PHB 18

Bil Iechyd y Cyhoedd (Cymru)

Public Health (Wales) Bill

Ymateb gan: Diabetes UK Cymru

Response from: Diabetes UK Cymru


Diabetes UK Cymru welcomes the opportunity to provide evidence to the Committee and asks that the evidence presented here is considered in light of improving and protecting public health in Wales. Whilst we praise the work already carried out on the Bill, we urge the National Assembly to go further in its actions to reflect the current priority areas of health in Wales. Appreciating that that the remit of the Assembly does not extend to some of the activity and recommendations below, we have included it as useful information and context.


Diabetes in Wales: Current situation


183,000 people are living with diabetes in Wales. A further 70,000 people are estimated to have Type 2 diabetes but are undiagnosed. Another 540,000 people in Wales are at high risk of developing Type 2 diabetes and that number is rising dramatically every year. If diabetes identification and diagnosis improves, the figure will exceed 300,000 by 2025. Type 2 diabetes usually appears in people over the age of 40, though in South Asian people, who are at greater risk, it often appears from the age of 25. It is also increasingly becoming more common in children, adolescents and young people of all ethnicities. Type 2 diabetes accounts for between 85 and 95 per cent of all people with diabetes.


Diabetes accounts for around 10% of the annual NHS Wales budget. This is approximately £500m a year. 80% of this expenditure is on managing complications which could be prevented. The total cost associated with diabetes in the UK is estimated at £23.7 billion. These costs are predicted to rise to £39.8 billion by 2035-36.


The main risk factors for Type 2 diabetes are: family history, age, ethnic background, being overweight, obese or having a large waist circumference. Type 2 diabetes is often treated with lifestyle factors initially – following a healthy balanced diet, getting regular physical activity and losing excess weight. However it is a progressive condition, and it is likely that medication will be required, which may include insulin.


Diabetes: An overview


Whilst Type 1 diabetes cannot be prevented, we know that the majority of the increase in prevalence is due to Type 2 diabetes, of which some of the risk factors are modifiable.

Obesity is the most significant modifiable risk factor for developing Type 2 diabetes. The main modifiable risk factors of Type 2 diabetes are increased waist circumference and being overweight/obese.


If waist circumference and being overweight/obese is reduced in the general population, a significant percentage of Type 2 diabetes could be prevented. To do this, there is an urgent need to create greater awareness of the modifiable risk factors which contribute to an individual developing the condition; empower people to make informed decisions; and develop an environment which is supportive of healthy living and conducive to behaviour change. This will require that action is taken in a number of areas, including efforts by individuals; government; the food and drinks industry; employers and the voluntary sector. In recent years, there have been welcome initiatives by the UK/Welsh Governments and industry to promote healthier living. Diabetes UK want to build on this work to ensure that meaningful, and sustainable, health benefits are delivered to the entire population.

In taking action, it is essential that decision-makers are cognisant that no one intervention designed to curb obesity, when enacted alone, will result in the impact required to significantly reduce the prevalence of Type 2 diabetes.

Diabetes UK Cymru believes that the Public Health Wales Bill in its current form represents a missed opportunity and it is a great omission that the Bill does not include any action to reduce overweight and obesity rates in Wales. As above, we acknowledge that the Assembly’s remit to take action in this instance is restricted either at Westminster or at European level. Nevertheless, there are important actions that can be taken at a Wales level that will help reduce the number of people in Wales who are overweight, obese and/or at a high risk of Type 2 diabetes.

Furthermore this omission is at odds with the key principles of the Our Healthy Future plan which aims to place a greater emphasis on prevention of long term conditions, placing the health and wellbeing of children at its heart and importance of early identification. To provide a consistent approach between Government policy and strategy, we recommend that the following actions are included within the Bill to deliver on these ambitions and truly seek to improve the public health of the Welsh population.

Key recommendations: Improving the obesogenic environment

1.   Labelling and transparency;


Food labelling in out of home sector:We think it’s important that everyone take responsibility for their own health. However in order to do this consumers must be provided with the information they need to make an informed healthy decision about the food they are buying. Whilst the ability to make front-of-pack nutritional labelling mandatory is currently restricted by the EU, we believe that the Welsh Government could take action to increase the level of transparency in the out of home sector.  This is increasingly important as eating outside of the home is no longer a treat with around 18% of meals now eaten outside of the home[1]. However, only a minority of food outlets provide nutritional information at the point of choice. A few also provide this information on their website. We recommend that the Bill makes it mandatory for out of home outlets serving food and drink to put calorie labelling information on their menus, at the point of choice in order to equip consumers with information about that is in the food they are eating. Evidence from New York, where mandatory calorie labelling was introduced in 2008 shows that this can reduce overall calorie purchase without a noticeable impact on company revenue.[2],[3] Further evidence shows that this can encourage companies to reformulate their products. [4] We would also like to see carbohydrate labelling to enable people living with diabetes to make informed choices.

