded groups) and include these groups in
the devising and delivery of healthy eating messages
 Rediscover the health and social benefits of producing, cooking and eating food
 Observe our duty of care to the environment
 Directly and positively influence the health of young people in the school environment
 Encourage food preparation in schools
Public and private sectors
 Make links between food producers and consumers
 Improve the availability of and promote local food produce
 Involve all sectors of the food chain, extending joint working to encompass environmental and
transport sectors
 Improve access to food in both local shops and supermarkets
 Ensure that consumers have access to clear, understandable information about food products
 Give caterers a clear responsibility for providing healthier foods
 Equip health professionals with the tools to address obesity and weight management issues
 Engage secondary care practitioners in the health improvement agenda
Resource
 Improve information about and access to funding for food initiatives
Measuring Impact
 Develop appropriate and accurate methods of demonstrating and recording the health benefits of
healthy eating interventions
The recommendations from the Food In Focus conference have been integrated into the strategy and
subsequent action plan.
The development of this Food and Health Improvement Strategy for Grampian is intended to provide a
strategic framework for the action required to enable, support, facilitate and co-ordinate resource for
24
improvements in the diet of the Grampian population. The accompanying action plan will be reviewed
annually to monitor progress and report to the NHS Grampian Board. This strategy will be reviewed in
2006.
Baseline indicators for consumption of fruit, vegetables, and food containing fat will be measured
against the 1998 Adult and 2001 Youth Lifestyle Surveys. Work is currently ongoing, lead by the
Food Standards Agency Scotland together with the Scottish Executive Health Department, to enable
the provision of more detailed regional data regarding the progress towards the dietary targets.
5.2.2 Related Regional Strategies:
In addition to the Food and Health Plan for Grampian specific strategic frameworks exist within NHS
Grampian and partner organisations, which have implications for the diet of the Grampian population,
they are identified below. It is important that there is an opportunity to explore and ensure consistent
messages are provided for population health gain. Where messages may conflict a public health
approach taking a holistic view of health improvement achieved through debate, and consensus is
advocated.
1.2.3
Future/proposed/existing related strategies and service plans
There are local specific and generic health improvement strategies and service redesign projects that
are in existence or are being developed that have implications and the potential to impact on dietary
improvement. It is important that the relevance of food and health issues be incorporated into
forthcoming strategies as identified in the Grampian Health Plan, Community Planning and other
relevant planning structures.
For example:















Breast Feeding
Coronary Heart Disease prevention strategy
Development of Managed Clinical Networks for CHD and Stroke.
Food Law Enforcement Service Plans –Aberdeen City, Aberdeenshire, Moray.
Framework for school nursing.
Grampian Physical Activity Strategy
Joint Health Improvement Plans – Aberdeen City, Aberdeenshire, and Moray.
Oral Health
GMS Contract
Management of diabetes
Hungry for Success
Potential redesign of obesity services
Redesign of health visiting
Sustainability Planning
Transport Planning
25
5.3 DETECTION, PREVENTION AND TREATMENT OF CLINICAL PRIORITIES
To identify evidence based interventions to ensure the detection, prevention and treatment of
obesity, stroke, heart disease, diabetes and cancer.
Obesity is a major risk factor for the development of many chronic diseases. With a prevalence of
approximately 50% in the adult population the prevention and treatment is an important public health
issue.
In order to prevent obesity, it is important that good dietary habits and an active lifestyle are
introduced, encouraged, and maintained through the early years, and into adulthood. Weight
management and addressing other risk factors such as lack of physical activity should be the priority in
the management of obesity. Major weight loss is to be discouraged but a 5-10% weight loss is
desirable47. The research evidence to support action to detect, prevent, and treat obesity is outlined
below.
5.3.1 Detection
It is important to ensure early identification of children and adults who are gaining weight; therefore it
is recommended that BMI and waist measurements be recorded in primary care at three-year
intervals47. Opportunistic measurements of BMI and waist circumference are also encouraged.
In Scotland the National Child Health Surveillance System routinely collects information on preschool and school children using standardised techniques. This tool has been used successfully to
examine the prevalence of obesity and under nutrition in Scottish children, which has found that
routinely collected growth data can be used for surveillance of under nutrition and obesity in children
(www.show.scot.nhs/isd/child_health/child_health.htm).
It is anticipated that this system will be introduced in Grampian in the near future. Currently the Child
Health Record and the assessments undertaken by midwives and health visiting teams are recorded on
a child-by-child basis and acted on accordingly. At present data is not aggregated for Grampian. This
does not and should not preclude primary care and school nursing staff from initiating an intervention
to promote healthy eating and active living messages as part of their health improvement role.
5.3.2 Prevention
In children
To date there has been limited quality data on the effectiveness of evidence of obesity prevention
programmes with young people48. Obesity is multi-faceted, effective prevention strategies must tackle
the issues by working across agencies. Limited studies have been undertaken to examine the efficacy
of obesity specific interventions in school to date the evidence is still weak. However promising
evidence has been found in relation to encouraging the reduction in sedentary behaviours and in family
therapy to prevent the progression of severe obesity in children48.
In adults
There is currently limited evidence to support or advise against community based obesity prevention
methods49. It is therefore identified that more research is required in this area. Limited evidence from
the United States has shown that community based educational programmes linked with financial
incentives may have an effect48.
26
5.3.3 Treatment
In children48
The following have been identified to be effective in the treatment of obesity in children:
 Interventions designed to reduce sedentary behaviour
 Benefits of parental involvement may be of greatest values for those aged 5-8 years but may vary
in effectiveness according to the age of the child thereafter.
 The effectiveness of treating adults and children together provides conflicting evidence.
In Adults50
The following have been shown to be effective in the treatment of obesity in adults:
 Lower fat diets with total caloric reduction produce greater weight loss that lower fat diets alone.
 A combination of a reduced calorie diets and increased physical activity produces greater weight
loss than either component alone.
 Diet is more efficacious in treating obesity, however physical activity is more efficacious in
decreasing mortality.
 Promising findings for behavioural therapy in relation to cue avoidance, daily weight charting,
behavioural therapy by correspondence and extending the length of the intervention period used in
conjunction with other weight loss strategies may be of benefit48.
5.3.5 Grampian action:
There are wide ranges of initiatives, which are in development or being implemented in Grampian, that
serve to detect, prevent and treat chronic disease. Some examples are listed below:
Early years:
 Implementation of the breastfeeding strategy
 Oral health policy for nurseries implemented
 Free fruit provision for pre-school groups and primary 1 & 2
 Weaning projects – including ethnic weaning resource
 Training for childminders, nurseries and others in the promotion of play and activity co-ordinated
by the Childcare Partnership and others.
 Pilot of implementation of SIGN 69 guidelines for the management of overweight children
Teenage Transition
 Health Promoting School – food and health, oral health and physical activity
 Implementation of Hungry For Success - a whole school approach to school meals
 Food skills programmes targeted at young people.
 Physical activity provision in the school and community setting through a variety of programmes.
 Pilot of implementation of SIGN 69 guidelines for the management of overweight teenagers
Workplace
 Promotion of Scotland’s Health at Work (SHAW) award scheme incorporating the development of
healthy eating policies and creating opportunities to be physically active at and during the working
27

