We are very disappointed that there is no specific mention made of dietitians as part of the consultation document. We believe dietitians have a central role to play as nutrition and diet experts in promoting healthy eating messages and promoting increased physical activity, utilising holistic approaches and behaviour change techniques to help people to reach or maintain a healthy weight. Dietitians are leading members of multidisciplinary weight management teams, both in providing direct advice and in supporting other healthcare workers to help patients. They work with patients to devise individual, realistic weight-loss targets in complex medical cases using evidence-based practice. They provide personalised, specific, age and culturally appropriate advice, taking into account the whole patient, not solely dietary aspects, resulting in a positive experience of care.

We urge the Scottish Government to support the establishment of a long-term and comprehensive weight management service within health and social care whereby dietitians train and support the wider workforce, communities and volunteers to deliver programmes that can have wide impact.

Dietitians can play an even wider role in preventing people from becoming overweight or obese in the first place by developing education and information campaigns, utilising their behaviour change skills. This includes expanding and developing the information made available through NHS Inform.

We recognise that any successful interventions cannot be delivered by dietitians alone, so support the Scottish Government aim to support increased training for the wider health and social care workforce and recognise the need for tiered approach to treatment. This should include giving doctors, nurses, midwives and health visitors, for example, the skills to provide basic nutrition and weight management advice, as well as giving them the tools to signpost/refer individuals to a range of appropriate weight management programmes and specialist interventions for those with complex needs (such as multiple conditions or those requiring bariatric services)

There are a range of effective weight management programmes developed in Scotland that have been shown to produce >5% weight loss, which has a clinically significant impact on the development and management of conditions. Many are also great examples of non-NHS specialist staff delivering effective interventions for weight loss with training and ongoing support from dietitians which are recognised in the consultation document; e.g. football coaches within the Football Fans In Training (FITT) programme7 or the BeWEL project for those with colorectal cancer8 .

The Scottish Government and COSLA’s first obesity prevention strategy (The Route Map)9 published in 2010 focused on four preventive actions. The Scottish Government also required NHS Boards to deliver on Child Healthy Weight interventions, a tiered approach to Adult Weight Management and a range of HPHS actions. We are strongly supportive of the Scottish Government’s ambition to build on this with concrete actions to prevent and treat obesity.

As the factors contributing to overweight and obesity are complex, no single intervention can halt the obesity epidemic. A range of strategies that take into consideration the interaction between the individual, the environment and the social determinants of health are needed over the long term. It will be important for the government to illustrate the rationale for such a multi-faceted approach, and ensure its campaigns are positive in their approach. We welcome the Scottish Government’s intention to tackle obesity across the life course from breastfeeding and maternal obesity to food promotion and adult weight management.

The strategy needs to include specific steps to address health inequalities, as obesity in Scotland shows a strong link with inequalities. Lower socio-economic status is associated with higher levels of obesity10 We also know that those with learning disabilities are also more likely to be overweight or obese11 . The strategy should be co-produced with the public and patients, to ensure wide engagement and increase effectiveness.

We agree that the Scottish Government should build upon and support the sugar reformulation work being undertaken by Public Health England as this will clearly impact on products sold in Scotland. Further work which will look at calories and saturated fat should also be supported as much as possible. Changing the nations dietary habits by reducing total sugars and sweeteners, rather than simply substituting sugar for alternative sweeteners, should be the long term aim. Dietitians can support Small and Medium Enterprises in Scotland to translate these recommendations (and others) into practice.

Any strategy must base its success on evaluating long term trends. The BDA sees the merit in targeting shorter term gains, such as interventions for those at risk of developing diabetes, but the overall target must be a reduction in obesity and overweight figures in the population as a whole over the next 20 years or more.

Any population-level public health strategies also need to address weight maintenance among healthy weight individuals as well as attend to both prevention of further weight gain and weight loss for those who are overweight or obese.