An excellent example of influencing the out of home sector in Wales is the introduction of the Food Hygiene Rating system.



2.   Making products healthier;


Portion size review: We know that portion sizes are getting bigger.[5] Research also shows that when presented with a large portion people are more likely to eat more.[6] In addition to this, portion size guidance from the UK Government is now over 20 years out of date. Therefore the food industry has been left to manufacture portion sizes with no guidance. We therefore recommend that the Welsh Government commission a review of food portion sizes in Wales and commit to reviewing this bi-annually. This should inform two pieces of work, a basis for a public education campaign on correct portion sizes and providing advice to food outlets in Wales on appropriate food portion sizes.


Sugar Reformulation Programme (Public Health England):Diabetes UK supports Public Health England’s sugar reformulation programme. We participated in target setting for sweet and chocolate confectionary and other sugary foods. We additionally call on Public Health England to include salt, fat and calorie reduction to the programme as soon as possible, as we know the public are eating too much sugar, saturated fat and salt than is recommended.


3.   Encouraging healthy choices in the retail environment;


Government food buying standards:Assembly and Local Authority buildings should look to adopt the Government Food Buying Standards as a way to ensure these locations serve food that promotes health as well as addressing other key challenges such as sustainability and waste.

Hospitals setting leading examples:The Bill already makes significant provisions to make hospitals smoke free zones, making these environments leading examples of smoke free workplaces and centres to promote public health. We would welcome discussion around introducing a sugary drinks tax as is currently being developed by NHS England in hospitals in Wales. The aim of this is to reduce sales of a product that has no nutritional benefit other than energy consumption. We’d also welcome a commitment for high fat, salt and sugar (HFSS) food promotion to be in the first instance, redressed to be less than 50% of promotions but eventually stopped within hospital settings as well as new contracts with hospital caterers, or outlets on site being negotiated to promote healthier choices. As places of wellness and health promotion, these locations should be providing food and promoting a diet that aligns with the Eat Well guide.

4.   Strengthening marketing restrictions to children;


Advertising: Diabetes UK calls for the UK Government to restrict marketing of high fat, salt and sugar (HFSS) products to children before 9pm on TV, to introduce further restrictions for non-broadcast.


5.   Incentivising healthy choices and fiscal regulation;


Soft Drinks Industry Levy (SDIL):Diabetes UK supports the Government’s proposed Soft Drinks Industry Levy (SDIL). The Levy is an important step in reducing the nation’s sugar intake, particularly children’s intake as well as encourage the drinks industry to reformulate their products to reduce the sugar content. We know that people are eating too much sugar which can lead to being overweight or obese, a risk factor for Type 2 diabetes.


It is also important to note that any SDIL is introduced in a way that does not negatively impact on people living with Type 1 or Type 2 diabetes and their families who rely on high sugar products to treat low blood glucose levels. Diabetes UK conducted a series of interviews with people living with diabetes to inform our response to the public consultation on this Levy. We asked the Government to monitor the impact of price changes and reformulation as well as explore ways that products can be added to the NHS Drugs Tariff to protect those using these products as treatments from having to pay extra.


6.   Increasing physical activity levels;


Benefits: While we all know that being active is good for our health, both physical and emotional, it’s important to be aware that getting active and staying active can help manage Type 1 diabetes, Type 2 diabetes or help reduce the risk of Type 2 diabetes. UK Chief Medical Officers’ Guidelines state that physical activity can reduce your chance of Type 2 diabetes by up to 40 per cent as well as reduce risk of cardiovascular disease, cancer, joint and back pain, depression and dementia. 


Local facilities: An important element of increasing physical activity levels is that people have access to facilities in their local area, including safe places to walk and cycle, parks and other recreational facilities. Diabetes UK Cymru has been concerned by the recent closure of popular leisure centres across Wales and have noted much debate about this in recent plenary sessions. We reiterate the calls made by Assembly Members to ensure that sufficient resource is allocated to Local Authorities for this purpose and that where local authorities have received this allocation, all efforts should be made by both the Local Authority and Welsh Government to ensure that where appropriate, such facilities remain open to local communities.  

