 Good morning, and welcome to the 31st and last meeting of the Health and Sport Committee in 2017. I can ask everyone in the room to ensure that their mobile phones are switched to silent, because we can, of course, use them for social media but please don't film or record proceedings. We have apologies from Alec Cole-Hamilton and Colin Smyth. The first item on our agenda is supporting legislation with two negative instruments to consider. The first a the novelty to Scotland regulations in 2017. There has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Can I invite any comments from members? No comments. Is the committee agreed to make no recommendations? That's agreed. Thank you. The second instrument is the sale of nicotine vapour products when the Machine Scotland regulations 2017. Again, there has been no motion to annul and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Can I have any comments from members? No, no comments. Is the committee agreed to make no recommendations? That's agreed. Thank you. Agenda item 2 is our inquiry on preventative agenda. This is the first of a series of one-off sessions that this session will look at type 2 diabetes. Can I welcome to the committee Brian Kennan, chair of the Scottish Diabetes Group and National Managed Clinical Network, Andrew Job, secretary, Edinburgh Lothian local support group with Diabetes Scotland, Linda McLean, regional engagement manager and Alison Coburn, who is a lead diabetes cardiovascular risk for NHS Lothian and is a pharmacist. Thank you all for attending this morning. We'll move direct to questions. Sandra, would you like to begin? Thank you very much, convener, and good morning panel. Thank you very much for coming along. The papers that we've got and the general information that we have are a number of issues that cause obesity, which therefore cause diabetes, such as being a weight of obesity relative to type 2 diabetes, having high blood pressure or cholesterol levels. I was interested in one of the areas that came up in the papers in regard to environmental aspects of it. We've been given the evidence, a growing body of evidence, in regard to obesity and diabetes as the rapid rise in exposure to a number of chemicals in the air, soil or water. I just wanted to ask members if they're aware of that, of any trials that's going on and the information that we've received and the risk factors and how it might impact on the prevention of obesity and all types of diabetes. If someone would like to open up, I don't know if you are aware of it, but I thought I'd throw it out there. I wouldn't profess any degree of expertise in that area in terms of associations and environmental factors. Undoubtedly, most of the trial evidence, particularly around interventions, have been about lifestyle issues such as, as you've said, weight and physical activity. I know that there have been some weak associations between environmental factors and type 2 diabetes, but they've never been proven to be necessarily causative. Therefore, to the best of my knowledge, there hasn't been any randomised control trials looking at controlling for those variables. Certainly, when we're thinking about the prevention of type 2 diabetes, I think quite rightly that the key areas that we would focus on would be diet and physical activity, because that's where the evidence base lies today. I dare say that this is an evolving field and it may be that in years to come there'll be a stronger evidence base in which we might need to consider things like vitamin D exposure and things, because that's often associated with many different conditions, not just diabetes, but today there isn't firm evidence that that allows a scope for intervention. Anyone else in the panel want to come in in that particular one? With that, I think that, as Brian said, there's very little evidence of randomised trials where we might be some links is if there's an autoimmune response from the costogenic or from the environmental chemicals, but I don't know what that autoimmune response might be, so it is an emerging field and at the moment it's just a case we just have to keep an eye on that and look at research and see what the results are. Thank you. The evidence that we've been given is not just exposure through air, obviously it is air pollution, but also exposure through ingestion, through obviously chemicals, perhaps in farming or whatever, and through the placenta, so you're saying that there's not been enough trials done or enough evidence to support these? Yeah, I mean, again, I wouldn't claim any significant degree of expertise in this area, but like many conditions, I think you're right to highlight that in utero experiences, so during pregnancy is there potential maternal exposure to environmental agents that could cause harm, then that's difficult to ascertain. We do know that certain drugs are associated with diabetes and increased risk of developing diabetes, like the use of steroids, certain HIV therapies and things like that, but they're more of a direct mechanism as to how they work. The side effect is then to increase your risk of developing diabetes rather than what you're obviously describing would be environmental exposure to carcinogen, so to the best of my knowledge, there just isn't a firm evidence base that one particular factor is causative as opposed to just associated with it, so I think it's an area that needs further progress and work. Thank you. I was interested in understanding about the causes and the risk factors and where most of the cases are coming from and it looks to be that weight control obesity is the single biggest issue, so it was to understand how well that's understood because there's a lot of numbers thrown about if we can control that, the amount of money that would save further downstream in the health service, so I don't know if you want to maybe just talk round about your understanding of that data and what the biggest risk factors are and where we would save the money if we were managed to control obesity. I think and I'm speaking as an A person in this respect, the link between weight and obesity and type 2 diabetes in my mind is very well proven. I'm a case where I was severely obese and going down a very slippery slope in terms of type 2 diabetes and the complications attached to it, I turned it around by losing a lot of weight and now I'm off medication, so in effect if I put myself into remission and based on that experience I would say it is simply, it sounds terribly simple to say lifestyle is what you eat, how much you eat and I think its quantity as well as quality of food and how much activity you do. It's a very simple equation in my mind, calories you take in you really should be spending and if you're not spending it you're going to put weight on, that puts pressure on various mechanisms inside your body and one of the consequences can be type 2 diabetes and all the complications then fall off of that or the increased risk factors that fall off of that. So it's quite simple but very complex, that sounds trite I know but weight and the risk of type 2 diabetes are associated. How you tackle the issues around people gaining weight, not taking enough exercise and so on are very complex. Yes, some relationship but more difficult to influence. I mean I was just going to pick up on that point from Andrew, clearly type 2 diabetes is multifactorial, you have a genetic predisposition, age is actually one of the biggest risk factors so the older you get the higher chance you've got a developing type 2 diabetes and we also know the ethnicity, so a lower body mass index than individuals from south east Asian communities will develop or be at higher risk of developing type 2 diabetes. I think for this committee in terms of a preventative agenda then it's effectively modifiable risk factors we should be looking at and I think as Andrew is an excellent case and point is that the biggest modifiable risk factor for us as a society would undoubtedly be obesity, weight and weight reduction. I've got certain figures that say three out of five cases of type 2 diabetes can be avoided and they're linked to obesity and being overweight and if we can avoid those that would be, you know, it's a proven fact and the prevention programme in England is doing a lot of work on that, proving the loss of weight and then putting the diabetes into remission. It's not only the outcomes in terms of fiscal outcomes for NHS, it's also in terms of quantitative life outcomes for the person living with the condition and so all of those, the quality of life outcomes for people living with the condition are probably more difficult to quantify but nevertheless are as important. I'll say about the comorbidities associated with type 2 diabetes and obviously my clinic where I see patients with cardiovascular disease, complications and renal impairment, these are like the more complex end of things but obviously can be prevented as well with the prevention strategy of encouraging patients to lose weight, exercise etc. In terms of targeting resource, I think it's really important to target patients who are in perhaps positions of greatest need, who have perhaps got the most complications, the poorest quality of life and evidence has shown that although the preventative strategies in terms of weight loss and encouraging exercise at a population level are very useful, it's difficult to actually prove to make substantial benefits compared to targeted individualised programmes. In a full understand of course it's very important for individuals concerned to be saying it isn't but there would plenty of discussion about that but just focusing down on the fiscal aspect of it. Where do those costs manifest themselves so what are the things that are expensive about treating diabetes? I mean ultimately what I'd like to get to if you know what I was able to cast an elite on it is the relationship between a thousand pound or a million pound spent treating it and what you could do if you had money on the prevention side of things and how much that would save over a period of time. We know that one of the problems of someone who's got type 2, who's diagnosed with type 2, they potentially have had the condition for several years before it's been picked up. During that time there's been changes so they're developing the complications such as problems with vision, potential problems with kidneys, potential problems with circulation so if you think that 80% of those complications could potentially be of the ones that we spend the most money on and if someone's in hospital for related to a non-diabetic condition they're likely to be in hospital about four to five days longer so that you've got an extension of a stay which roughly will cost another 2,000 pound per person and if you think there's probably about 500,000 patients across a year with diabetes then that's an awful lot of money. It's also around if you can prevent someone going on the medication then considering what the pharmacological bill is for Scotland if we can prevent some of people having to go on to the medication then your savings there and then it's also savings in terms of going to more specialist services as well so it's across the board. I'd like to hear your comment about let's get this down to pounds and pence then. We know that 80% of the expenditure on type 2 diabetes is probably on complications and some of those will undoubtedly be avoidable with early detection and indeed early intervention. There was a recent big meta analysis that was just published last month in the British Medical Journal that was actually looking at the cost effectiveness of interventions and there's a real difficulty in distilling that data because it partly depends on the population that you're studying so if you address high risk individuals who are very high risk of developing diabetes then your intervention will be much more cost effective than if you go for a potentially a population-wide screening approach but the meta analysis suggested that a quality adjusted life year worked at about £7,500 for a lifestyle intervention programme and in the grand scheme of things that's cost effective. There have been some studies that suggest that it's cost saving and others that have had qualities that are much higher than that so it partly depends on the population that you're studying but undoubtedly there's a cost effectiveness to prevention agenda and initiatives that would lead to that and that's true of lifestyle intervention and some relatively inexpensive pharmacological interventions with a drug called metformin. I'm sitting in the cross-party group for diabetes in Stelatino. If we extrapolate that, I've made the key point further than that and we look at prevention because what we're talking about here is a well intervention once they have contracted diabetes or that has manifested itself. How far back can you trace diabetes to as an age? If we had children that were more active or we could adopt their relationship with food back then, how far back do we need to go? On reflection I would say that I was showing symptoms of diabetes around about 12-15 years before I was diagnosed and that was largely around I used to play rugby, stopped playing rugby, didn't change, stopped doing exercise in any meaningful form because of various other factors and again in my own case I feel it was me putting weight on and lack of activity that promoted me up the scale. I have a family history of diabetes, type 2 diabetes as well, which made me a bit more predisposed but yes, I would say 10-15 years before I was diagnosed, I was showing symptoms of having diabetes and that obviously builds up an effect inside me. That's where the screening comes in and that's really important to actually pick up the pre-diabetes state that people go through. That's a role that certainly community pharmacists are well placed for and perhaps reaching the more deprived areas, people who are less likely to engage with the health service routinely. To target resources that we already have in the community better, such as the health centres, the pharmacies, etc., to implement screening so that you can pick up those people because it's so much more expensive to be chasing up after the event once they have contracted diabetes and have the complications, etc., and apart from their quality of life being potentially much poorer and perhaps a shorter length of life as well. The cost-effectiveness analysis that I gave was actually for prevention of diabetes, so that wasn't in cohorts who already had diabetes, but those who were identified as having pre-diabetes. As a Scottish diabetes community, we should be very pleased that Mike Leane, who I don't think is giving evidence in the next session, was one of the lead authors and researchers that was published a week ago that shows exactly what you were highlighting of early diabetes and being able to put it back into remission with a very intensive lifestyle intervention. I don't want to step on anybody's toes who's potentially in the next session talking about obesity, but we're now getting an increase in evidence that if we intervene early in a disease process, so after type 2 diabetes has been diagnosed within, well, this was six years, then with fairly significant lifestyle intervention, you can actually put more and more cases back into remission. I think that there are areas of evidence where you can tackle the pre-diabetes stage with high-risk identification and then the early onset of disease. I think that there is evidence around children and young people, and there are policies out there about flourishing Glasgow, which clearly recognises that children in deprived areas need to have access to activities and healthy foods. If you don't have that legacy, then that legacy of that in childhood actually can manifest in adulthood as well. That's why we say it's not just around the health service, it's around environment, it's around education, it's around actually giving people the skills to actually access healthy foods, know how to cook them, et cetera. The sooner we can embed those skills and that knowledge in our young people, the better chance we have of them living longer, healthier lives. That is actually where my real interest lies in, is that sort of access to that learning opportunity. I think that the following one from Ivan McKeith's point is this, if we invest in that, we know exactly where the deprived areas are, we know who have access to opportunity and who doesn't. If we focused on those particular areas and we invested in those particular areas there in terms of their relationship with food, in terms of understanding food, in terms of understanding physical exercising and getting access to physical exercise, has the various studies done there that would indicate, it's pre-prediabetes in fact, it's prevention right at the start, are there any studies there that suggest how much that's worth to the nation in terms of health? I don't know of any in terms of that direct correlation but certainly there are studies being done since the 1990s on that element of work and I'm sure the Glasgow population for health have got a lot of information on the just the importance of that health improvement aspects of things, that public health aspects of things and actually doing things on the ground so there are there is evidence there but I couldn't actually bring it directly to mind at the moment but there is evidence out there. How much is diabetes a if you like a class-based disease? It's really important I think when we're having a discussion that we distinguish between type 1 diabetes which is an autoimmune condition which there is no avoidable factors, that's just something that you develop and it's just luck effectively whereas type 2 diabetes we know there's a significant lifestyle component, we know there's a strong association between developing type 2 diabetes and deprivation, of course these things are always complex because they go hand in hand in terms of deprivations associated with less access to healthier food substances, less access to physical spaces in which to do exercise so it's complex but we definitely know that deprivation and type 2 diabetes go hand in hand. Not to the extent that weight would be a higher risk factor for it so it's back to an association rather than definitely being causative. But within certain demographics is the prevalence of diabetes much higher than in wealthier communities. The more deprived you are the higher instance there is of type 2 diabetes. Is that sharp, that divergence? There is a difficulty there because we know that obesity rates are higher in more deprived areas than in more affluent areas, we know that physical activity is less in those areas so it's not a direct correlation in that regard because it's so many different confinding variables that could be contributing to that onset of that disease. So it's almost like the cohort and nest together rather than being like a dose response curve that the less deprived you are the less likely you are type 2 diabetes because I think there's too many different factors in there to piece that out. Good morning panel, before I ask my question I need to say that I am the co-convener of the cross-party group for diabetes. I'm a registered nurse and I have type 1 diabetes myself. Henry VIII probably died of type 2 diabetes complications actually so it might not be just linked to a class or how much money you have so I read that somewhere down the line. I'm interested in prescreening and the pharmacy aspects of it and I know that GPs doing normal lab tests will pick up a high blood sugar which might then lead to fasting, glucose testing but if we are looking for screening aspects I am aware that Diabetes UK did a finger stick blood testing in Dumfries last year so you know that way to target people who might be pre-diabetic or looking at age. Is there a way that we should be looking at prescreening on a kind of national way like that? I think as I said before that the community pharmacists are really ideally placed to perhaps not only screen potential people who might have diabetes but also to advise them and give them advice on taking their medication for those that you know they can see for their prescriptions that they are diabetic and also reinforcing exercise, healthy lifestyle, giving up smoking or all of the other linked factors. Certainly the main issue just now with the community pharmacists is that they don't have access to GP records so for individual patients you can't as a community pharmacist look up a patient's history on the vision system that the GPs have so it's very limited as to what they can do with re-providing advice and the other potential negative factor is their time because their main focus is on producing prescriptions etc dispensing so that's something that pulls away from being able to provide the service that they would like to and there's a number of pharmacists who work as integrated care pharmacists that actually provide the sort of interface between primary and secondary care so will follow patients through on discharge to their GP practices and then help at that point of view also with making sure that the medications are right and everything transfers smoothly so there's a number of opportunities there where I think things could be made more slick and better for patients definitely. There used to be a programme in Scotland which was Keepwell which was a screening programme that targeted high risk people over the age of 40 for not just diabetes but hot disease as well and it used screening tools and that worked quite well because it wasn't just the screening it was the support afterwards for the person to be able to make those changes those behavioural changes so screening's okay it's a method of picking people up at high risk but it's then what you then do with them how do you support them and that is key to certainly the direct study that Professor Leane and Professor that they've been doing is it's not just about the diet and the obesity it's around the support people are given for the psychological support to be able to make those changes and continue those changes and certainly the that element of support is very very clear in some of the weight management programmes that are around across Scotland we've got some good examples of that where it's not just that clinical bit it's that psychological that support as well so if we are doing screening and it is important that people are supported so they can make those changes and not be left on their own Is he saying there used to be a screening programme? There used to be a programme called Keepwell. Well it was only funded for a few years and then the funding was a lot the health boards didn't continue the funding the funding came down from central government and then after a period of time a lot of the that funding went centrally so some health boards kept it going under the health improvement but there's not many of them around now and was there evidence that that was working? Yes it was it targeted a very specific high risk group so it targeted over 40 farms and it certainly worked within the deprived areas they are they actually employ people to make sure that patients would turn up for their reviews so there'd be somebody going round you know banging on their door saying you've got an appointment you better come because that's one of the key issues it's what we call the DNAs they do not attend I mean in you know the hospital outpatient clinics the diabetes clinics it's about a 40 per cent DNA rate and that's patients with diabetes you know so and was that a retrograde step? The stopping the keep well well it was definitely a programme that in its early stages was showing a lot of promise that was looking as though it was working and it was really focusing on the more deprived populations so unfortunately yeah it was just just to sort of give an update as to where we're at with the Scottish Diabetes group so you hear from Alison Dimon next who's chair of our short life working group but we're very much trying to tackle this prevention agenda and part of that will be identifying who are the highest cohort that we should be screening what screening should we be doing because there is a bit of debate as to what screening test should be used and the cohorts that you're identifying but as Linda's highlighted more importantly what do you then do about it and I think that's why this is opportune timing to have this discussion because with the on-going review of the diet and obesity strategy then there's an opportunity to say if you identify high-risk people what can we actually do meaningfully as not just a health service but as a community and as a society to actually address that and either put people avoid them developing type 2 diabetes in the first place or put them into remission if they're picked up early enough so we are trying to get that joined up thinking and I think historically weight management services have sat out with diabetes services and we're trying to promote that sort of co-dependency and thinking in that manner. Okay I'll go with the managed clinical network next because that was where my original I guess thoughts were when we are you identify a really good practice in one health board so and that comes to the MCN or however you engage with that I'm assuming that it gets disseminated across health boards so that they can look at who's doing good practice how do we share it how do we make sure everything's evidence based and then how do we cost it in probably the most cost effective way so can you tell us a wee bit about what the MCN does? Yeah I mean diabetes managed clinical networks have been established for some time now and we have got a good infrastructure as a single disease entity I think in the area of the preventative agenda then historically it's probably sat out with diabetes it's been more in public health and weight management services and that's what I mean by now we're trying to bring in that prevention agenda within the MCNs as well. We have regular MCN leads meetings whereby we do try and disseminate and share good practice in fact we've got a national conference in February of next year which will be about promoting good practice and seeing the progress against the improvement plan. I'm not going to sit here and be idealistic and suggest that every board then picks up every initiative that's been shown to be effective because undoubtedly a lot of successful initiatives have had funding to kickstart that process and get it established and then it's then identifying particularly within this current climate where you can then identify that funding and I think that's why there's an opportunity for us to think differently about how we utilise the resources that we have and I think we need to think not just about how much extra staff do we need what extra resource do we need but how do we utilise what we already have to give the best impact from an evidence-based perspective. The other thing as well is although we're very good at collecting data on diabetes in the pre-diabetes stage then the evidence gathering it and I think a BC Action Scotland even said that in their statement about having robust outcomes from weight management is difficult we're quite fortunate in diabetes that we've got a national IT system to capture that. The MCMs is an ideal vehicle for diabetes prevention and diabetes improvement across the board whether it's secondary prevention or primary prevention. I think where there are some disconnect is that the primary care and the integration boards are really fully integrating with the managed clinical networks. I attend every single managed clinical network across Scotland, there are some very very committed clinical staff on there but in terms of actually having support from primary care in some of those health board areas it's not that great so strategically we're not joining up as well as we could and if we could get that joined up I think we could make huge huge inroads into prevention and as Ryan said the opportunity we have now with the prevention subgroup and the work with the obesity consultation that gives us a really good opportunity to work together across the diabetes communities. I think some of their in submission suggest that there is a focus on treatment rather than prevention even though there's evidence to suggest that lifestyle changes might have longer outcomes better long-lasting outcomes than purely medical ones and the Diabetes Scotland Edinburgh group suggests that health boards don't prioritise support to nonclinical interventions and Diabetes Scotland state there is a weighted bias towards secondary care at health board level and that prevention hasn't been addressed in a strategic way. Sounds like this is something that we need to change and I just wonder what role you know how successful are your own interventions in changing that direction because it's obviously very expensive. I think there's the opportunity for the when the integration health and social care came on board that was an ideal opportunity to start doing some more joined up work together and I think we have got some good examples across Scotland where secondary care integration primary care are all working together for the prevention agenda. I think it's just historically the a lot of the clinical needs for diabetes across Scotland have been clinicians secondary care clinicians where we've had a GP who's a primary care lead or a joint lead then we know we're getting buy-in from primary care and everyone and other levels of the health board so I think it's about everybody recognising that prevention is not just and diabetes is not just a secondary care issue it's a primary care issue and prevention is everyone's issue and and I think we need to start that dialogue we have to start that dialogue otherwise we're going to open the flood gates and we're not going to be able to cope. I'd just like to reinforce that. The point I think I was trying to make was that there is this disjointed or disjointed situation between primary care and secondary care in terms of how the patient is looked at. I'm looked after by my GP and really sometimes it's like you're just the ticking boxes and left alone so are they if you're picked up how do you get picked up what is the pathway that is expected to be followed and again that there seems to be great variation in that and as Linda said we're quite fortunate I think in Lothian in so far as we do have a joint primary care lead in our MCN so it's probably better engagement with the GP community but there is still this disjointed thing they're not looking to prevent they're looking to manage a lot of the time. Just to pick up on that I mean I think that that's one of the reasons why as a Scottish Diabetes group we are trying to push forward this agenda of taking it pre-diabetes into diabetes so that we do start to get more of that joined up approach. Personally I'd rather we got rid of the terms primary and secondary care because I think it's an artificial divide it should be community based services and acute based services and that that's specialist resource if it's a specialist consultant resource or a diabetes specialist or a dietitian should be able to offer support in a community setting as well as an acute setting and that's the sort of rhetoric that we're trying to promote across diabetes services and indeed probably all long term conditions it shouldn't be based on your geographical site but more the expertise that you can bring to that pathway and I think that's key and I think all of us agree this it's clarity about the clinical pathway that we're trying to promote and therefore the interventions that you would expect at any given point on the pathway and to date there are pockets of good practice but it's how do we standardise that and how do we ensure that that we're trying to get a universal approach to that. Just to be interested in the the pharmacy to you know your own view on what role you can play in tackling this? Yeah I think there's been a number of initiatives with community pharmacists running clinics in community pharmacies where they've actually been able to help the patients manage their medications and also help provide advice when they've been admitted to hospital for whatever reason and then they come out again etc. I think that that's very piecemeal however these these clinics are not they're not you know per head of the population prorated or you know that there's not really many of them so they're like centres of excellence and then the patients in the acute sector they are seen by perhaps pharmacists on discharge and medications what we call medicines reconciliation processes are put into place to make sure that their medicines are correct on discharge but then they go back to their GP practice and may not actually see anybody else who reviews their therapy until their next GP appointment so there's quite a few gaps in the system for if you follow patients through on their journey from primary to secondary care and then secondary care back to primary care so there's a number of opportunities where I think things could be improved significantly for patients to make sure that we don't actually get medication errors occurring or that complications are developing that aren't picked up at an early enough stage. Can I ask one further question? If we'd been sitting here a few decades ago we wouldn't have been looking at the stats we're looking at now obviously this is a global epidemic and Scotland unfortunately is you know we're leading in areas that we don't want to lead on now the Government are looking at their diet and obesity strategy I just wondered if there's any particular you know route that you'd like to see them go down is it about tackling supermarkets is it about reducing you know deals that people in Scotland seem to be particularly susceptible to you know we have incredibly high figures for for being suckered in by by these deals to buy junk food so I'm just wondering if there's one thing the Government are introducing in that strategy what you would like it to be? I think it's that whole gambit of unhealthy foods the advertising for unhealthy foods it's the processed foods and the levels of sugar etc and the processed foods it's the whole gambit of issues that need to be to need to be looked at it's also around fuel poverty and around you know poverty of access to physical activity to green spaces so it's as Brian alluded to earlier on it there's a whole fiscal policy around there around environmental issues around food issues that need to be tackled and I think the obesity strategy just tried to do some of that in its consultation. The one thing actually from the strategy is the fact that it is multi-level and we know there are some countries who are going down a route of just screening treat high risk individuals with diabetes other countries like Finland are going at a population level as well as a high risk level and I think what the strategy allows us to do is to tackle a population level so a primary prevention of obesity but there's also that secondary prevention of once you develop obesity to try and stop you from developing type 2 diabetes so I think the one thing is actually it is multi-level and it is a population approach as well as an individual approach which I think we need. At this committee we hear a lot of people saying we've got a good strategy we've got a good report we all need to work together I mean great terrific but what I'm not hearing today is we're supposed to be looking at the preventative agenda so what systematic practical steps are being taken today to prevent people from getting type 2 diabetes what can you point to that's happening in a systematic way across the country that says this is preventative work that will stop someone getting the disease okay so just now in hs scotland we've got 14 boards and they are they have got different practices some practices are excellent with weight management services so much who's doing good work and what are they doing and who's doing not so good work and what are they not doing so I mean I'm not going to go down the route of the not the good work there are areas like Lordian and Glasgow well no because I mean I'm here as a diabetic at all just I'm not here as a Glasgow as a weight management service so that would be out with my remit I suppose what we've had today is a disjointed service between weight management and diabetes what I've tried to reiterate today and you're talking about hard facts what's actually happening what's happening on the ground is we've got a short life working group that's pulling together the expertise from public health weight management obesity experts diabetes dietetics pharmacy we're getting them together and with that strategy we'll pull out pockets of good practice what is already happening is surely we've done that before though well we've got an opportunity for us to standardise an approach and the mcn structure within diabetes allows us that any intervention can be rolled out more readily I mean there have been good examples of when we've had for example if I'd sat here two years ago and I talked about type one education there were pockets of good practice we actually took that good practice and we made it into a national initiative and that national initiative has now been rolled out across Scotland so that everywhere with the type one diabetes at diagnosis we'll get a similar education package and we can determine their outcomes because we'll have hard evidence and that's the route we're trying to get down with type two diabetes and diabetes prevention I'll not lie I think it is challenging between the changes in the primary care environment with the IJBs that London's alluded to and about diabetes and single disease entities within getting in within that environment but we have got an opportunity now with the current policy that's under review about us establishing a firm clinical pathway and with that hard outcomes and the advantage in diabetes is we have got that ability to detect those hard outcomes monitor those hard outcomes and see where it's effective or not and I think that's been the problem today how do you define success and that's been challenging but what you've referred to is after diagnosis no because I think we can extend it back to the pre-diabetes so we already have a register of people with impaired glucose tolerance with impaired fasting glucose with gestational diabetes we should be utilising that dataset to allow us to look at the outcomes from the more readily I mean Brian asked earlier about are we picking up people when they've had diabetes for a number of years well big landmark study showed that 50% of people at type two diabetes at diagnosis had complications we know that that's changed we know that that figure is getting less and less so suggesting we're picking up that disease earlier I mean to be honest I'm optimistic I'm optimistic that I think we're beginning to get several different things in place that will allow us to do this properly and in a in a standardised approach across Scotland I think the answer to your question is the moment at the moment no we're not doing it but there's not a consistent approach at the moment what Brian's talking about is something that Diabetes Scotland will really really support of doing and it's a piece of work that we need support for but at the moment it's just in the early stages but there's no consistent approach at the moment across the 14 health boards Sandra did you want to know in this point it was just it was just as it may be controversial I don't think it is though because you mentioned about the fact people working together my thoughts when I've listened to the evidence is do you think there's a degree of protectionism in certain aspects of the health service such as secondary primary not wanting you know basically to let go as you might say to bring things into a more community level so ultimately diabetes actually we've that protectionism has gone whether it by necessity or design and that most type 2 diabetes cares looked after in primary care now and actually we're trying to get a more dynamic interface with secondary care clinicians for more challenging cases with type 2 diabetes in Scotland certainly type 1 diabetes is still the remit of secondary care so I can understand where you're coming from I dare say there is a degree of protectionism in any of us in all our environments but I think in diabetes in NHS Scotland no I mean I think the challenge is actually to take this discussion out with the NHS because this is a societal issue type 2 diabetes prevention obesity strategy this is a societal issue this isn't about a primary care group of clinicians a secondary care group of clinicians and a third sector organisation who are going to solve this and I think that's why the early years initiatives and all these things that have been talked about are most welcome I think one of the key things is I'm not quite sure it's protectionism as you say I think some of it's around lack of understanding and a lack of awareness and a lack of realisation of the urgency of this and I think one of the key things as Alison alluded to earlier on was if you can prevent people developing type 2 and you can prevent some of the complications of type 2 such as heart disease etc we're going to have a huge impact so I think it's not protectionism certainly because my experience of the managed clinical networks is when we have primary care staff involved the partnership works really really well because people are there to improve care for people with diabetes where there is it's a lack of awareness a lack of understanding and maybe diabetes is not high upon the agenda of some of the integration boards on this point very briefly because we need to move on it's just taking up if I take on this point and Brian's point further than that are we talking then about an educational intervention or a health intervention here easy both when that so in that case then we need to get out of it put more in your mouth get out of these styles of a health budget and an education budget then and yeah I mean I think this is a societal issue that we should be having societal addressing it and that's why I think when we start looking at the proposed strategy then we have got transport in there we have got active living in there we have got diet and exercise marketing etc as well as just healthcare services what do you think the program in England is that when people are on program in England which is around group work around prevention diet and exercise and everything education learning so Rodd didn't call that education it's it's skills development and knowledge development and that skills development knowledge development and awareness of diabetes both for the people at risk for the person who's living with the condition and for the wider community is the thing that will help us tackle the stigma of the lack of awareness and maybe help us turn the corner okay ash morning mr Kenna I was quite interested when you were speaking earlier about different countries and you mentioned Finland so obviously we've been talking this morning about if you're spending money and you're spending money you know and prevention activities that in Scotland you know it'd be good to target high-risk individuals which we're doing but that balance between then things like national health campaigns obviously Brian's just been speaking there about education but getting into other issues like things like food labelling and things like fast food outlets you know really near to schools food advertising on television that's targeted to children and so on so I'm interested in the panel's view of where's the balance here between sort of medical intervention into high-risk individuals kind of on one hand and then the sort of wider societal issues that we've been speaking about on the other is it kind of a 50-50 approach or 70-30 where would you see that answer you've been short term mr long term as i'm thinking about very early prevention you know if we're talking about being overweight is being a you know a factor if we can address that earlier in people's lives then presumably that will have a knock-on effect yeah i mean i think that's true i mean recent evidence suggests that what's at 50% of your weight gain is by the age of seven or something like that so undoubtedly the early years are important if you had to say to me here's your budget how much would you give for both then off the top of my head i'd probably go 50-50 because i think i think as soon as we start placing undue importance on one area you've got the potential to lose the whole system approach and i think ultimately it's the whole system approach as a diabetologist i should be sitting here saying i'll take 100% of that for early type 2 diabetes and it should all go into the direct study that's recently published great remission rates for diabetes that's once people've already got exactly but if we're looking at this as a sort of longer term view for Scotland then i think you have to have equal investment in both okay and i'm just wondering in countries where there are other countries that have got good practice on this you know how are how are they splitting up the the spending do we know got any information on that no which is there's no country that's doing well on this because actually this is a pandemic that's increasing increasing increasing but i think there's an increase in recognition across the international diabetes community that diabetes and silo can't just worry about it once you develop diabetes we have to take a lead in preventative measures as well do we need to follow what's happening in england in terms of the prevention programme sorry do we need to follow what's happening in england in terms of the prevention programme the prevention programme in england is doing quite well there was a substantial amount of money put into it the eight pilots showed quite a lot of improvement in terms of people losing weight and maintaining it and so there'll be another review of the our report for the programme in april but you can find out all the evidence so far from it on the diabetes UK website and is there do you have a view on it whether that's what we should be taking up here personally i think yes i think we should think there should be investment in these prevention programmes but i think they need to be community based they need to be multifaceted and they need to involve a range of individuals from healthcare professionals health psychologists third sector peer support so it has to be a partnership approach and and if you look at what's happening in the borders in terms of their prevention programme that's very much an example of a model that is trying to be expanded in the borders and hopefully we will get some good evidence from that over the next five years any other comments on that yeah i mean i've got to say i think we should learn from good practice wherever it is in the world i don't think that the english diabetes prevention programme in isolation is a model that we should be adopting wholesale and i say that because if you only have a strategy that identifies high risk individuals screens them and intervenes then i think you're missing the opportunities at a population level so there are some aspects of that that i think we could look to mirror i think their intention of trying to standardise the intervention that they're offering is is worthwhile but i think we have an opportunity to go further than that and look at it more at a population level as well as just that high risk level okay thanks emails thank you convener i wanted to develop two points which the panels touched on already this morning firstly for someone who has type 2 and to what extent across scotland are they having at least an annual review to see whether or not they should be on medication or whether or not they could be supported to come off that and then secondly one of the members of the panel touched on the bme community and levels of prevalence what work is currently taking place in scotland to focus specifically on them and potential language barriers as well around diabetes in terms of the first point a minimum is an annual check-up but ideally i think it should be six monthly and but around that there's always the constraints of resources timing availability and and so on but it has to be a minimum of 12 months it really depends on the individual from what i understand and where they are in terms of improving stable or deteriorating and is everyone in Lothian you believe receiving that i believe so there's variation across the country in terms of the the standard of how many people with type 2 are getting all the the nine care processes and their annual review i think as a whole Brian you might have the exact figure of what scotland is as a whole but in terms of there is variation there are some very good pockets where people are getting the annual review Lothian is one of the good examples Glasgow is one of the good examples and it's it's about giving that getting that back up what you have to realise as well is within the terms of the annual review we do have a lot of people who just don't turn up for it so we will always have DNA rates but it is it is patchy but it's certainly improving and it could certainly improve it is a minimum though isn't it it's just it's like the lowest common denominator and it's just it is really a kind of tick box exercise check you know hb1c blood pressure etc so the the nine measures that the mcns look at individually in each board assess all of these areas and for example the blood pressure one which is really key to my interest is really a kind of population level blood pressure it's not your ideal for diabetics because you know we would really struggle to to reach that so so it's kind of like there are broad brush indicators of the diabetic population in a board we've got the annual scottish diabetes survey which gives you data for each of the boards and their performance against these nine measures i think actually we've been able to collect data for a long time in diabetes and i've said that repeatedly actually the what we the key now is how do you turn that data into improvements in care and that's why we've introduced over the last two years mcn quarterly reportings whereby each mcn and each board get their performance against 12 measures and the hope is that the board and the mcn take ownership of two or three areas that they can introduce health improvement and drive that so it's not just a matter of ticking the box and saying oh well we've collected the data but what are you going to do with that data to drive forward improvements and that's one of the key areas that we're working on in the scottish diabetes group because we are cognizant that there are lots of reasons why it's not 100% and not everybody's getting it and we need to identify that and work it on in terms of the bme then as mcn lead for gg and c then we have a specific health quality of access group that have tackled some bme issues they tend to be quite standalone specific projects personally i've got a when we talk about a quality of access i think deprivation actually in Glasgow the hardest to reach communities aren't necessarily just bme but it's actually the private areas as well and there's some work to try and address that but i wouldn't pretend that any of that's easy and it's not challenging. Mdals like to come in on any issues just before we finish up. Ash Denham alluded to the split between health and education on this and I think Brian Whittle picked up on it too so i just wanted to ask specifically Linda Mclin and Andrew Job actually in your submission you recommend making education available in schools to teach about nutrition so they leave school with the appropriate knowledge to prepare and recognise healthy food i thought that was already happening in schools to your knowledge is it not happening and do you as an organisation ever work directly with schools themselves? If it is happening we don't see much of it coming through at the other end I don't know about in terms of what we do as a local group we do talk occasionally to school groups but it's not a regular thing it's not organised in any shape or form it really depends if we're invited in and what we have started or i've started to do is working with employers so we're getting in and talking to groups of employers i was recently down at Haddington talking to the company that was building rebuilding hospital there we had all their contractors in and we had two or three very good sessions in terms of education about food and the balance between food and exercise and so on and healthy living but we are not involved in any structured or organised programme but i do believe education being able to make have the knowledge to make the choices is really fundamental to improving lifestyle We do go in and talk to schools again it's an ad hoc basis based on the invite coming from the school to go in and talk to them about diabetes talk to them about the need for healthy eating et cetera we did a harfa programme a few years ago which was we actually went into school we had a joint programme with the science festival and we went in and and we did a six week programme with schools in deprived areas it was called live for it and it was around looking at raising awareness about diabetes it was around awareness about healthy eating et cetera and that was aimed at schools in primarily deprived areas and we did quite a few up and down the country and we did that for a while but unfortunately due to funding that programme stopped but so it's we do go into schools and i think one of the things that seems to seems to happen is i think the children in secondary school will have home economics up until first or second year and it's mandatory after that they don't do any more and i think there's a wee little bit to be said around keeping that those core skills in the curriculum i think in my personal experience it's not mandated that they're not allowed to take it they can choose to take it the end of sd in my experience formally as a teacher with regard to the funding issue though that you flagged up there obviously through the pupil equity fund that's been given to head teachers head teachers now have a lot more power in terms of what they can spend their money on and do you as an organisation therefore see an opportunity for Diabetes Scotland to create perhaps a pack of materials or to look at what you do as an organisation and to perhaps bid for something that funding that's available to head teachers now well we have a few resources and information already we have a programme called making the grade which is around looking at how children are looked after in school with diabetes within that it looks at different elements of managing diabetes and it looks at healthy foods so at the moment i would say it's probably not something we've considered but i'm not i wouldn't rule it out but we certainly do have resources that are available to schools already that they can have access to can i ask if those resources are linked to the curriculum content in curriculum for excellence in the health and wellbeing curriculum area which already sits there the making the grade is but not the not i would general packs i would general packs or around just giving people advice on diabetes okay thanks two final things before we go um when is the report from the working group due to be published and when is the strategy due to be published so Alice and diamond links up next in the next group of sessions she's chairing that group so maybe we'll leave it to that yeah that's called passing the buck yes very skillfully done and finally professor lean couldn't attend this session because he's in South Africa for a conference but his co-author will be on the next panel so we'll hear from them then okay thank you very much for your evidence this morning and we'll now suspend briefly to change the panel okay we continue with our session on the preventative agenda looking at type 2 diabetes can i welcome to the committee dr Lynn Douglas steering group member of beastie action scotland and director of allied health professionals nhs loading i'm from nhs loading sorry pete richick co-convener scottish food coalition and director nourish scotland heather peace head of public health and nutrition food standard scotlands professor falco stehota professor of behavioral medicine and psychology new castle university and allison diamond chair of prevention subgroup scottish diabetes group and lead uh loading uh lead in loading weight management service diabetes and metabolic dietician nhs loading it's a big title big title okay can we move to opening questions sandra do you want to open up again thank you very much kindrina in regards to prevention that i did ask the previous panel about the environmental aspects of it i don't know if you have any thoughts on that particular one but one of the about the causes one of the other issues which was raised previously as well is regard to fast food outlets unhealthy food poverty it's a huge list of them so first of all obviously regarding the causes and prevention would you say that there is evidence there that could say that there is environmental aspects of carcinogenics which causes a biticity there for causes obviously diabetes and the second question for me kindrina is regarding obviously the fast food outlets and what we can do with obviously we don't have the powers over certain areas to stop you know sugar getting into foods if there's any comment you'd like to make on whatever one you want to pick up in leave it to yourselves okay yes i'm happy to pick that up from environmental i take it that you mean the food environment in which we well there is we were given evidence in regards to the fact that heavy metals in the air pollution that type of thing although the previous panel had said that there wasn't that much evidence in regards to that so i don't know if you feel no sorry i can't enough to pick up answer on that one so the other question would be obviously in regards to fast food fats sugars how do we prevent particularly younger kids to for the prevention strategy of access in this and my mind goes back to many years ago trying to to campaigning to get these fast food vans taken away from outside schools which we found very difficult to do and we still can't always do it so i just wonder what your thoughts are on that particular issue yes i'd be happy to pick up the second point i don't have any evidence on heavy metals i'm afraid my the second point is more around the food environment that we we all kind of navigate and buy and consume our food and the our view in food standard scotland and the view of the board is that education on one hand is really very important we don't deny that we do a lot on the education front but actually to move things forward towards healthier eating we do need to see changes in the food environment and that may be in what we call the out of home environment which is where we purchase food and consume it outside the home so that takes you into the takeaways and that whole arena it's quite a complex area it's one that food standard scotland has done some work on and has published information describing that landscape in scotland and we've made proposals as to how that may change as part of the current scottish government consultation on obesity then there is a part in there that talks about developing an out of home strategy for scotland which at one time you might have called that a catering strategy but actually out of home also encompasses supermarkets that sell food on the go so it's from that right up to the high end and all the stuff in between the takeaways etc so we absolutely recognise that this is an area that needs to be tackled that it's a part of the diet that's expanding that people are eating more in this way and that we do need to get a handle on it and we will be moving forward to develop a strat and I think food standard scotland will take a lead with with partners to start to develop a strategy that may help to address and we'd hope to help to address that out of home environment in scotland obesity action scotland recognised that the crisis within our our weight within scotland is highly attributed to the obesogenic environment which is the second part of your question and therefore is looking to ensure that we do have a significant contribution to the out of home strategy and also to for example regulate and control portion sizes and take on board issues such as regulation of price promotion to tackle obesity with regard to high calorie food which is a key obviously impact in terms of that obesogenic environment and also the soft drinks levy in terms of reducing the likelihood of individuals wanting to buy these foods and drinks which we think is an important part of the strategy that's out for current consultation it's important to emphasise that there's overwhelming evidence for the link between type 2 diabetes and both geographic and socioeconomic factors and the two of them go together scotland has got one of the best statistics for neighbourhood levels levels of multiple deprivation and you can use those quite easily and you can have a very impressive mapping of the relationship between those and it's important to look into geography and environment and socioeconomic status in conjunction and understand where the pockets are where geographic risk is particularly high and some of the policies that were proposed they have a good evidence base they are easily available and they are feasible and have been used elsewhere yeah i mean food coalition wants to incur with that and to point out that the last addition to the footsie 100 index is just eat right so which doesn't have any outlets and doesn't make any products what it does is get you see your picks quicker right so that whole since 2008 the number of fast food outlets in the UK has risen by around 50% we've got an industry which needs to sell more we've got a more or less static population in scotland and we need an every industry is on a growth curve so something's got to give what's giving at the moment is our health and that's not just in scotland it's globally you know we've got an industry that's trying to you know it's got perfectly legitimate growth targets but we can only eat so much and stay well you know and and something's got to give and then the quality of what we're eating is changing and has changed significantly so i think in our view it's not just the calories it's the degree of processing in food and it's also the lack of fibre in food so the world health organisation recommends at least 20 grams of fibre a day foods stand in scotland around 30 grams of fibre a day we're coming in under 12 grams of fibre a day and that has significant impacts on our health and is linked to the instance of type 2 diabetes thank you i just wanted to follow up and it was one of the issues that the convener raised in the previous panel as well in regards to poverty obviously areas of deprivation poverty where diabetes seem to be would be much much more diabetes there and more affluent areas and i just wonder what your thoughts are on there because i'm thinking about the fact about you know you're eating more processed foods so would you look to a strategy that would target certain areas as we've got the deprivation pointers there would you look to a strategy that would target certain areas do you think it's more prevalent in areas of deprivation that diabetes would come about rather than more affluent areas well in your answer and is there any evidence at the moment of resources being directed to target those communities in very practical ways i suppose from our point of view absolutely people on lower incomes have worse diets and that's not because of a lack of education it's because of lack of finance and if you look at them you know per calorie you know carrots are three times more expensive than processed food they just are you know so although we may think that food is cheap and it's cheaper in historical terms it has been for people who are trying to manage on a a fixed and constrained diet a budget then the cost of good food is prohibitive and that's the fact that lots of people find they can't afford to eat the food they know they want to eat um and we don't have a systematic approach at the moment in scotland for rebalancing that we have free school meals which is a bit of a help we have healthy start which we're trying to revamp a little bit at the moment which is a very small scheme but a population level the last time we balanced the diet was during the second world war and that was the last time we saw major increases in in in you know equality equalization of public health outcomes just to say a little bit about the scotish diet which we have been tracking for quite a long time to see what the changes are and really there are very few changes over about 20 years that's stuck i think in terms of inequalities in that we see that across the whole population i think everybody whoever they are is eating too much fat too much sugar too much salt so those sort of less healthy or the unhealthy parts of diet we're all equally consuming it may be in different forms it may be that somebody's going to buy their saturated fat in a cheap form or sugar in a cheap form or some of the rest of us may be going off and buying it in a fancier form but the nutrient profile is the same where we do see the difference is in those foods that are perhaps more protective to health so peat is absolutely right we see lower fruit and vegetable consumption in in in lower source economic groups we see a woeful amount of vegetable consumption in children in scotland particularly we see less oil rich fish being consumed in lower source economic groups and less fibre and whole grains so you know across the piece we have we all have problems but i think and we haven't done the work in this really the costing of of that diet but i can quite see why those more health enhancing parts of the diet may be more expensive and more and less accessible in that sense to the children's weight screening we know that the children who are in the most deprived areas have the highest incidence of obesity and overweight and currently in 2015 the population at the primary one stage was at 22 percent of children accessing primary one have or are at risk of obesity or indeed being overweight so there is a link and there's an evidence base around the social economic impact the prevention strategy we're trying to work with across health and social care and actually deliver services through local council and leisure venues which incorporate healthy eating access to self-esteem mental health side of things as well as a physical activity so certainly we're trying to take the services to the community because access and being able to get to areas of services can be an issue as well in the lower income areas in the deprivation areas we're also trying to work with the kind of social planning and even things like when there's licenses for fast foods it's almost like trying to ensure that there's a cap put on how many venues are within areas so trying to kind of work across the kind of health and social care agenda we have looked at different areas across scotland examples of good practice and we are trying to bring it together to try and develop a framework that will suggest what is good practice and offer practical guidance on how we could implement it can i say i've not heard really a single policy that people know of that is deliberately targeting resource areas of deprivation it might be that you just don't know but i asked for examples and i'm not really getting them example of midlothian in lothian because i am lead for the weight management service in midlothian we've been trying to implement the prevention because midlothian is quite a small board and we have in terms of the health and social care integration we've met probably four or five times we've had events we've worked with the schools we've worked with social planning and we are trying to create a pathway of a kind of one stop shop for this to try and ensure that it has been seen has been kind of joined up and developed together and again in terms of the the big thing in delivering these types of prevention programmes is the finance aspect of it and midlothian have made as part of their implementation joint board that actually that's the area that they're going to focus monies on so we've actually as a group in midlothian decided which services will provide and made that be a priority okay yes the challenge around is there anything happening policies around inequalities i think the one one does spring to mind that scottish government sponsor which is the scottish grosser federation and this is an initiative in small convenience stores where they mainly in more deprived areas where the fruit and vegetables are put to the front and there's encouragement to do that there so that is one that springs to mind activity would probably another thing and that the council areas are providing free or classes or access to gym etc for a pound so they're actually making physical activity more accessible and more economical yeah i mean 20 years ago we set up the Scottish diet action plan 1996 and since then there's been funding for community food organisations it's been piecemeal it's been small lots of those organisations struggle year to year to actually get budget and they do very good work within their own community to try and prove access to fruit and veg and healthy cooking and you know they operate at the community level but i think it's very small scale compared to the scale of the problem that we're actually facing and many have closed due to local government cutbacks in my area yeah they're always scraping around yeah that's two slightly different examples so that's in Edinburgh is the Petrosa cohort group this is work around South Asian communities which i think has been really important to mention and of course there are non-community related interventions that have an effect on health inequalities so it takes the minimum pricing for alcohol it's likely to have a stronger effect as a financial disincentive on communities where money you know is tighter than communities where money is more available so there are ways of targeting more deprived communities without necessarily thinking about community-based actions as well so there are i think a few examples okay ash good morning um professor siota was very interested to hear more about your direct trial that you've carried out because i think they're certainly up until recently there was this imagination that you know if you got type 2 diabetes you were kind of stuck with it and we were you know the health service was left with really sort of managing those symptoms and preventing it kind of escalating but you showed through your trial that that actually is not the case and you've got extremely good rates of remission can you tell us a little bit more about it please yes so the news is not that um you can beat diabetes into remission type 2 diabetes that is through a dietary intervention because that has been built up as evidence over a while now and of course all started with the physiological hypothesis that professor taylor has put forward and then we have had this really positive collaboration between the north of england and scotland in working this through i think the big news of this um intervention is that you can potentially scale this effect up by delivering it in a standard healthcare environment at a rate that um i suppose really fuels fantasies of of rolling out a service that can provide diabetes remission to a large proportion of the population and i think that is the great news so the result is quite quite um strong in that we understand the physiological mechanisms well and that we previously showed similar effects in smaller studies but we now see that at the level of of a sort of population approach we reach targets of almost 50 percent remission and so there is clearly an opportunity to adopt this early into policy but it's also important to note that at this stage it's a trial it's a lot of additional work needed to know what is needed to turn this into policy but um this is the opportunity i suppose for the scotland parliament to to work out what these steps are and to fill the gaps and so that would be delivered in a primary care setting so in the community is it in small groups and i think you're saying here it's um interventions for about three to five months and then our longer term support so it's a total meal replacement for three to five months where um we're looking into into a balanced um low energy diet and i suppose for the for the older ones of us it's important to note that when these low energy diets first came up you know people talked about losing their hair and all those kind of side effects and that's still somewhere in the back of people's mind and of course nowadays these interventions are so nutritionally balanced that they're probably better than the typical Scottish diet if i may say so and and so so we have a higher than people expected hit rate on getting people through this initial period of of um adhering to the intervention and then there's a structured reintroduction of normal food and then there is a structured approach to supporting weight loss maintenance and together i think the the results speak for themselves it's quite effective and clearly if you were to roll this out beyond research interested practices beyond the people who are joining studies some of those main indicators in particular weight loss percentage of people gaining the target of 15% weight loss or number of people actually experiencing remission that might be a little bit more variable and might be a little bit lower but given the i think enormous power of those findings you could well afford you know lower follow-through rates at population levels as you do always when you translate trial evidence into population services and still have a very very cost effective service which not only is a sensible thing to do for health services but it's also something that i think empowers people with type 2 diabetes and i know that professor Taylor in england in particular receives a large number of of messages emails letters every day of people telling him how important it is that there is a way to get offices diagnosis of type 2 diabetes and of course we should briefly say we have seen similar reversal effects in bariatric surgery in the past so again it isn't a total surprise effect where the community wouldn't have thought that would happen we thought it would happen we didn't quite appreciate at what level it would happen and how scalable it would be and i think that's the game changer from a policy perspective here okay thank you so i asked the previous panel this question as well so obviously what we've been discussing here is you know preventative intervention but at the point where people are already diabetic or targeting high-risk individuals before they cross over but if we're talking about early prevention if we're talking about educating people about food choices about food labelling advertising to children fast food and all those type of things and that's kind of on the other hand in terms of the preventative agenda where would the balance be in the spending you know would it be 50 50 between sort of early things to do with food or would it be would you spend the money more on the high-risk individuals how do you see that can i please comment on this as well so i've been the principal investigator of the formative evaluation of the first two phases of the english diabetes prevention service as well so that's an area i'm particularly interested in what happens if you if you look into some of the upstream interventions is of course that they don't only affect type two diabetes but they affect a range of other things so the question isn't perhaps well perceived because you can't balance a budget 50 50 when the target and the potential effect of these interventions is quite different so i think the question would be difficult to answer because if you manage to to affect the scottish diet the the energy intake the physical activity environment of the scottish population you would see benefits across the board it would affect depression potentially attainment productivity so to limit this into the perspective of type two diabetes prevention would be narrow and perhaps undervalue that kind of a part of the approach with regard to the obesity action scotland group we believe that the primary prevention in terms of the prevention of obesity and overweight in our population there's a key opportunity that the scottish programme for government has with regard to the healthier future consultation and indeed by addressing both the obesogenic environment so we have that primary prevention to prevent people from becoming obese due to lack of physical activity and overconsumption of nutrient dense food is a key pillar in actually delivering a healthier future but in addition to that there are no consistent services that actually target type two diabetes and the prevention of across scotland and the publication of the review with regard to weight management services in scotland in 2014 which is in a paper that you have had cited also indicates that there's no consistency so there's a key opportunity and been able to address both the primary prevention of obesity and overweight within our population by introducing the measures that we addressed earlier in the conversation but also in terms of that targeted intervention for those that are most at risk by actually consolidating the weight management services that we currently have available in scotland because without obesity then the chances that 47% of the type two diabetes can be attributed to obesity and as 65% of our population are already regarded as either obese or having or are overweight then the measures around obesogenic environment are not going to be enough and therefore we do need to think about being able to underpin these core weight management services that will impact not just on the development of type two diabetes but also the contribution that obesity then makes in our common cancers and cardiovascular disease. I was interested in a couple of points I think that are linked one by Peter one by Alison around access to healthier foods and also access to activity and it strikes me that surely the place where we can the leveler especially around the more social economic poor areas is surely school. I'm not sure we have an opportunity at school to introduce and to the kids to healthier food especially around school meals and following on for that I did admit a few of the schools talking about the free school meals and the uptake of free school meals and it transpas even one of the schools that was less than 20% of pupils who are eligible to have free school meals actually took them and the rest still chose to leave the playground and go and take take this high calorie food so if we're unable to stop the planning applications we're unable to stop vans parking outside the schools do we need to stop kids leaving the school playground and I said should we should we be focusing very much on what we can change which is around the school food environment the school activity environment. I think there is already quite a lot happening in schools around the education part I think kids are by the time they go through school they are pretty savvy to what the healthy diet is it's they're not ignorant but knowledge doesn't always translate into action and there are quite strong drivers I guess for young people to go out of school and to experience what is out beyond the school gate and it is an issue it is a problem I think whether or not you could keep children all the children in over a lunch page it's probably not practical given the size of the schools so the size of the dining room and the shortness of the lunch break so these are really big challenges I think I think school is important there is currently a review of the standards underway at the moment and we need to look at how they might become tighter but I wouldn't place all my eggs in one basket here actually there's no single silver bullet there's a whole package of measures that need to come together for diet and the Scottish diet to change and I don't want to dismiss the school angle but it's not the only one and I think in terms of other actions around that obesogenic environment there are many things that may may help to clean that up and even when the when kids are going out into that environment it's less it's less um less obesogenic but we need to see things like price promotions changing we need to look at um issues around advertising and marketing to children um we need to think about reformulating the actual food that is out there to take the take some of the salt and fat and sugar out of it so that you don't have to make that choice oh will I have this or actually the choice there is better than it was um I think the board the food standard Scotland would also argue that there needs to be taxation measures that go beyond the soft drinks industry levy I think that the we we absolutely agree on the education side around um public campaigniness is helpful but it's not going to answer it all I think that we have stated that education specifically on diabetes in schools or just generally diabetes education and diabetes would be useful and somebody was talking about that in the earlier session about going in and talking about the consequences of diabetes because I don't think that's really well understood and I think there is work to be done on addressing the affordability and acceptability of a healthy diet because you know we all know I think most of us here will know what the healthy diet is and what the components are and there are many reasons as to why we don't do it and one of those bars would be accessibility and affordability for some and I think the other thing that is really important and all of this is the provision of constant diet consistent dietary messaging so that we don't get messages from everywhere that are inconsistent and confusing so yes schools are an important focus but concentrating eggs in one basket there wouldn't be enough sorry if the prevention framework we're looking at a kind of birth to the end of your life can approach this and I think one of the things we've identified is that we need to look at pregnancy we need to look at breastfeeding then weaning and there's been a big health visitor review and how health visiting is delivered in Scotland is changing just now as well we're introducing kind of more screening of weight and height which previously wasn't done for large gaps we're trying to look at working with mothers who are overweight during pregnancy and trying to get them into weight management programmes once they've had their babies to try and prevent further weight gain in between pregnancies provide pre-diabetes support for those women who do have gestational diabetes because we know they're a high risk group as well trying to encouraging breastfeeding and encouraging healthy weaning because usually by the time children do get to five the kind of health eating habits are almost ingrained and we're trying to encourage that it's a family approach as opposed to individuals rather than therapeutic it's and again in terms of the behaviours around eating they're learned behaviours from the family home which we're trying to influence from every stage so that's a big part of the work we're doing is the maternal and infant nutrition strand of things as well to try and go from that even that earlier staging from pregnancy and to try and give guidance pre-pregnancy as well about health eating about weight management and about the importance of preventing diabetes Pete yeah just I think it's absolutely right we we did change the alcohol environment we did change the background environment and we can change the food environment and I think we have to take it very seriously as you say it has good effects across the board not just on diabetes and we need to let nutrition do the heavy lifting here and we we know that for example the volume of fruit of veg we buy in Scotland from the supermarkets is about a third of what it should be if we were going to have a balanced diet we know that it's much lower for out of home the the company to which provide our food environment which create our food environment are creating food environment which is not what we need to eat according to our dietary targets so we need to change what they provide not necessarily individual products but the basket of what's provided needs to be changed otherwise we can't eat healthy with the exception of our breastfeeding you know we we depend on the food industry to deliver our food environment and we need to change what it delivers if we want a better food environment for all of us to grow up in okay I've got Jenny and Ivan on the specific issues yeah convener just as a brief supplementary to Brian Whittle's point I appreciate what you said Heather piece with regard to it not just being about school meals however for a growing number of children in Scotland that free school meal might be the only meal they have all day I therefore wonder has any research been conducted with regard to the nutritional content of school meals in Scotland because in my experience as a former teacher it varies across the country what kids are offered sure you're right that it varies across the country what there are the moment in place are standards for school meals that are in legislation what I can't answer is exactly how well those standards are being met but I would you know anecdotically I think the answer is probably it varies across the country so some some schools and areas will be doing really well against those standards and others may not be it's important that I think the the free school meal is extremely important I accept the point that it may be the only meal that that child gets and therefore the standard of that meal is important yeah so I would not I'd not go say anything other than that actually the school meal regulations are currently under review they were done last in 2007 eight and since then there have been a number of different recommendations evidence-based recommendations on diet and health for example to reduce sugar content and two of the diet and increased fiber for example as well as looking at the role of red meat on colorectal cancer risk so there's all that that has happened in terms of advice since the since the regulations were set so that's something that heather peace said and also something that Pete Ritchie said earlier as well round about the relative costs of good foods and bad foods if you like that the good foods are more expensive in general and you mentioned taxation policy perhaps so I suppose I just wanted to explore what you would propose in that space either taxation and or subsidy and any examples of other countries that have done that varying in mind that the cost of diabetes to the health services is probably around a billion pound a year so if we get this right there's money there to support initiatives so I don't what your thoughts are on that well the example at the moment that's current is the UK government's soft drinks industry levy which will come in to play in April I think next year however in advance of that being the case the soft drinks industry have really removed a lot of sugar from their drinks it's done that reformulation thing which we need to see our problem and I think that's great we do need to see that and I think also that is a it's almost a totemic measure to say enough's enough that you don't need to put that amount of sugar into any of your products take it out please so I think that's really important however what we see in monitoring the diet overall that that same amount of sugar isn't removed from the whole diet so some of it must be going back into other products so you know do we need to start to think about other products that are that that they're sitting below the soft drinks industry the obvious one would be confectionary for example which is taking a lot of sugar and it's completely discretionary in the diet we all like it in particular this time of year but actually we don't need it so there's a lot of that kind of food in the diet that that could have scope for for taxation to improve diet I think in addition to that the tackling the regulation to tackle price promotions for the high fat high sugar energy dense foods that are particularly drawn to people whose budget perhaps is limited in terms of buying nutrient dense foods and so we certainly think that's an action and a key opportunity within the healthier future strategy that's currently out for consultation and in addition to that the wider impact of reformulating key products because we consistently miss our targets as a nation in terms of our intake of saturated fat and free sugars so in particularly impacting on on the diet of children if we were able to reformulate some of the high consumption foods even if we were to reduce the sugar intake by 50% in key products we would therefore be able to lower the sugar intake for around 12% in 9% in adults and from 15 to 10% in children so we think that reformulation of reducing the sugar content of key foods that are available in our in our supermarkets and also increasing fiber and reducing saturated fat would actually have a significant impact on the the dietary goals that people are achieving later there is evidence for legislation on advertisement being effective in particular advertisement of high energy dense food for children in children programs so there has already been legislation in the UK and there is good evidence that has been successful in terms of decreasing the popularity of certain food options and subsidies for foods that are good for you i think there's a good argument for increasing availability of free vegetables particularly for children i can't see why you wouldn't do that and make that easier for children obviously you've got the issue of targeting it's a universal benefit then if you do it for all children but i think actually increasing vegetable intake is one of the things you can do that would be actually very helpful we've been running a voluntary initiative with the major retailers in the UK and we've got over 50% of them signed up to increasing their vegetable sales but i think all voluntary initiatives suffer from a problem that they they can lose traction after time so we would argue in the food coalition for raising the bar continually on regulation and expecting our multiple retailers and particularly the outfo environment to reach reach some minimum standards in terms of both you know the lack of the the high fat sugar and salt stuff but also the positive presence of whole grains and fiber in the food so you just make it harder for anybody just to set up and open a food outlet and sell whatever they want i think it's you know it's vital to our health and it's a very under regulated thing at the margins of anybody can set up and you know sell stuff which is not very good for our health okay thank you we did of course have free fruit in schools previously but that's going by the wayside sorry Heather very briefly and then i'll bring in Alison done a little bit of consumer work and certainly the idea of taxation coupled with subsidy is quite popular Alison thank you convener i think i'll direct my question in the first instance to Pete Richie the Scottish Food Coalition in your evidence um you're asked well all asked um to what extent you believe the Scottish Government's diabetes improvement plan and the approach by integration and authorities in NHS boards is preventative and the Scottish Food Coalition say that the that it's entirely focused on the quality of individual treatment and care this is not a prevention strategy and makes no mention of diet and other lifestyle factors so you're quite critical of that and also you're pointing out that there's no global analysis on the balance of government spending between prevention and treatment of ill health so they're fairly critical and direct comments but you do think there is hope you think the healthier future document is much clearer and you're also off the opinion that the good food nation agenda has real potential for change i just wonder what you know does the good food nation have the power to counteract what's not happening in other areas in our view over a generation it probably does but we have to take what we described in our evidence as a whole of society and a whole of government approach you know this isn't just about diabetes and it isn't just about sugar it is about what sort of a country we want to be and how healthy do we want our population to be and if we want to live in a country where you know we're not just marginally less unwell but we're actively brimming with health as a population then we have to change a lot of things about how we organise our society and you know congestion charging is probably as important as as sugar tax reduction i mean is all those things go together if we want to make a society where we're healthy and things brian talks about in terms of changing the way we do things in schools you know what you done on on active lifestyles it's all part of a peace but we have to be serious about wanting to make radical change and in criticising the strategy i'm afraid all i could do with read what was written on the page in terms of the words that were said and i'm sure that colleagues in working in the field are very focused on on on prevention a very keen to see prevention but the strategy itself didn't spell that out and didn't allocate resources for primary prevention i changing the food environment which is a beast action scotland say is the thing that's driving a lot of people in scotland and worldwide towards type 2 diabetes i was horrified to hear your comments around justy when you opened and i think previously met with professor charles mill and i think that was a it was a discussion with the fsa at that point and he pointed out and i i questioned this figure but he thought that potentially up to 15 percent of scotish households didn't actually have cutlery um which which was a statistic you know you you can almost understand why that might be happening now given the access to you know to eating outside and so on but you know we seem to have two different cultures we're known globally for the quality of produce um in scotland but we seem to be buying serving and eating markedly different um produce how do we go about changing that and also you've got the challenges of you know more and more people now relying on what is provided for them at food banks and so on you know how do we ensure that those people are getting anything like the amount of fiber they need on a daily basis okay well we have to we have to make improving nutrition as i said a goal not just the health committee but across government um at you know the most senior level in government it has to be seen as our whole government thing um and and you're absolutely right it has to start you know pre-birth that's when it starts in the first thousand days and we have to re-engineer if you like the whole way that we we get food to people we're not going to go back to a time where everybody's going to grow their own vegetables or even everybody's going to go home and cook seven days a week we're not going to go back to that um but we do we can ensure that even if you are getting something from a takeaway that it's got the right stuff in it you know and at the moment if you go to a takeaway you can get something very cheap that's immediately filling for 99p or you can spend £3.50 on some quinoa and salad now if you're hungry you buy the stuff that fills you up for 99p and you know whatever your income is and at the moment we're so we have to change the food environment so that you know eating stuff which is good for our health is as cheap or cheaper than anything stuff which isn't so good for our health but also changing the whole way in which we our culture looks at eating opportunities and we've crammed so many more eating opportunities into our days and into our lives it's very hard for people to just go well i'm not going to eat anything now and it relies on people having huge amounts of self-discipline and motivation to do that um so we need to change how easy it is for us to just fill up on stuff all the time you know we didn't have food in garages when i was growing up now you can't get through a petrol station without being asked to buy more food that you don't need so i you know i'm not wanting to sound puritalical about this but if we want to have a healthier society we need to do something about our relationship with with food and part of that is regulating the food environment just like we've regulated other environments emails morning to the panel some of the gps we've had giving evidence to the committee have said they're not comfortable about speaking about weight with patients and one of the specific areas i'd asked in the past was around social prescribing and actually looking towards where people can go and i was just interested to hear from the panel their views on how that should be developed specifically maybe with regards to the use of private weight management companies like Weight Watchers and others to be able to use that capacity which is out in the country which is maybe not being utilised all right in NHS Lodian when we got a small amount of money to provide our weight management service we looked at what was available and Greater Glasgow and Clyde had gone out to tender and got Weight Watchers but the Weight Watchers aspect of it is about making money through people losing weight and it doesn't involve the behaviour change aspect of things it doesn't involve the physical activity side so we then were able to provide for a cheaper price a service that we did in unison with the communities with health and social care we use an evidence-based model we trained our colleagues in the leisure centres who were trained to reps level four in terms of physical activity and we mentor them and support them and we see ourselves as a wider team so we've then provided across all of Lodian a service which is a huge model of care which enables patients to access wherever they are and to have subsidised physical activity etc rather than go down the kind of commercial route which actually at the end of the day is promoting Weight Watchers locality chocolate bars etc which is not the message and I do think in terms of funding for weight management services if we can roll it out in that way and use what we've got and work together then it can be done economically rather than the presumption that it would be cheaper to go out to tender because then we've qualified professional staff at the different levels providing it we certainly encourage self-management we've tried to go into the communities we've done specific groups for carers who find it difficult to access groups otherwise and we've provided specialist swimming lessons for not swimming lessons swimming classes for Asian women's groups that they need to attend privately etc so I do think going into the communities and seeing what is available and providing services that are going to suit everyone is better than going down the commercial routes so perhaps I should say that I have no interest to declare but I think the wider evidence perhaps draws a slightly different picture so there are trials of weight management services and they show consistently that the commercial providers do as good or usually better than than any NHS related provider so that's quite strong evidence and there's a specific trial that I apologise if I give you an example from south of the border south of the border in this case sorry um there's a trial showing that um a simple referral into a commercial weight management program that takes the GP less than 30 seconds published in the in the Lancet this year by the Oxford group led by Paul Aviard results in spectacular effects on on weight over a year and they asked actually patients whether they found it was appropriate to be referred to by the GP they found rather effective so I think it's a it's a more measured approach there is good evidence to suggest that commercial providers have something to offer in that picture and that the health economics of it aren't necessarily unfavourable and there are effective and proven methods of referring people from primary care services into weight management provision so I think that it's worth looking at it from different angles and consider the local and the global implications of decisions you said you had no declaration to make it there's none of the research you've been involved in has been associated with any of these companies that's fine thank you I think probably for a lot of people with commercial programs they might want to go and they might have the means to go and it might be prescribed but certainly within our weight management service something like 40 percent of the patients we see have underlying disorder deating patterns who are morbid lobby certainly and usually they need psychological input prior to embarking on weight management so we've found huge success in doing quite extensive screening with our very complex patients I think for patients with possibly mild to moderate obesity then potentially the commercial might have a place if that's something they're motivated to do but I think in terms of even if think about our population in Lothian we have huge comorbidities our average comorbidity for our tier four is four comorbidities our lower tier which we had initially thought would be more preventative there's an average of three comorbidities in that group and there's usually quite a lot of mental health self-esteem depression issues which need to be tackled and need to be aided prior to weight management and I think that's the assumption we always think if we just give you weight management you'll lose weight but there's so many other things that need to be kind of dealt with from a healthcare environment as well and I do think motivated people might do well pro-met but I think as healthcare there's much more issues I'm going to bring one in but we're running really really short of time so I need every day to finish brief with our answers. I'm sure that just to pick up on that point and to say that the diabetes improvement plan was obviously published in 2014 and there's no consistent approach yet to the prevention of diabetes across Scotland and the evidence that has been submitted for your information around weight management services also shows that there's no consistency in the weight management services however there is evidence that these existing services are hugely underutilised for the secondary prevention of diabetes in the obese population so I guess there's a huge opportunity with the primary care modernisation with what we know about what is effective in terms of evidence based around tiered weight management and the recent evidence around targeted prevention of type 2 diabetes to actually raise the bar in terms of the services that we currently have to be able to achieve a consistent service level that would achieve these outcomes that relate to what GPs can refer into. To what extent do you think there's also a divide within urban and rural provision? The committee, some of the committee members went up to Avi Moore on a visit to look at the community sports hub there and part of that was actually trying to build facilities to overlap for people so putting their kids into a group but then if their white management group starting 15 minutes later so they could attend. Do you think there's work going on like that in Scotland across Scotland? I can only comment, I know that there's exactly in terms of the new builds in terms of in Midlothian for example the co-location of buildings in terms of using the new school alongside the new health centre as a hub in terms of being able to do exactly that type of intervention and I know in terms of the locality planning groups are looking at exactly that in relation to what their population needs are so that they can co-locate services and integrate to achieve maximum benefit with the resources that they have. Two people just a bit more need to be very quick on us, Brian, and then Emma. Emma, that was very quick. We're having this discussion today and there's already a Government consultation going on right now looking at that and I'm sure you'll all be feeding into the consultation but it sounds as if there is a consensus of a bit of disparity out there of how people are joined up or not and I'm hearing about allotments locally, I'm hearing about local planting of veg, engaging wanes, planting apple trees so there's stuff going on out there that obviously will be all brought together and the Fixing Dad programme which we heard about at the cross-party group for diabetes last week where a family intervention engaged in a man to lose seven stone and now he's off all these diabetes meds so there's stuff going on out there and I'm sure the consultation will feed into that but just your quick brief thoughts on the consultation and the process. The consultation is out due to be completed at the end of January and there's been consultation events to try and get more people involved with responding to it. One of the things the Scottish Diabetes Group is trying is almost we're trying to make sure that we marry up very well with the consultation and that's why in terms of the prevention subgroup we've involved a lot of obesity and public health people in that diabetes prevention group which formally as part of the Scottish Diabetes Group was just diabetes people so once the consultation is published and we see what the results are we're then going to make sure that the Diabetes Prevention Framework sits well with that. There's a significant amount of money being pledged to try and implement the results of that and I think a big thing was to make sure that diabetes prevention was kind of throughout it again from pregnancy right through so I think in terms of the timescales of that it is going to be finished at the end of January and then we're going to try and move as quickly as possible with that because there is a lot of good work being done and certainly you mentioned Miles about the rural, Argyll and Buter doing a lot of great work, Aisha and Arryn are doing great work, I've been working with them as part of that and I think we are trying to look at different issues in different areas but again trying to provide evidence based approaches to what is going to work rather than one fact size fits all. Just very briefly I suppose our response as a food coalition is that we would always emphasise focusing on the environment, making it easier for people to eat more veggie, eat less sugar, make it easier for people to change the environment and don't concentrate too much on educating individuals. We've done a lot of that and I think we now need to change the environment. Do they also just like to reinforce from our perspective very much around the obesogenic environment but also tackling the inequalities that result and lead to obesity and type 2 diabetes and making sure that from a sustainability and value perspective that the resources that are pledged within the healthier future are actually an evidence-based intervention in terms of both weight management services but also targeted intervention for prevention of diabetes? I think our board, the Food Standards Scotland board, will be making a response to the consultation and it's for them really to do that but I think just to make the point that the content of that consultation has relied quite a lot upon the evidence from Food Standards Scotland around the diet and other aspects but also that we're very pleased I think that the food environment has been single, it's a strong part of the consultation for exactly the reasons others have said and to a large extent in line with the proposals that Food Standards Scotland made to Scottish ministers back in January 2016. Okay, thanks. On the prevention, the evidence suggests that the issues are around age, gender, genes and ethnicity and weight management. Sadly, we can't do much about the ageing process, I really wish we could but there's limited impact we can do on gender, genetics and ethnicity so clearly weight management is the focus and I'm sure we all hope that out of the two strategies that are coming forward that we see significant practical actions that are going to address this because the potential impact of having a really proactive preventative agenda is massive for the health and social care budget in Scotland but also for the health and wellbeing of people. So thank you very much for your attendance today and we now move into private session.