We welcome the recognition that government needs to lead by example. We are disappointed that no mention is made of the Health Promoting Health Service (HPHS), which we believe is a key way of leading by example. The HPHS has as part of its core themes a commitment to support healthy eating and physical activity, as well as weight management for NHS staff12; this is welcomed. However, obesity is not explicitly included as part of the remit and could be strengthened within the HPHS. NHS Scotland needs to commit to supporting weight management not just for staff but for patients and visitors too. We would encourage the Scottish Government, each HSCP and all NHS Boards to sign up to healthy meeting initiatives, such as the Scottish Cancer Prevention Network’s healthy meeting scorecard13 or BDA Work Ready.

As part of the HPHS hospital premises can play a role in creating healthy environments, for example making the stairs easier to find or ensuring the layout of food service outlets encourage healthy eating choices and discourage consumption of HFSS products. Staff, visitors and patients should be encouraged to walk to and within their worksites and clinical areas whenever appropriate.

Obesity is a long term condition. It is not a lifestyle choice. The public health problem of obesity which is manifested by poor diet and inadequate physical activity, cannot be solved by education and personal responsibility alone. Creating environments that encourage healthy eating and physical activity will enable the population to exercise their personal responsibility in relation to food choices and physical activity levels.

We are pleased that the government has recognised that encouraging healthy retail environments is particularly important. Research indicates that retail promotions are used extensively on goods which are high in fat, sugar and salt14. There is also considerable evidence of the effectiveness of such promotions, especially to children15. Buy-one-get-one-free offers, discounts and marketing around checkouts need to be regulated to help the public make healthier food choices. The Scottish Government should provide incentives or encouragement for supermarkets or food business to change the ratio of the promotional food towards healthier foods and drinks such as fruit & vegetables. They should also take steps to limit the way that unhealthy HFSS products can be marketed within the retail environment. Retailers who already take steps to improve the way they promote healthier food in their stores should be recognised and promoted as exemplars.

We strongly believe that the planning process can also be used to promote healthier towns and cities and allow people to be more physically active in everyday life16. For example restricting the building of fast food outlets in an area, particularly in close proximity to schools; encouraging and supporting spaces where people can exercise and participate in active travel. Supporting walking and cycling to school and work through the design and layout of our towns and cities is not a quick fix but can have a long term benefit.

The Scottish Government cannot currently legislate to limit the broadcast advertising of HFSS products, but we agree that they should put pressure on the UK government to implement such changes and at the same time pursue a robust and comprehensive strategy to limit promotion in all of the areas (such as nonbroadcast advertising) that are within its control.

The strategy must ensure it builds upon existing successes, including the Child Healthy Weight (CHW) Programmes that are delivered in every NHS Board17. Dietitians have played a key role in developing and leading CHW programmes across Scotland, and we believe this work has to continue and requires continued, long term investment.

Indeed, while we support efforts to address and prevent obesity in the first years of life, work on CHW with children aged 5-15 should continue alongside it. CHW programmes have come under financial strain in recent years and to allow them to be scaled back would be a retrograde step and would compromise the Scottish Government’s ability to achieve the outcomes of the Diet and Obesity Strategy.

Investment and support for CHW must be part of a wider investment and support for exercise, sports, healthy eating and food skills’ programmes (such as the BDA’s Let’s Get Cooking). These other programmes may be delivered through schools, in the community or as part of health services, and all have a role to play in helping children learn the appropriate skills to maintain a healthy diet and weight into adulthood.

We welcome Scottish Government’s recognition of the importance of school food itself as a means of promoting health eating. Improving quality as well as access will have positive benefits.

It is important that skills and exercise support mechanisms are also available for the adult population, as obesity is a problem across the life course. In particular, we are concerned that NHS Boards, which are under significant financial pressure, may consider decommissioning their weight management services, as has happened to local government weight management services in England. Any such cuts are a false economy and the Scottish Government must do more to properly fund public health and weight management services.