Health Impact Assessments: Because of the omission of overweight and obesity prevention in the Bill, it is unclear if the proposals for health impact assessments (HIA) will include consideration on the weight of the nation in their assessments. Diabetes UK Cymru believe that it is important to specify that impact on weight would fall under physical health in this context and therefore should be considered in all health impact assessments. This will be particularly relevant for decisions of local planning, decisions taken in contracts, for example in hospitals or schools. All should seek to provide the service users with access to healthy, affordable food that aligns with the diet recommended in the Eat Well Guide and to provide a safe, affordable environment to be physically active.

It also remains unclear whether the recommendations made by the HIA will be binding, or advisory. We recommend that in order to best protect public health, the recommendations should be binding.

7.   Promoting healthy living.

Public awareness campaigns:Public awareness campaigns in public health have been shown to work, particularly in the field of tobacco control. We would like to see the Welsh Government commit to a public health awareness campaign from 2017 to promote the importance of a healthy lifestyle.

Equipping local authorities with powers to design healthy food environments: We would welcome a consultation between the Welsh Government and Local Authorities to establish what policy levers they are lacking, or feel would be beneficial to promote healthy environments at a local level in order to promote public health in their local setting, within the context of obesity and physical activity.

Public Health Wales & the Inverse Care Law: Following discussions with the Cabinet Secretary for Health, Wellbeing & Sport, Public Health Wales recently initiated a new cross-charity collaboration with the British Heart Foundation and the Stroke Association called the CVD Alliance. It is hoped that the Alliance will better harness third sector expertise for addressing cardiovascular and diabetes challenges facing NHS Wales.


The first project for the CVD Alliance is the Inverse Care Law initiative. This is a collaboration and partnership with NHS Wales on a new pan-Wales three year project with £1m budget to deliver cardiovascular and diabetes risk assessment in primary care and community venues in all health boards across Wales. In 2015, Aneurin Bevan and Cwm Taf University Health Boards started to deliver population-scale risk assessment in GP clinics and community venues in local communities focussing on preventative practice and modifiable behaviour change. Brief interventions and motivational interviewing techniques are used, supporting people to identify personal goals where improvements can be made to reduce their risk. Results are electronically shared with GP systems using customised software, with protocols and pathways in place to enable direct referrals. The initiative is being adopted by two further health boards in Wales in 2017 with all health boards joining the programme in 2018.


8.   Further information: Welsh Government and the Together for Health: A Diabetes Delivery Plan


Welsh Government has recently launched the Together for Health: A Diabetes Delivery Plan 2016 – 2020. It commits to the following key service actions to assist in the prevention of diabetes in Wales:


1.   Public Health Wales to lead a comprehensive prevention programme to minimise population-level risk of disease, including diabetes.


2.   Public Health Wales to promote a holistic approach to motivational interviewing across providers, under the umbrella of Making Every Contact Count.


3.   Health boards to continue to roll out the cardiovascular disease risk assessment programme to support those at high risk of developing diabetes.


4.   Health boards to implement the Wales Obesity Pathway at all levels, for both adults and children.


5.   Health boards to support community pharmacy campaigns to encourage people to consider the risk of diabetes and to undertake testing where appropriate.


6.   Health boards to ensure women with previous gestational diabetes receive appropriate advice and support on lifestyle change and, where necessary, weight reduction.


7.   Health boards to continue to work with the third sector to provide high quality, reliable advice on reducing the risks of diabetes


8.   The Diabetes Implementation Group to develop resources to support primary care, community care and those in social care settings on preventing type 2 diabetes.


9.   Progress on tackling risk factors for diabetes will be monitored and reported through the Public Health Outcomes Framework.



[1] Public Health England (2016) Childhood obesity plan: PHE’s role in implementation. Available at Accessed 14/12/16

[2] Dumanovsky et al (2011) Changes in energy content of lunchtime purchases from fast food restaurants after introduction of calorie labelling: cross sectional customer surveys. BMJ.  doi: 10.1136/bmj.d4464

[3] Bollinger. B, Leslie. P, Sorensen.A (2010) Calorie posting in chain restaurants. NBER working paper series

[4] Product Reformulation, Centre for Science in the Public Interest (September 2012)

[5] British Heart Foundation (2015) Portion Distortion: How much are we really eating? Available at file:///C:/Users/amysm/Downloads/bhf_portion_distortion_oct2013%20(1).pdf Accessed 14/12/16

[6] Faulkner GP, Pourshahidi LK, Wallace JM, Kerr MA, McCrorie TA, Livingstone MB. (2012) ‘Serving size guidance for consumers: is it effective?’ Proceedings of the Nutrition Society. Nov;71(4):610-21. Available at: