1.1 Scottish Health Policy
In June 2008, the Ministerial Task Force on Health Inequalities published its report regarding the priorities for government action in addressing the problem of health inequalities. It emphasised that early intervention was paramount to a successful strategy and intervening during children's very early years is critical to ensure a healthier future particularly for more vulnerable children in disadvantaged circumstances (Scottish Government, 2008a).
In 2007, the Government launched the Better Health, Better Care Action Plan which explained the measures which the Government will take to improve Scotland's health, address health inequalities and improve healthcare access. An additional £11.5 million has been allocated which, over the next three years, will be used to help, particularly children, tackle obesity through diet and physical activity initiatives. The Better Health, Better Care document announced the upcoming launch of a Food and Health Delivery Plan in 2008 which will complement the ongoing development of a national Food and Health Policy (Scottish Government, 2007).
Proposals in the Better Health, Better Care document have been developed further in the Healthy Eating Active Living Action Plan in 2008. The latter Plan aims to address the growing problem of obesity, tackle Scotland's poor diet and promote physical activity. It announced that a total of £56 million, of which £40 million is new funding, has been allocated for the following three-year period to promote good health and address health inequalities primarily through healthy living initiatives (Scottish Government, 2008b).
Initiatives aimed at dealing with obesity, poor nutrition and low levels of physical activity have been a permanent element on the Scottish policy agenda for many years. In 2006, in the Delivering a Healthy Future action framework (Scottish Executive, 2006), the previous government administration outlined the development of a new strategic, evidence-based approach to addressing obesity in Scotland. The Health Scotland Delivery Plan for 2007-2008 highlighted how NHSScotland would aim to meet the outlined government targets, so as to reduce health inequalities and the life expectancy gap (NHSScotland, 2006). Key areas of action included nutrition, physical activity and obesity. There is a clear recognition of the importance of early intervention in this document, with maternal nutrition (including nutrition before and during pregnancy), and infant nutrition (from birth to two years) being two of the areas of focus.
Social policy on nutrition and health has developed considerably following the publication of the influential Scottish Diet Report in 1993 (Scottish Office, 1993). This was followed by the announcement of the Scottish Diet Action Plan in 1996 in the Eating for Health: A Healthier Scotland document (Scottish Office, 1999a). The importance of promoting good health and healthy diets was thereafter highlighted in numerous policy publications, of which the most important are listed below:
- Towards a Healthier Scotland (Scottish Office, 1999b)
- Our National Health: A plan for Action, a plan for Change (Scottish Executive, 2000)
- Social Justice: A Scotland where everyone matters (Scottish Executive, 1999)
- Building a Better Scotland (Scottish Executive, 2004a)
- Improving Health in Scotland: The Challenge (Scottish Executive, 2003b)
- Eating for Health: Meeting the Challenge (Scottish Executive, 2004b)
- Delivering for Health (Scottish Executive, 2005)
1.2 Policy on Nutrition for Children
In Scotland, breastfeeding promotion first arrived on the policy agenda with the launch of the Scottish Joint Breastfeeding Initiative in 1990. In the 1994 Scottish Dietary Targets it was hoped breastfeeding take-up in the 6 weeks following birth would rise from 30% to 50% by 2005. In 1995, an appointed National Breastfeeding Adviser was to work with Local Breastfeeding Initiatives in raising awareness regarding breastfeeding benefits. The Integrated Strategy for Early Years in 2003 aimed to improve children's health, and increase the proportion of breastfeeding women (Scottish Executive, 2003). Indeed, Scotland became the first nation to make breastfeeding a legal right in 2005 with the Breastfeeding etc. (Scotland) Act 2005.
Recent Government policy has paid extensive attention to the importance of good nutrition in infancy and continues to stress the importance of promoting breastfeeding. The Better Health, Better Care Action Plan outlines how NHS boards will be expected to support breastfeeding so that one third of all infants are being exclusively breastfed at 6-8 weeks by 2010-2011 (Scottish Government, 2007). To support this goal, a national Infant Nutrition Co-ordinator was appointed in May 2008. The main role of the co-ordinator is to lead the development and the implementation of an Infant Nutrition Strategy. Consultation on a draft of the Infant Nutrition Strategy has already been sought (Scottish Executive, 2006b), and the strategy will be aimed at improving nutrition in infancy and improving children's chances for a healthy future.
The Better Health, Better Care Action Plan stated that nutrition in the early years is a key field of policy focus for the developing Food and Health Delivery Plan and for Scottish food policy. The Food and Health Delivery Plan is to include measures aimed at promoting good nutrition in pregnant women and those of childbearing age, as well as measures to support breastfeeding and optimal weaning in infants. (Scottish Government, 2007).
The Healthy Eating, Active Living Action Plan, specifies that £19 million, half of the newly allocated budget of £40 million, will be spent over the next three years on initiatives aiming to improve nutrition among women of childbearing age, pregnant women and children under 5 in disadvantaged areas (Scottish Government, 2008b).