week including active transport, active tasks and active living messages.
Promotion of Scottish Healthy Choices Award Scheme (SHCAS) which incorporated breastfeeding
friendly policies, the promotion of healthy catering and inclusion of healthy options on the menus
in a range of catering venues in a healthier environment.
Communities
 Participation in weight management programmes
 Promotion of the Walk to Health programme
 Implementation and development of the Now You’re Cooking food skills.
 Implementation of the SIGN guideline 8 for adult obesity management.
 Redesign of services to facilitate more appropriate chronic disease management exploring the
potential for integrated working through Managed Clinical Network (MCN).
 Involve parents in programmes aimed at addressing weight management issues especially with
young people aged 5-8 years
28
5.4 DEVELOP AND DELIVER FOOD AND HEALTH ACTIVITY IN PRIORITY SETTINGS
Identification of mechanisms and services in Grampian delivering health improvement activity
in relation to food and health focusing on socially disadvantaged and rural areas.
Appendix 1 outlines the areas in Grampian identified within the 10% and 20% most deprived in
Scotland. In addition rural disadvantage in Grampian should be addressed and considered in terms of
issues relating to food access.
Individuals and communities together with voluntary, statutory and private sector
agencies/organisations have a role to play in prioritising and supporting work in this area. Where
social disadvantage and rurality exist the impact of this on the ability of the community to adopt
appropriate food and health improvement practice will be a key priority:
Early Years:
 When working in partnership with initiatives such as Sure Start, Healthy Living Centres, Childcare
Partnerships, Family Centres, health visiting and midwifery staff to promote and raise awareness
of:
 Healthy eating during pregnancy
 Breakfast grant schemes

In the development and implementation of health promoting policies in childcare settings.
Teenage Transition:
 In the provision and development of nutritional resources targeting vulnerable young people.
 To be taken into consideration when promoting the Health Promoting School concept and
supporting the implementation of Hungry for Success, as well as healthy food choices provided at
breakfast clubs, tuckshops and after school clubs.
 To prioritise young people as a key group requiring training on basic food skills – incorporating
shopping, preparing, cooking and serving meals. Knowledge of the principles of a healthy diet will
be delivered via the 5-14 curriculum.
.
Workplace:
 Activity should be targeted through Scotland’s Health at Work (SHAW) NHS and the Local
Authorities should lead by example as the largest employers in Grampian
 Healthy eating policies, encompassing breast feeding support, weight management, and physical
activity programmes should take into account social and rural disadvantage.
 The Scottish Healthy Choices Award Scheme (SHCAS) should prioritise caterers delivering
service to large-scale workplace dining rooms targeting whole workforce.
Communities:
 The development of the Community Food initiative Northeast (CFINE) should continue to promote
availability and access to healthy options amongst our most disadvantaged communities.
29


CFINE working in partnership should be supported in the development of the Crisis Fare Share**
project in Aberdeen, which links with supermarkets to allocate food to the homeless or otherwise
vulnerable members of our communities.
Community engagement in local food initiatives such as food co-ops, food tasters, food skills,
community growing schemes and farmers markets should be encouraged.
**
The aims of Crisis Fare Share are primarily to distribute food that is safe to eat to vulnerable groups of the population.
The foods available may not constitute a healthy diet.
30
5.5
Protection from food related hazards, which impact on health
Ensure that measures are in place to support and promote ongoing adoption of food safety practices.
5.5.1 Breastfeeding
Breastmilk contains antibodies to protect babies from infection. This is a unique property that cannot
be duplicated by artificial milk. Work to promote breastfeeding is delivered through the Grampian
Breastfeeding Strategy.
5.5.2 Food Safety
The national and local context of food safety activity has been outlined in section 3.5. The following
activity has been successfully implemented in Grampian to promote food safety.
Public Awareness Activity in Grampian
In order to promote food safety NHS Grampian and partners organisations have developed the
‘Getting to grips with germs’ Campaign. The focus of the campaign has been on hand hygiene and
the preparation and storage of food in particular packed lunch boxes in schools.
The focus for activity in 2003 will centre on food and environment safety advice to youth leaders
responsible for groups of children on field trips, for example teachers or scout leaders. This initiative,
reflects the Scottish Executive food safety programme and seeks to:



enable leaders to make risk assessments of the venue to be used
provide advice on hand hygiene
provide information on the prevention of infection in the countryside.
31
5.6 INDIVIDUAL, GROUP AND POPULATION CAPACITY BUILDING
Utilisation of individual, group and population based approaches to develop skills to
enable people in Grampian to make healthier food choices in particular in deprived
and rural areas.
There is no single solution to improve the diet of the people in Grampian. This strategy therefore
adopts a wide range of methods and approaches to encourage the provision and uptake of a balanced
diet. The recommendations from the Food in Focus conference are outlined in section 5.2.2 and
provide valuable local information on the approaches required to enable people in Grampian to make
healthier choices.
5.6.1 Population approaches:
The importance of communicating information in relation to healthy eating to stimulate consumer
demand for healthy products has been energised through the recent Scottish Executive ‘healthyliving’
campaign. Advertising in the press, radio, billboards, television and magazines supports the campaign.
A website and a call centre to provide practical advice to consumers. It is important that local
initiatives maximise the potential of this national resource and the coverage that it will have in our
communities. Key health improvement activity should incorporate the ‘healthyliving’ branding
together with local relevant brands to enable consumer confidence in the quality of the information
provided.
Information on healthy eating and active living should be easily accessible to all those living in
Grampian through the distribution of health information resources in a wide range of settings. In line
with the recommendations from Food in Focus, specific target groups should be included in the
development and delivery of messages to promote healthy eating to ensure their relevance.
Key national initiatives should also be supported such as:




Breastfeeding Week
National Smile Week
Food Safety Week
British Dietetic Association ‘Food first’ Campaigns
To maximise available resource and increase the impact of public awareness campaigns local influence
in the development of national campaigns should be prioritised to enable resources and campaigns to
be regionally sensitive. This approach aims to minimise the need to use limited local resource to
duplicate local material. All campaigns incorporating healthy eating should be inclusive of and
communicate the key strategic objectives as outlined in section 2. Campaigns should be planned in
order to consider the cost effectiveness of such interventions and the sustainability of the input.
5.6.2 Current Individuals or Group Activity
There are currently a wide range of generic health improvement or specifically focused healthy eating
initiatives that can be accessed individually or collectively and prioritise different age groups and
settings. It is therefore important that the messages that are provided in these interactions are sensitive
to the needs of the individual/group and/or setting while also being consistent in terms of the healthy
32
eating advice as outlined in this strategy. It is also important to refer to the recommendations from
Food in Focus Conference as noted in section 5.2.1
Examples of current resources and activity are outlined below or identified in other components of
section five and will not be repeated here.
Early years:
 Development of parental skills to adopt healthy weaning practice
 Development of skills based initiatives to support breastfeeding to 6 weeks
 Increasing the skills and knowledge of carers of pre-school groups to include healthy eating as part
of play activities and snacks
 Food handling and preparation skills for children e.g. Sandwich workshops
 Food handling skills for carers who have to potential to promote healthy eating in their day to day
work e.g. family centre staff, classroom assistants
 Training in nutrition for staff working with early years age group
 Bottle to Cup initiative – best practice for parents
 Equipment grants to schools to increased cooks skills aiming to include more fruit and vegetables
in school meals
Teenage Transition:
 New Community Schools incorporating the Health Promoting School programmes
 The Mobile Information Bus (MIB) health information to young people in rural areas
 Cooking Initiatives for young people.
 Equipment grants to schools to increased cooks skills aiming to include more fruit and vegetables
in school meals
 Develop skills a knowledge of key stakeholders to implement the educational component of
Hungry for Success
Workplace:
 Healthy Options programme offering weight management and physical activity skills
 Resources Direct workplace health information service
 SHAW and SHCAS ensuring caterers and serving staff have the skills to incorporate healthy
choices into the menu and market the healthy choice appropriately
Communities:
 Cooking programmes focusing on the needs of participants from remote or deprived areas.
 Healthy Helpings Weight Management Programme providing participants with the skills to change
behaviours
 Use a community development approach when working with communities to develop appropriate
skills base
 Respond to needs assessments and requests for food skills identified by communities in community
learning plans
33
5.7
SECTOR, AGENCY AND COMMUNITY CAPACITY BUILDING
Identify mechanisms for developing the health capacity of Collectives, local authority, voluntary
sector, and communities to encourage health eating.
The Grampian Health Plan, the Community Planning process and the development of Joint Health
Improvement plans offers a opportunity to ensure commitment to the development of health capacity
within the health and social care communities. Raising awareness of and linking to existing initiatives
and identifying gaps to support the development of skills and knowledge to promote healthy eating
should be prioritised. Explore other methods for increasing healthy eating activity e.g. protocol
development and the promotion and sharing of best practice.
The NHS QIS standards on ‘Food, Fluid and Nutritional care in Hospitals51, have been developed
following extensive reviews of the evidence and the experience of NHS staff across many disciplines.
The standards cover all aspects of the food chain and are applicable to all patients in all hospitals in
Scotland. The standards stress the importance of patients receiving food and fluid appropriate to their
needs and the contribution that this makes to the overall outcome of their care. All aspects of food
delivery are covered including policy and planning, assessment/screening and care planning, delivery
of food to patients, information and communication and staff awareness training. Meeting the
requirements of these standards and successful implementation will be a challenge requiring multidisciplinary co-ordination and co-operation. The particular focus of this standard is the prevention of
malnutrition in the hospital setting. Work to progress this action is delivered by the NHS Grampian
Food, Fluid and Nutritional Care Group.
Examples of Activity to date:
Early Years:
 Training and resources provided for health visiting staff to encourage and facilitate the adoption of
healthy weaning practices.
 Cooking skills based programmes offered to the priority group of parents.
 Development of peer breast-feeding support groups.
 Training key professionals to support the development of nursery oral health policies.
 Implementation, in partnership with LA partners, the School Nutrition guidelines - Hungry for
Success
Teenage Transition:




Training to support the development of health promoting schools, in relation to oral health, food
and health and physical activity.
Development of training programmes, and documentation to support the development of breakfast
clubs/healthy tuckshops and after school clubs.
Implementation of the School Nutrition guidelines - Hungry for Success in partnership with pupils
and staff.
Support the development and implementation of School Nutrition Action Groups.
Workplace:
 Scottish Healthy Choices Award Scheme (SHCAS) promoted and training sessions provided to
34



assist in the completion of SHCAS portfolio.
Training provided to support the implementation of the SHAW award.
Healthy Catering training delivered targeting school cooks and other caterers.
Commitment to the development and implementation of local authority healthy eating policies.
Communities:
 Train the trainers Now You’re Cooking programme – developed and delivered by Moray College,
the Robert Gordon University and potentially Banff and Buchan College. Targeting community
learning, NHS and voluntary sector staff.
 Support community health needs assessments to respond to health needs in relation to food and
health issues such as the development of growing schemes and other local community food
initiatives.
35
5.8
MEASURING IMPACT AND ASSESSING EFFECTIVENESS
Identify mechanisms in place to audit and measure the quality, uptake and
impact of programmes related to diet in Grampian to inform planning
A range of systems, models, and procedures exist to assess the impact, uptake, and effectiveness of
food related initiatives. At present there is no one central system for collating this information. The
development of this strategy and subsequent monitoring of the action plan will assist in the coordination of food and health activity through identified lead agencies and subsequent delegated
officers. The collation of healthy eating activity requires the development of a wide reaching all
encompassing database. Resource is also required for evaluation and sharing of data.
It has been recognised in this strategy that wider health improvement activity may also incorporate
activity or messages in relation to healthy eating. Therefore it is proposed that the health improvement
network in Grampian (www.hi-net.org) will be a useful tool to ensure information sharing, exchange,
and monitoring progress. The monitoring of this strategy and related health improvement activity will
be posted on the HI-Net.
In 2003 Grampian responded to the Health Improvement Performance Assessment Framework on food
and health improvement activity. The purpose being to measure progress against the eight health
improvement functions across the four themes. It is anticipated that this will serve as a baseline to
measure progress in the performance assessment exercise in relation to food and health scheduled for
2005/06.
It is anticipated that useful working partnerships with national and local higher education institutions
and research bodies will be advantageous in developing tools to collect data.
Examples of current audit and monitoring systems are outlined below:
Early Years
 Monitoring of the number of mothers delivering a low birthweight babies.
 The number of admissions to RACH for food safety related illnesses.
 Currently child health records report height, weight, and other relevant information in relation to
general child health and development at key stages completed by health visiting staff. At present
this data is collected at practice level to enable appropriate treatment or care response. Grampian
is intending to introduce an interim system in 2003 to enable central collection of information to
measure progress towards the breastfeeding targets and other child health information to enable
eventual transfer to the National Pre School Surveillance system.
 Contributing to the Grampian implementation of Hungry for Success – a whole school approach to
school meals.
 Audit of bottle to cup initiative to assess change in practice.
 Change in feeding practice of children.
Teenage Transition
 Ongoing negotiation and collaboration with those undertaking national surveys should ensure more
collaboration and regional significance of national survey data.
 The implementation of Hungry for Success
36
Workplace
SHAW and SHCAS work in conjunction to promote healthy eating in the workplace setting. SHAW
is designed around three award levels – bronze, silver and gold. For each level there is a set of
mandatory and additional criteria. The provision of healthy food choices/facilitates in the workplace
where relevant is set as additional criteria for bronze and as mandatory criteria for silver awards.
SHCAS is designed around two levels – commended and highly commended awards. Both schemes
have scheduled audits and reassessments at set intervals.
Communities
A range of initiatives, programmes, and services are delivered at a community level. Therefore
specific monitoring and evaluation criteria are developed to meet the requirements of each. The
Grampian evaluation framework or the Learning Evaluation and Planning (LEAP) model are the most
commonly used framework for evaluation of health improvement activity. In addition service audits in
relation to waiting times, consumer satisfaction surveys and number of clients seen for the dietetic and
nutrition clinics are recorded.
37
6.0
Measuring Progress
6.1
Progress towards the Adult Dietary Targets for 2005
It has not be possible to exactly measure the progress of the Grampian population in relation to the
dietary targets as part of the Diet Action Plan for Scotland.
The Lifestyle Surveys ask specific questions which permit the identification of trends in eating habits
and intention to make changes to behaviour. This enables us to provide some self reported measures
of progress against the trends for the majority of the targets. The ability to specifically measure
progress against the targets regionally, in relation to the desired increased/reduced target quantity,
would require significant resource and therefore is not possible at this stage.
Table 1: Recommended increased daily consumption targets and progress
Daily
dietary
targets
Increased
consumption
Target*
Grampian data: **1998
1.
Fruit & vegetables
5 portions
(equates to doubling baseline
intake to 400gms)
24% of adult population achieve 5
or more portions per day.
Average consumption 3.4 pieces
per day.
2.
Bread (mainly using
wholemeal or brown
breads)
5 slices
(45% increase on baseline
consumption of 106gms per day)
3.
Cereals
Small bowl
(30g per day)
4.
Increase non-sugar
carbohydrate intake
through increased
consumption of fruit,
vegetables, bread,
breakfast cereals,
rice, and pasta and
increased
consumption of
potato.
A half an egg sized potato
(30grams - 25% increased
consumption)
(154gms – 25% increase fruit,
vegetables, bread, cereals, rice,
pasta consumption)
% of respondents consuming
bread 6-7 days per week
20.3% wholemeal bread
8.1% brown bread
32.8% white bread
Daily self reported cereal
consumption:
41.5%
Indicator of eating habits:
21.5% eat potatoes daily (no
indication of size)
72.6% eat rice, pasta, grains 1-5
days per week.
Table 2: Recommended increased weekly consumption targets and progress.
Weekly
dietary
targets
Increased
Consumption
Target
6.
White fish
Maintain at 1 portion per
week
7.
Oil rich fish
1 portion per week
(eg tin of sardines)
(Increase from 44g per week
to 88 gm per week).
Grampian data:
Total fish consumption indicator: 1/2
days per week:
42%
Behaviour change indicator:
Respondents who would like to
increase oil rich fish consumption:
14.4%
38
Table 3: Recommended decreased daily consumption targets and progress.
Daily
dietary
targets
8.
Decreased
consumption
Targets
Grampian data
Total fat:
Reduce to 70g per day.
To be no more than 35% of
total food energy.
Indicators of adult fat consumption.
16.4% use butter
1-7 days per week:
45.8% eat chips
31.3 % eat other fried food
47.7% eat cakes/scones
55.8% eat crisps
28.1% eat meat pies
57.5% eat confectionery
9.
Saturated fat
See above for relevant indicator
10.
Salt
11.
Sugar
To be no more than 11% total
food energy
Reduce to a teaspoon per day
(6g)
Average intake not to increase
Behaviour change indicator:
35.1% would like to eat less salt.
Indicators of sugar consumption 1-7
days per week:
56.7% drink soft fizzy non diet drinks
Behaviour change:
44.3% like to eat less sugar
* Scotlands Health a Challenge to Us All – The Scottish Diet 1993
Reference: 1998 Grampian Adult Lifestyle Survey data
6.2
Progress Towards Children and Young Persons Dietary Targets 2005
The data available to measure progress towards these targets is limited and therefore activity already
identified by NHS Grampian as a priority in terms of child health surveillance and work being
undertaken nationally to monitor progress towards the dietary targets should encompass the targets for
children and young people. In Grampian the Youth Lifestyle Survey completed every three years
provides an indication of the trends on young people (aged 11-17) eating habits and indication of
motivation to make changes in eating habits. Therefore the progress identified below is a measure of
trend for young people aged 11-17 only who live in Grampian.
Table 4: Recommended decreased consumption targets and Grampian progress.
Dietary
Target
Decreased
consumption
Target
Grampian data
confectionery consumption in 29% have at least one sugary snacks
children should fall by half
& non diet fizzy drink every day.
products: 75% of children should eat
meat products less than twice 61.7% of 11-17 year olds
weekly
1.
Confectionery:
2.
Meat
Table 5: Recommended increased consumption targets and Grampian progress.
Increase consumption
Target
Grampian data
39
3.
Fruit
vegetables:
and all children over 2 years of age
3-4 portions per day
adolescents is 5 portions daily
4.
Bread:
5.
Milk:
6.
Fish:
7.
Adolescents:
8.
Breastfeeding:
47% of young people aged 11-17 eat
5 portions of fruit and vegetables per
day
whole grain or granary bread
10.6% (11-17 year olds) eat
or cereals should be consumed
wholemeal bread every day.
twice daily
75% of children over 2 should
consume semi-skimmed milk
68% aged 11-17 drink semi-skimmed
milk
75% of children should eat
19% eat fish twice a week
fish twice weekly
particularly
those
from
disadvantaged areas, should be Refer to activity in early years and
targeted to receive good teenage transition outlined in section 5
dietary advice to ensure their for progress on this target.
own fitness for child-bearing
and child-rearing and to ensure
that good dietary practices are
passed on to their children
over half of the mothers in
Scotland in each region should be
breastfeeding their babies for the
first 4 weeks of life. At a local
level the following target has
been set:
70% of babies predominately or
fully breastfed at 6 weeks
following birth.
No local data
40
References:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
Joint WHO/FAO expert report on diet, nutrition and the prevention of chronic disease
Leon et al, (2002) Scotland’s Health In an International Context. Public Health Institute for Scotland.
Eating for Health: A diet action plan for Scotland. (1996) The Scottish Office, HMSO, Edinburgh.
Partnership for Care: White Paper (2003) Scottish Executive Health Department. HMSO, Edinburgh.
Improving Health In Scotland: The Challenge (2003), Scottish Executive Health Department, HMSO,
Edinburgh.
Grampian Health Plan 2003-2004, NHS Grampian.
Eating for Health: A Diet Action Plan for Grampian (1998) Grampian Food Strategy Group.
Food in Focus - from plough to plate. A conference reports 2002.
REF
Lobstein T. If they don’t eat a healthy diet, it’s their own fault! Myths about food and low-income.
National Food Alliance 1997
Caraher M., Dixon P., Lang T., Carr-Hill R. (1998) Access To Healthy foods: Part 1. Barriers to
accessing healthy foods: differentials by gender, social class, income, and mode of transport.
Farnham, M et al Aberdeenshire policy paper
The Grampian Food Shopping Basket Survey (2000) Grampian Heart Campaign.
The Scottish Diet Report (1993) The Scottish Office Department of Health.
Scottish Health Survey 1998
Management of Obesity in adults (SIGN 8)
NHS Quality Improvement Scotland: 2003 Clinical Outcome IndicatorsReport. P33-39 Obesity in
Children: Using Body Mass Index as a Measure
Scottish Intercollegiate Guidelines Network (69) 2003
Grampian Adult Lifestyle Survey 1994 Grampian Health Board
Grampian Adult Lifestyle Survey 1998 Grampian Health Board
Cancer Scenarios: An aid to planning cancer services in Scotland in the next decade (2001) NHS
Scotland.
Free fruit in schools initiative: Detailed Guidance (2003). Scottish Executive
Day N (2000) Cancer Mortality Target, Department of health, HMSO, London.
Food, Nutrition and the Prevention of Cancer: A Global Perspective (1997) World Cancer Research
Fund and American Institute for Cancer Research.
Narayan KMV, Gregg EW et al Diabetes a common, serious, costly and potentially preventable public
health problem. Diabetes Res Clinical Pract 2000; 50 77-84,
Puska P, et al The North Karelia project: 20 year results and experiences. Helsinki: National Public
health Institute (KTL), 1995.)
Chisholm et al Diabetes Medical (2000) 17 (12): 867-871
Tuomilehto et al Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with
impaired glucose tolerance. N Engl J Med 2001:333: 1343-50)
Lean MEJ, et al. Obesity, weight loss and prognosis in type 2 diabetes. (1990) Diabetes Medicine 7(3):
228-233.
British Diabetic Association Nutrition Subcommittee. (1992) Dietary Recommendations for people with
diabetes: An update for the 1990’s. Diabetes. Medicine 9: 189-202
Evidence-Based Nutrition Principles and recommendations for the Treatment and Prevention of
Diabetes and related complications. American Diabetes Association (2002) Diabetes Care 25: 202-212
Richmond Committee
Food Standards Agency Strategy on Foodborne Disease
Cancer in Scotland Action for Change (2001) Scottish Executive Health Department, HMSO,
Edinburgh.
Our National Health: A Plan for Action a Plan for Change (2000) Scottish Executive Health
Department, HMSO, Edinburgh.
The Coronary Heart Disease and Stroke Strategy for Scotland (2001) Scottish Executive Health
Department, HMSO, Edinburgh.
Healthy Start Proposal consultation
41
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
Steinmetz,K. and Potter, J. (1996). Vegetables, fruit and cancer prevention: a review. Journal of the
American Dietetic association 96 (10): 1027-39
Hungry for Success A Whole School Approach to School meals in Scotland (2002) Scottish Executive,
HMSO, Edinburgh.
European Council Drinking Water Directive
Food Standards Agency Scotland (2003) Draft Diet and Nutrition Strategy: Our Role in Implementing
the Scottish Diet Action Plan. FSA, Aberdeen.
Eating for Health- A Diet Action Plan for Local Authorities (1998) Health Promotions, Grampian
Health Board.
WHO Framework health improvement
National diet and nutrition strategy
Grampian Youth Lifestyle Survey 2001 NHS Grampian
Grampian Youth Lifestyle Survey 1998 Grampian Health Board
Cochrane review, Campbell et al, 2001
NHS CRD York, 1997
Douketis et al, 1999
Draft Clinical Standards: Food Fluid and Nutritional Care (2002) Clinical Standards Board for Scotland,
(now NHS Quality Improvement Scotland) NHS Scotland.
42
Appendix 1: Designated Areas of Deprivation in Grampian
Aberdeen City 1
Aberdeen City 2
Aberdeenshire 2
Alexander/Hayton
Torry
West Fraserburgh
Ferrier/Sandilands
Middlefield
Tillydrone/Seaton
Northfield
Gadlebraes (Peterhead)
Printfield
Powis
Tullos
Mastrick
Moray 2
Forres (parts of)
Cummings Park
Rosemount Square
Froghall
1 Scottish Office Deprivation Indicators within the worst 10% in Scotland 1991 Census
2 Scottish Office Deprivation Indicators within the worst 20% in Scotland 1991 Census
43
Glossary
Agenda 21
Hi-Net
Hungry for Success – Scottish Executives response to the Health Improvement Challenge is to
introduce national nutrient based standards for school lunches. Diet is a key theme with emphasis on
children and young people with early years and teenage transition identified as priority areas for
action. Key agents are local authorities working in partnership with caterers, schools, school
communities and the NHS.
Performance Assessment Framework
Scottish Healthy Choices Award
Scotlands Health At Work
44
Grampian Food and Health Improvement Action Plan
This action plan has been developed in order to guide the implementation of the Food and Health Improvement Strategy for Grampian. The values,
vision and targets of the strategy underpin the actions detailed in the plan. The actions are presented under the themes as outlined in the document
Improving Health in Scotland – The Challenge (2003).
The themes are:
 Early years – focusing on healthy pregnancies, infancy and pre-school children and parenting;
 Youth Transition – key transition points in primary, early stages of secondary school and adolescence to adulthood focusing on schools in
partnership with the home and the community;
 Adults of Working Age - incorporating the workplace setting as an opportunity to support health improvement throughout adulthood;
 Community – encourages support and enables individuals and communities to take shared responsibility for their health and seek to support action
to address inequalities.
The following 4 key aims have been identified in relation to food and health improvement activity within the four theme areas.
Early Years Aim:
1. To seek to promote healthy eating in the early years including pre-conception in order to maximize the potential for a healthy start for children born
in Grampian.
Youth Transition Aim:
2. To seek to promote healthy eating with young people at key transition stages, in relation to the key settings of school, home and communities.
Adults of Working Age Aim:
3. To seek to provide opportunities and increase awareness for adults of working age to have access healthier food.
Communities Aim:
4. To seek to build individual and community capacity to address food and health inequalities.
All programmes, projects and initiatives incorporating healthy eating messages should promote the consumption of fruit and vegetables, reduction of
45
fat and promotion of the active living message involving consumers in the development of these messages where possible.
In addressing issues of food access it is essential that this strategy supports capacity building in communities to enable healthy food choices to be
made. For the purposes of this document capacity building is defined as skills, knowledge, resource and levels of empowerment. Therefore all
programmes, projects, and initiatives should consider and include measures to promote and enable the following principles in relation to food choice:






1.
Awareness
Access
Availability
Acceptability
Affordability
Culturally Appropriate
EARLY YEARS
Aim: To seek to promote healthy eating in the early years including pre-conception up to primary school age in order to maximize the
potential for a healthy start for children born in Grampian
Objective
1.1
To promote the
consumption of a
healthy eating, in
particular the
promotion of fruit
and vegetables,
reduce saturated fat
and promotion of
active living
messages to parents
and young children
in partnership with
others.
Free fruit was given
in nurseries as well



Examples of
activity
Food and
Health HIF
initiatives
Kids in
Condition –
body rock
programme.
Guidelines for
development
of Oral Health
Policy for
Nurseries.
Action/anticipated
outcome/outputs
 Co-ordinated and
consistent
messages delivered
in line with and
sensitive to the
needs of the client
group.
 Targeted input to
support future
parents and
promote the
importance of diet
in early years.
 Consistent health
information and
support for
Lead Agency/ies
Timescale/targets
NHS
Grampian/Local
Authorities
Ongoing
-
Public Health
Collectives
Community
Dietetics
46
Resource
Core
funding
Additional
resource
required
Policy/Guidance/
Evidence
Improving Health in
Scotland – The challenge
(2003)
1.
EARLY YEARS
Aim: To seek to promote healthy eating in the early years including pre-conception up to primary school age in order to maximize the
potential for a healthy start for children born in Grampian
Objective
Examples of
activity
as primary schools
1.2
1.3
Raise awareness of
the use of
appropriate
supplements and
additional support
during pregnancy.
Support the
implementation of
the Breastfeeding

Development
of a
breastfeeding
Action/anticipated
outcome/outputs
healthyliving and
other relevant
public awareness
activity.
Lead Agency/ies
 Encourage the
uptake of folic acid
supplements prior
to and during
pregnancy through
the distribution and
promotion of
relevant
information through
NHS and other
information points
 Raise awareness of
the ‘Healthy Start’
scheme and
encourage the
uptake of milk
tokens during
pregnancy through
the disseminate
information in areas
of deprivation
 Increase uptake of
free dental
treatment during
pregnancy through
promotion in health
and other relevant
settings.
 Influencing NHSG
culture towards
breastfeeding
NHS Grampian
- Maternity
services
- Pharmacy
- Community
Dentists/Dent
al Practitioner
- Collectives
Timescale/targets
Ongoing
Resource
NHS core
funding
LA
funding
NHS core
funding
Policy/Guidance/
Evidence
Social Justice – A Scotland
Where Everyone Matters
(1999)
The Right Medicine: A
Strategy for
Pharmaceutical Care in
Scotland (2002).
‘Healthy Start’ - reform of
the Welfare Food Scheme
‘Sure Start’
Oral Health Strategy for
Scotland/Grampian
Breast
Feeding
47
Breast feeding
rates:
40-45% at 6 weeks
NHS core
Funding.
Breast feeding Strategy
1.
EARLY YEARS
Aim: To seek to promote healthy eating in the early years including pre-conception up to primary school age in order to maximize the
potential for a healthy start for children born in Grampian
Objective
Strategy for
Grampian (2002).


1.4
Support and develop
initiatives to
promote healthy
weaning practices

Examples of
activity
centre
Peer support
groups
established
across
Grampian
Training for
midwives &
health visitors
Action/anticipated
outcome/outputs
 Develop and
implement
guidelines for best
practice for
antenatal and
postnatal support to
breastfeeding
mothers.
 Implement health
professional and
peer support
interventions to
promote, support,
and sustain
breastfeeding.
 Increase the
initiation and
duration of
breastfeeding
 Ensure mothers
feeding babies
formula milk are
given correct
information
 Development of
systematic data
collection system.

Weaning
HIF weaning
incorporated into
projects: bottle
CPD training and
to cup
undergraduate
initiatives,
training for Health
weaning
Visitors.
demonstration

Recommendations
and ethnic
for good practice
weaning
promoted and
resource.
Lead Agency/ies
Timescale/targets
Implementation
Group.
by 2005
NHS Grampian
- Collectives
- Community
Dietetics
September 2003
48
Resource
HIF
funding
2003/04
NHS core
funding
Policy/Guidance/
Evidence
Improving Health in
Scotland – The challenge
(2003)
1.
EARLY YEARS
Aim: To seek to promote healthy eating in the early years including pre-conception up to primary school age in order to maximize the
potential for a healthy start for children born in Grampian
Objective
1.5
Support the
implementation of
the Oral Health
Strategy for
Grampian (1998).
Examples of
activity

56.2% of
under 5’s free
of dental
disease.
Action/anticipated
outcome/outputs
implemented.
 Support the
implementation of
the Toothnology
dental awareness
programme in
Grampian.
 Address dental
inequalities
 Promote sugar free
medicines.
Lead Agency/ies
Timescale/targets
NHS Grampian
- Community
Dental
Service
- Dental
Practitioners
- Pharmacy
Ongoing
49
Resource
NHS
Grampian
core
funding
Policy/Guidance/
Evidence
Oral Health Strategy for
Grampian (1998)
The Right Medicine: A
Strategy for
Pharmaceutical Care in
Scotland (2002).
2.
TEENAGE TRANSITION
Aim: To seek to promote healthy eating with young people at key transition stages, in relation to the key settings of educational
establishments, home and communities.
Objective
2.1
Raise awareness of
healthy eating in
particular increasing
the consumption of
fruit and vegetables,
reducing fat
(especially saturated
fat) and promotion
of active living with
young people.
Current activity




2.2
2.3
Implement free fruit
in primary 1 & 2
scheme in all
Grampian primary
schools.
Implement the
nutritional
guidelines for school


Action/anticipated
outputs/outcomes
Development Promotion and support
and promotion of :
of health
 HPS food and
promoting
health
school (HPS)
 HPS oral health
programme.
 HPS physical
Promotion of
activity
the Health
 SHAW
Promoting
 SHCAS
University/Col
 School Nutrition
lege
Action Groups
Scottish
(SNAGS)
healthy
 Support the
Choices
implementation of
Award
breakfast clubs.
Scheme
 Consistent health
Scotlands
information and
Health at
support for
Work Scheme
healthyliving and
other relevant
public awareness
activity.
HIF funded
 SEHD guidance on
short-term
free fruit scheme
initiatives in
implemented and
parts of
reporting
Grampian.
mechanisms in
place.
School meal
provider
agreements

Promote a positive
school/whole child
ethos.
Lead
Agency/ies
Local Authority
& NHS
Grampian
- Public
Health
- Collectives
Timescale/targets
HPS in all schools
by 2007
Resource
Policy
Joint Local
Authority
& NHSG
resource.
Breakfast
Club
Grants
Changing
Children’s
Services
funds
Social Justice – A Scotland
Where Everyone Matters
(1999)
Improving Health in
Scotland – The Challenge
(2003).
Lets Make Scotland More
Active - Physical Activity
Strategy for Scotland
(2002)
A Scottish Framework for
Nursing in Schools (2003).
Local Authorities
Supported by
partners including
NHS G.
Reporting March
& November
NPAF* claim
forms
2003 - 2006
Local
Authorities
50
Guidelines
implemented in
Special and Primary
NPAF
Moray
(£36,631)
A’Shire
(£94,346)
A’City
(£68,597)
Local
Authority
Improving Health in
Scotland – The Challenge
(2003).
Free Fruit in Schools
Initiative for Primary 1 &
2, Detailed Guidance
SEHD, 2003
2.
TEENAGE TRANSITION
Aim: To seek to promote healthy eating with young people at key transition stages, in relation to the key settings of educational
establishments, home and communities.
Objective
meals - Hungry for
Success in
Grampian.
2.4
Seek to build
capacity of young
people to purchase,
prepare, cook and
present healthy food.
Current activity





2.5
Developmental
activity is required
to address weight
management issues.
Activity to address
Action/anticipated
outputs/outcomes
with Local
 Pupil consultation
Authorities.
on school meals.
Aberdeen City  Eliminating stigma
Recipe book
of free school
programme.
meals.
 Managing the
process of
providing school
meals.
 Influencing choice
of healthy school
meals.
 Providing
incentives to
improve uptake of
school lunches.
Now You’re
 Raise awareness of
Cooking
food labelling
Programme
 Support the
Home
development of
Economics
food skills
Provision
 Seek opportunities
Bi- Annual
for food taster
Get Set to
demonstrations
Cook
 Seek opportunities
Competition
for partnerships
Rattle those
with private sector
pots and pans
– producers,
resource.
retailers and
catering staff
 Pilot guidelines for
childhood obesity
in Kincardine and
Deeside
components of
Lead
Agency/ies
Timescale/targets
Policy
schools by Dec
2004; Secondary by
Dec 06.
Hungry for Success:
Nutritional standards for
school meals, 2002.
2004/05 –
preparation towards
targets.
A Scottish Framework for
Nursing in Schools (2003).
NHS Grampian
– Public Health
- Collective
- Community
Dietetics
Local Authority
Private Sector
Partnership
Partnership with
FE colleges.
Ongoing – linked to
HPS targets
NHS Grampian
 Collectives
 Community
Dietetic
Department
2004/05
51
Resource
Seek
funding
Potential
SponsorShip
Improving Health in
Scotland – The Challenge
(2003).
Evidenced in Grampian
Youth Lifestyle Survey
(2001)
Food in Focus Report
(2003)
Core
NHSG
resource
Seek
additional
Cochrane review2001
NHS CRD York, 1997
2.
TEENAGE TRANSITION
Aim: To seek to promote healthy eating with young people at key transition stages, in relation to the key settings of educational
establishments, home and communities.
Objective
Current activity
weight management
should involve
parents/guardians in
programmes with
children aged 5-8
years and friends
and family for older
age groups with a
particular focus on
the teenage groups.
Action/anticipated
outputs/outcomes
Aberdeenshire
Collective.
 Support the
dissemination and
implementation of
the SIGN
Guideline for
Childhood Obesity.
 Build capacity in
for example
nursing in schools
to address obesity.
 Review various
NHSG weight
management
programmes to
inform future
delivery.
Lead
Agency/ies
 Public
Health
Timescale/targets
Resource
resource as
required
Policy
Sign 69
Evidenced in Grampian
Youth Lifestyle Survey
(2001)
A Scottish Framework for
Nursing in Schools (2003).
* NPAF – National Priorities Action Fund
52
3.
3.1
3.2
WORKPLACE
Aim: To seek to provide opportunities and increase awareness for adults of working age to have access to healthier food
Objective
Current activity
To support and
encourage the
development of
healthy eating policies
in the workplace.
The provision of
healthy food
choices/facilities in
the workplace is
mandatory criteria for
silver and gold
awards. The current
numbers of
workplaces in
Grampian that have
silver are 52 and
gold 23.
 12 award holders
Support the promotion
and implementation of
Scottish Healthy
Choices Award
Scheme (SHCA)

25 registered
clients

2 upgraded
award holders
Action/anticipated
outcome/output

Lead
Agency/ies
Promotion and
uptake of
Scotland’s Health
At Work (SHAW)
programme.
Healthy eating
policies developed
in public sector
workplaces.
NHS Grampian

Pilot offshore
installations award
process.
NHS Grampian

Increase number
of award
applicants.

Timescale/targets
National and local
audits & evaluation
Ongoing
National and local
audits & evaluation
Resource
NHS
Grampian
Core
funding.
Income
Generate
National
SHAW
funding
Improving Health in Scotland –
The Challenge (2004)
NHS
Grampian
Improving Health in Scotland –
The Challenge (2003)
3.3
Raise awareness of
the benefits of fruit
and vegetable
consumption, active
living and the
reduction of saturated
fat amongst adults of
working age with
particular focus on
messages applicable
adults aged 16-24,
men and the
importance of diet
Workplace direct
services/workshops
delivered which
include healthy
eating element:
Men’s health – 33
Health Needs
Assessments – 11
Fitness assessments
– 14
Healthy Eating – 5
Lifestyle Checks –
35
Women’s Health – 6
Health Fairs – 4
Maintain existing
award holders.

Targeted input
focusing on
messages
provided to men.
Food First 2004
campaign will
target adult men
aged 35+, social
classes IV and V
via workplaces,
sports clubs and
fitness centres
Targeted input
focusing on the
diet of those aged
16-24 years.


Eating for Health: A direct action
plan for Scotland (1998)
Catering for Health – aid for
teaching healthier cooking
practices (2002)


Policy/Guidance Rationale
NHS Grampian
53
National SHAW
impact evaluation
(2002) and ongoing
Ongoing local
audits and
evaluation of
workplace direct
services/workshops
NHS core
funding
Additional
resource
required
Potential
sponsorship
Evidence in Adult Lifestyle Survey
(1998)
3.
WORKPLACE
Aim: To seek to provide opportunities and increase awareness for adults of working age to have access to healthier food within the workplace
Objective
Current activity
Action/anticipated
outcome/output
Healthy Options - 5



Lead
Agency/ies
Consistent health
information &
support for
healthyliving and
other public
awareness
activity.
54
Timescale/targets
Resource
Policy/Guidance Rationale
4.
COMMUNITIES
Aim: To seek to build individual and community capacity to address food and health inequalities.
Objective
4.1
Ensure that the needs of
communities are taken into
account to enable access
to, improve affordability
and availability of healthy
food choices. Including
facilitating and encourage
local food networks to
support growing schemes
and/or promote the
consumption of local
produce.






Current
activity
Community
Food
Outlets in
Aberdeen
City
2 cafés at
present
Moray food
& Health
project
Healthy
Roots community
led growing
scheme in
A’City
farmers
markets
(Aberdeen,
Peterhead,
Elgin)
supermarket
consultation
complete
2000
Action/outputs





Support and
promote
community food
initiatives across
Grampian such
as community
kitchen project,
grow your own
schemes, Food
Co-ops.
Implement,
monitor and
evaluate Moray
Food and Health
Project
Support the
further
development of
community cafés
in Grampian.
Develop
networks and
explore
opportunities to
support the
promotion of
locally grown,
produced food
products.
Consistent
health
information &
support for
healthyliving
and other
relevant public
awareness
Lead
Agency/ies
Timescale/targets
Ongoing
NHS
Grampian –
Public Health,
Collectives &
Partners Producers/Ret
ailers
Resource
External
funding
sources –
NOF, HIF
Core NHSG
resource
Policy/Guidance/
Rationale
Improving Health in
Scotland – The
Challenge (2003)
Evidenced in Adult
Lifestyle Survey (1998)
Evidenced in Grampian
Youth Lifestyle Survey
(2001)
Food in Focus Report
(2003)
Moray Food &
Health Group
Local
Authority/
Voluntary
Sector/NHS
Grampian,
Producers/Ret
ailers
55
Local
Authority
funding
Some
additional
resource may
be required.
Agenda 21: Sustainable
development
4.
COMMUNITIES
Aim: To seek to build individual and community capacity to address food and health inequalities.
Objective
4.2
Enable the development of
practical cookery skills
Current
activity


Now
You’re
Cooking
(NYC)
project
Approx. 25
NYC
courses per
year.
Action/outputs



4.3
Ensure action to promote
food and health
improvement seeks to be
socially inclusive.



NYC
delivered to
vulnerable
and groups.
Healthy
eating pilot
with mental
health user
group –
Peterhead.
Ethnic
weaning
resource

activity.
In partnership
with FE
Colleges in
Grampian
implement
training for
trainers
programme for
NYC.
Review,
develop,
promote,
implement and
evaluate NYC
programme.
Support
development of
Community
Kitchen project
in Aberdeen
City.
Improve access
to food for
vulnerable
groups such as
homeless
individuals
through the
implementation
of the Crisis
Fareshare
Project in
Aberdeen and
inputting into the
homelessness
action plans in
each Local
Lead
Agency/ies
NHS
Grampian
&FE Colleges
Timescale/targets
Ongoing
Resource
Additional
Sponsorship
may be
required
Policy/Guidance/
Rationale
Improving Health in
Scotland – The
Challenge (2003)
Evidenced in Adult
Lifestyle Survey (1998)
NHS
Grampian
NHS
Grampian
Core Funding
Evidenced in Grampian
Youth Lifestyle Survey
(2001)
Food in Focus Report
(2003)
NHS
Grampian &
A’City
Council
2003/04 pilot
CFINE
Ongoing
All agencies
56
HIF
Multiple
Sources
CFINE Business Plan
2003-06
Additional
Funding may
be required
Health and Homelessness
Strategy NHS Grampian
(2003)
Aberdeen City
Homelessness Action
Plan 2003
Aberdeenshire
Homelessness Action
Plan 2003
Moray Homelessness
Action Plan 2003.
4.
COMMUNITIES
Aim: To seek to build individual and community capacity to address food and health inequalities.
Objective
Current
activity
Action/outputs


4.4

Co-ordinate efforts to
address the food and
health needs of older
people.

4.5
Develop and nurture links
with University, FE
Colleges, local and
national research bodies to
support the development
of knowledge and skills in

Provision of
training for
trainers in
Moray
College and

Authority.
Continue to
ensure materials
produced/provid
ed are
considerate of
ethnicity.
Ensure
initiatives and
information can
be adapted to
incorporate the
needs of those
with a physical
disability and/or
other special
needs.
Continue to
implement core
standards on
nutritional care
of older people.
Raise awareness
of food and
health issues and
address training
needs of carers,
domestic staff
and others
involved in food
preparation for
the elderly
Examine and
assess the
nutritional
component of
undergraduate
Lead
Agency/ies
All agencies
Timescale/targets
Resource
Policy/Guidance/
Rationale
Improving Health in
Scotland – The
Challenge (2003)
Social Justice – A
Scotland Where
Everyone Matters (1999)
Food in Focus Report
(2003)
Choices for our Future –
Grampian Strategy. for
Learning Disability
Ethnic Minority Strategy
NHS
Grampian &
Local
Authority
NHS
Grampian and
partners.
- Communit
y Dietetics
- Collective
57
Ongoing
Ongoing
NHS
Grampian &
Local
Authority –
health and
social care
resource
Ageing With Confidence
(2000) – A Joint Strategy
for Older People in
Grampian
NHS Core
Funding
Food in Focus Report
(2003)
Additional
resource may
be required
CRAG guidelines (2000)
4.
COMMUNITIES
Aim: To seek to build individual and community capacity to address food and health inequalities.
Objective
relation to food and health
improvement issues
including the integration
within undergraduate and
post graduate training.


Current
activity
The Robert
Gordon
University.
Input to
Catering for
Health
Course
Aberdeen
College.
Healthy
Catering
Training
Action/outputs



4.8
Develop a co-ordinated
approach to support the
implementation of
programmes to build
capacity to address weight
management and obesity
issues in adults.



20 Counterweight
Intervention
sites
Grampian
& Highland
20 Healthy
Helpings
2002/03
16 Now
You’re


and other
training courses.
Needs assess,
develop and
deliver training
programmes to
increase food
and health
improvement
capacity in a
range of settings
such as primary
care, other
clinical settings,
hospitality and
catering
industry.
Support the
implementation
of the REHIS
programme in
Grampian.
Determine and
progress
research
priorities.
Review the
existing
provision of
weight
management and
food skill
programmes,
incorporating the
views of
service/potential
service users.
Project plan,
Lead
Agency/ies
s
- Public
Health
NHS
Grampian
 Practices
 Collective
 Pubic
Health
 Communit
y Dietetics
 Nutrition
Clinic
58
Timescale/targets
2003/04
Resource
Review
existing NHS
Grampian
core
allocation
Seek
Additional
funding as
required
Policy/Guidance/
Rationale
SIGN 6
Improving Health in
Scotland – The
Challenge (2003)
Grampian Local Health
Plan 2003/04
4.
COMMUNITIES
Aim: To seek to build individual and community capacity to address food and health inequalities.
Objective



Current
activity
Cooking
2002/03
Walk to
Health
Programme
Danestone
weight
managemen
t pilot
programme
Moray food
and Health
Project
Action/outputs

Lead
Agency/ies
implement and
evaluate a
revised
programme and
service
provision.
Disseminate
findings and
publicise
services.
**CFINE – Community Food Initiative North East
59
Timescale/targets
Resource
Policy/Guidance/
Rationale