Scottish Government

TOWARDS BETTER ORAL HEALTH IN CHILDREN: ANALYSIS OF CONSULTATION RESPONSES

CHAPTER 5: PROMOTION OF BETTER DIET

The consultation stated:

Schools are the key vehicle for the promotion of healthy lifestyles to children and young people.

Education Authorities are increasingly on board with this concept and every school is being encouraged to become health promoting. To help schools promote good health, the Scottish Executive launched in May (2002) a Health Promoting Schools Unit.

The Scottish Executive Expert Panel on School Meals published "Hungry for Success: National Standard for School Meals" for consultation in July 2002. In addition to producing nutritional standards, the panel reported on measures to eliminate stigma and improve the presentation of school meals. The report sets out a vision for a revitalised school meals service in Scotland and presents a number of far-reaching recommendation connecting school meals with the curriculum as a key aspect of health education and health promotion.

Two specific initiatives established as a direct result of the Scottish Diet Action Plan and which have a particular focus on improving diet…are the Scottish Community Diet Project and the Scottish Healthy Choices Award Scheme which encourages catering interests to provide and promote healthy food choices.

The Food Standards agency is looking to work with consumers, enforcement authorities and industry to develop a set of guidelines on best practice in labelling and promotion for foods aimed at children. It is also undertaking a series of activities which will help support parents who are trying to provide their children with a healthy, balanced diet.

More could be done to promote better diet through the newly appointed Scottish Food and Health Co-Ordinator. Parents need to set positive examples with key roles for midwives and health visitors in advising parents with young children. Mothers should be encouraged to breast feed exclusively for the first 6 months. Nurseries, playgroups and Family Centres all provide a suitable environment for dissemination and discussion and encouraging good habits especially among the most disadvantaged children.

Consultees views were:

In Detail:

Many respondents referred to the urgent need to promote better diet and eating habits. Some responded in general terms, others were more specific about promotion through schools, through parents, at a community level, via health professionals or promotion through advertising. These are taken in turn below.

GENERAL PROMOTION

It was interesting to see so many responses (professional and public) identifying the need to educate the public on better diet. Where respondents specified further details these took the form of advocating focused campaigns, programmes, initiatives and advice, promoted vigorously (Faculty of Public Health Medicine) with the involvement and backing of political representatives and adequate publicity (HMIE). Specific programmes were identified such as the UK Food and Drink Manufacturing Industry's "foodfitness" - an information programme promoting good diet and nutrition. Some respondents deplored people's " lamentable ignorance of nutrition" (indiv 471) and supported the earmarking of funds to develop promotion of diet through education. One GDP (1266) considered that "scare tactics" would be effective to make parents aware of the damage caused by sugary food and drink.

There was a call, however, for more simple messages to be conveyed, " consistent, simple, achievable messages" (Royal College of Physicians, Edinburgh), to address the current confusion about dietary recommendations (Barnardos Scotland). A few respondents stressed that messages needed to be accurate and realistic. For example, advocating exclusive breast-feeding for 6 months was not seen as helpful (indiv 1062) although frequently recommended.

It was suggested that emphasis should be placed on the frequency of intake of sugary foods in addition to overall levels (NHS Argyll and Bute). The relative costs of healthy and unhealthy diets could perhaps be made clearer (Dental Surgeon 1362) and more imaginative use made of promotional information (Gorebridge Community Council).

Financial incentives and sponsorships were viewed by some as having the potential to contribute to promote healthier diets. The extension of fresh fruit sponsorship schemes was recommended (Borders NHS Board), whilst several individuals suggested that increasing taxes on unhealthy food and drink would make them less accessible (indivs 224, 290, 368, 1108). By the same token it was considered that subsidising " fruit, vegetables and whole-meal bread could bring these further within people's budgets and increase their accessibility" (indiv 926). Some respondents called for a better control over the sale of confectionery and related foodstuffs, one respondent requesting that the Government step in to administer and regulate this sector (indiv 1185).

It was suggested that promotion through education could very usefully be aimed at early years - through antenatal dietary advice (indiv 838, Greater Glasgow Primary Care NHS Trust) and support for breast-feeding mothers (indiv 196) with such effort seen as reaping long term benefits (indiv 849).

A few respondents emphasised the need for promotions to integrate both nutrition and oral health within their remit in a holistic fashion (indiv 1105, NHS Forth Valley Board).

PROMOTION THROUGH SCHOOLS

There was much support for greater promotion of better diets through schools. This was envisaged in a number of ways:

Curriculum

Some called for mandatory cooking and nutrition lessons (e.g. indiv 249) with extension to cover all stages of schooling (indiv 291). Again, consistency of message was advocated (N. Aryshire Council). Suggested content of lessons comprised " basic cookery" (Forth Valley LHC) and " dietary information" (Lothian LHC) but lively reinforcement could involve celebrities (Brannock High School) and eating fun days (Dundee City Council).