The Hungry for Success initiative, originally only for school children, has been extended to pre-school and child care centres as outlined in Nutritional Guidance for Early Years: Food choices for children aged 1-5 years (Scottish Executive, 2006). Previous to this, the Integrated Strategy for Early Years (2003) focused on improving service provision particularly for the vulnerable children from pre-birth to 5 years of age and their families (Scottish Executive, 2003:2). The strategy aimed to improve children's health by improving their diets. The foundations for these policy initiatives were laid out in the Sure Start Scotland initiative introduced in 1999-2000 (Scottish Office, 1998). Sure Start is a more comprehensive approach in promoting young children's health and well-being and is part of a broader framework to promote social inclusion of children 0-3 years old and their families, with one of the four main objectives being to improve children's health. It focuses primarily on improving the accessibility and quality of childcare for less privileged families with very young children.
Scotland has worked on a series of initiatives aimed at children of school age. In October, following the evaluation of a free-school meal trial for children in P1 to P3 (MacLardie et al., 2008), the Government announced a Scotland-wide roll out of the scheme making school meals free to all P1 to P3 pupils.
As outlined in the Better Health, Better Care Action Plan, an additional £11.5 million will be invested over the next three years to address primarily the problem of obesity among children (Scottish Government, 2007). The Healthy Eating Active Living Plan, launched in 2008, has part of its £40 million budget allocated to promoting sports, dance, walking and healthy cooking projects to children and young adults at school to encourage more healthy living among these particular age groups (Scottish Government, 2008b).
The recent policy attention on school-aged children has been epitomised by the passing of the Schools (Health Promotion and Nutrition) (Scotland) Act 2007, which enforces Scottish Ministers and local authorities to see to that food and drink provided in all local authority and grant-aided schools complies to the government set nutritional requirements. The Act was based on the Hungry for Success document, which set out a whole school approach to school meals in primary and secondary schools in Scotland (Final Report of the Expert Panel on School Meals, 2003). A central element of the strategy was to set out nutritional standards for school meals which would encourage healthy eating. Other government publications focusing on this age group include the Health for all Children (Scottish Executive, 2004) document which consulted on methods for the implementation of health promoting strategies targeted towards children in their early years and children of school age.
1.3 Policy on Physical Activity for Children
A National Physical Activity Strategy was outlined by the Scottish Government in the Physical Activity Task Force report Let's Make Scotland More Active: A strategy for physical activity (Physical Activity Task Force, 2003). The strategy addresses adults and children living in Scotland and outlines specific targets regarding children's physical activity. By 2022, the Scottish Government aims to have 80% of all children aged 16 or younger meeting the minimum recommended levels of physical activity, currently set at one hour of physical activity on each day.
More recent policy support for physical activity was announced in the Healthy Eating, Active Living Action Plan, 2008, which stated that the national budget for physical activity projects will increase from £6 million to £12 million.
There have been a number of recent ongoing initiatives targeted particularly at school-aged children through the Active Schools programme, which aims to incorporate sport and physical activity in a whole school approach (Scottish Government, 2008b). A successful initiative targeting pre-school children is the Play@home scheme which is currently being rolled out across Scotland (Scottish Government, 2008b). Play@home encourages parents to understand the importance of movement and exercise in babies, and entails a three-stage physical activity programme for parents and children from birth to 5 years of age.
Progress towards the different government targets over time is to be monitored and reviewed via the Scottish Health Survey ( SHS), which will run annually from 2008 to 2011 but was also conducted in 1995, 1998 and 2003. The survey is a key tool for monitoring Scotland's health, and includes questions on children's physical activity, as well as on adult smoking, drinking and eating behaviours. In 2003 children aged 0 to 16 were surveyed for the first time (Bromley et al., 2005). The Health Behaviour in School-Aged Children ( HBSC) study is another important cross-national survey of the health of school aged children (ages 11, 13, and 15) in different countries, which provides comparative data on Scotland and other countries (Alexander et al., 2004).
The National Physical Activity Strategy is underpinned by a wider framework for action laid out in the aforementioned Improving Health in Scotland - the Challenge (Scottish Executive, 2003). To support this challenge, the Scottish Executive appointed a National Physical Activity Co-ordinator in 2002, and committed an extra £20 million over the period 2004-2007 to the development of Active Primary Schools and School Sport development officers. Current policy on physical activity dates back to 1997, when the Health Education Board produced a policy framework which provided the current government recommendations and guidelines for physical activity for young people (Health Education Board for Scotland, 1997).
1.4 The Report
This report uses data from the Growing Up in Scotland study to explore the prevalence of, and many issues related to, food and activity in Scotland specifically in relation to young children. Findings are based on data taken specifically from the older cohort involved in the study and which was collected over the first 3 years of GUS. The data therefore refer to a period when the cohort children were aged between 2 years and
10 months (sweep 1), and 4 years and 10 months (sweep 3). Interviews were carried out annually between April 2005 and May 2008. In the main, data in this report comes from interviews with the child's main carer (usually the mother), but also draws on data from partner interviews (usually the father) at sweep 2 and information from child height and weight measurements collected at sweep 2. However, all data is from the main carer interview unless otherwise stated.
The report is divided into four sections which address the following broad questions:
1. What are children eating? What eating behaviours are we seeing? And what factors and beliefs influence these?
2. Are children participating in physical and sedentary activities? What types of activities do children do? How does this vary by socio-demographic and neighbourhood factors? Do parental behaviours and attitudes have an impact on children's activity levels?
3. Is there a relationship between diet and activity for young children? Are children who eat less healthy foods also doing less physical activity and/or more sedentary activity? What is the relationship between activity, diet and BMI in young children?
4. The children who were breastfed more likely to be having a healthier diet at age 4? Is there a relationship between breastfeeding and BMI?