Other Promotion Ideas

Requests were made for focused training (or specialist education) of teachers to enable them to promote healthier eating (indivs 248, 282, Dental Surgeon 1297, NHS Lanarkshire, Academic 1329, Springburn Health Centre Respondent 1). It was suggested that any staff involved in food preparation should also be provided with specialist training perhaps through Childcare courses (indiv 98). Some thought that school nurses could contribute to promoting a more consistent healthy eating message (e.g. indiv 57) with a call for better diet promotion information to be displayed prominently in school canteens (indiv 788). Other respondents were in favour of more individual school campaigns aimed at ensuring, " that children are properly fed" (indiv 165) with an " emphasis on a low sugar diet" (indiv 850).

It was recognised by many respondents that several healthy eating initiatives were already in place. Continued support for the Scottish Healthy Choices Award Scheme (Angus Council, Scottish Liberal Democrats) was recommended, with others favouring, " awards for schools who improve their eating habits" (Borders LHC).

Extra support for schools was suggested, for example via the recruitment of, " dieticians to put in personal appearances at schools to monitor school lunches…and advise on the stocking of tuck shops" (indiv 862). Others considered that useful help could take the form of national policy and guidance on school diet and its implementation, including tuck shops and sponsorship of food products and initiatives (Dept of Community Social Services Orkney Council, SW Glasgow LHCC Oral Health Group, CDS sub-committee to Lanark Area Dental Advisory Committee, NHS Forth Valley Board).

Joined-Up Approaches

The importance of consistency of message, policy and priority throughout schools and their wider framework of professional and organisations was stressed repeatedly. Some saw local businesses and authorities co-operating more closely (Scottish Liberal Democrats), other hoped for closer working with parents (Greengables Nursery School). An innovative and successful approach in Somerset had involved a working relationship between a school and a local farm (Medical Centre, Kemnay). New Community Schools were perceived as having the potential for promoting a consistent message across professionals (Argyll and Bute Council Education Service, Greater Glasgow PCT) and some calls were made for the establishment of School Nutrition Action Groups in all schools (e.g. Highland Area Dental Committee, Beechbrae Education Centre, HMIE, Scottish Community Dental Service, indiv 1024).

PROMOTION THROUGH PARENTS

Many respondents stressed the role of parents in promoting a healthy diet at home. Some individuals held strong views that parents were perfectly capable of supervising their children's diet, just as they, themselves had done (indivs 534, 586, " I go to great measures to encourage healthy eating and drinking in my family" (indiv 543)).

A major theme to emerge was the need to educate parents on healthier diets, one individual commenting that, " education of parents is more important than the education of children" (indiv 856). Many individuals and professionals identified the need for more education, with some expressing surprise at the levels of ignorance and behaviour they had encountered (e.g. "… amazed at the amount of sugar parents permit their children" (CDS Lerwick)). One suggestion was to make parents aware of the cost of the damage done to their children's teeth from over indulgence in sugary foods (Dental Surgeon 1297).

Some advocated focusing education on mothers, especially those with very young children (Health Promotion Department, NHS Lanarkshire, indivs 875, 973). Other ideas included more support for breast feeding, more advice on diet after weaning (Consultant in Dental Public Health), discouragement of the use of dummies with sugar (indiv 1356), using "scare tactics" and offering weaning packs with a blender included at a subsidised price (LHCC Easterhouse Health Centre) or even free (SW Edinburgh LHCC).

Others recommended extending the education to encompass fathers, " boys need a male role-model" (GP 163), grandparents (GP 191, Banchory Health Clinic, Grampian PCT) and other carers (Consultant in Dental Public Health) including those " guardians of youths and special needs children" (indiv 540).

One further focus for education was seen as parents in areas of social deprivation (indiv 573, BMA Scottish Office). The notion of parents and communities working in partnership was perceived as attractive, with NHS Argyll and Bute highlighting the success of previous community development approaches which involved parents and organisations as partners committed to change.

PARENTS TAKING RESPONSIBILITY

A large number of respondees placed the responsibility for children's diets very firmly on their parents' shoulders. Notable amongst these were people against fluoridation of water, one typical comment being, " the Scottish population should not be getting mass medication because a few irresponsible people can't look after themselves or their children" (indiv 185). Many other people and organisations saw increasing parental responsibility as a key approach to tackling poor diet. For some, irresponsible behaviour was caused by laziness, over indulgence or dysfunctional parenting (e.g. indiv 1341) with " parents nowadays quite happy to buy or give their children a packet of crisps or sweets instead of an apple or other fruit" (indiv 963).

Several respondents argued that the individual rather than the state should be responsible for bettering children's diet (indiv 461, " parents - and not politicians - should take charge of children's health regimes" (indiv 576), " it's not up to the Scottish Executive to act a nanny" (indiv 733)). The theme of parents taking responsibility extended to their exercising, " greater influence and control over the regulation of children's sweets and juices" (British Heart Foundation).

PROMOTION THROUGH COMMUNITY

Many respondents perceived a role for diet promotion within a community setting although there were mixed levels of optimism about progress in this context, e.g. " after practising dentistry for 38 years… admit feeling depressed over the failure of the community to change children's eating habits" (CDS 26).

Others saw opportunities for constructive messages in a variety of community environments, including:

• New Community Schools (e.g. NHS Argyll and Bute, NHS Forth Valley Board)

• Healthy Living Centres (e.g. NHS Argyll and Bute)

• Youth settings/youth clubs (e.g. indiv 190, Falkirk Council, N. Aryshire Council)

• Child and Family Centres, residential institutions and foster homes (Dundee City Council)

And a variety of initiatives, including:

• Food co-operatives (e.g. LHCC Hamilton, Blantyre and Larkhall, Lanarkshire CDS, Consultants in Dental Public Health (CADO Group), Forth Valley LHC)

• Fresh fruit (Fife Council Children and Adult Services, Greater Glasgow Health Council - based on positive experience of initiatives run by Glasgow City Council)

• Farmers Markets (Scottish Liberal Democrats)

• Healthy eating projects/cookery classes/family health and fitness programmes (SW Edinburgh LHCC)

• Healthy eating cafes (Dundee City Council, Dental Surgeon 1401)

Useful joint ventures to promote better diet in the community were suggested between schools and supermarkets (indiv 41) and schools, local authorities and businesses (Scottish Liberal Democrats).

It was stressed that all community workers coming into contact with children should be trained in the benefits of healthy eating (NHS Lanarkshire), with the focus of community promotion largely in areas of social deprivation and where skills are limited (Paediatric Dental Specialist 214, Greater Glasgow PCT, Dental Hospital and School, indiv 1201, Lothian Health Council, Dental Surgeon 1401, Aryshire and Arran NHS Board).

PROMOTION THROUGH HEALTH PROFESSIONALS

A common theme was the need for public health facilities to support the better diet message by offering free water and banning any fizzy drink vending machines. Within this context it was recommended that consistent messages be conveyed by professionals to provide a seamless service on diet promotion. For example, one suggestion was for PSDs and dieticians to work together to deliver, " advice evenings or literature for parents who are providing their children with lunch boxes" (indiv 862). Others called for linking of, " education, health, dental and community institutions to encourage healthier eating" (Paisley University) or promotion put forward in a co-ordinated way by doctors, midwives, health visitors, nurses and dentists (Community Dental Officer 26).

The involvement of health professionals in teaching within educational establishments was advocated (Perth and Kinross Education and Children's Services, Beechbrae Education Centre). As a precedent, Dental Health educators already worked within Glasgow primary schools (Springburn Health Centre Respondent 1). A call was made for the co-operation of community dieticians and pharmacists to work more closely with school meals services (Scottish Community Dental Services).

Some people saw the need for those in the dental professions to be able to promote healthy eating messages (indiv 170, Unison, Argyll and Bute Council Education Service). Ante-natal health professionals were seen as a vehicle for good diet promotion (indiv 446, Greater Shawlands LHCC) as were health visitors (indiv 805, Royal College of Nursing, Dental Surgeon 1287, NHS Lanarkshire). Promotion through pharmacists was envisaged by their dispensing of sugar free medicines (Area Pharmaceutical Committee, NHS Lanarkshire, Scottish Specialists in Pharmaceutical Public Health) and their advising on baby foods, use of dummies and so on (Argyll and Clyde Area Pharmaceutical Committee).

PROMOTION THROUGH ADVERTISING

An overwhelming message was concern over the level of advertising of sugary products on TV, and especially the focus of advertising on young children. Many different organsiations and individuals favoured a complete ban of, or severe restriction on, TV advertising aimed at young children. The disproportionately large budgets of those advertising such products were compared with the relatively small budgets of those promoting better diets. The situation in some Scandinavian countries where TV advertising to children had been banned was applauded by some.

Others saw advertising as a means to promote positive diet messages. Specific ideas included:

• Use of celebrities in promotion (Brannock High School, Aryshire and Arran NHS Board)

• Introduction of a healthy eating kitemark, " recognisable even by dyslexics or those who do no have English as a first language" (Scottish Green Party)

• Use of interesting, colourful posters and information leaflets (NHS Shetland, Community Dental Officer 26, Royal College of Nursing, Scotland)

• Introduction of vegetable consuming super heroes - as in Wales (NPWA)

The deployment of shock tactics in the form of booklets showing photos of children with and without bad teeth was suggested by one respondent (indiv 922).

Some respondents requested simply that adverts be more accurate, truthful and should not mislead (Scottish Food and Drink Federation, School of Nursing, Midwifery and Community Health, Glasgow Caledonian University, Beechbrae Education Centre).