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Select Committee on Public Accounts Ninth Report


NINTH REPORT


The Committee of Public Accounts has agreed to the following Report:

TACKLING OBESITY IN ENGLAND

INTRODUCTION AND SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS

1. Most adults in England are overweight, and one in five—around 8 million in total—is obese. The prevalence of obesity is increasing world wide, and, in England, has nearly trebled in the last 20 years. The most likely causes are an increasingly sedentary lifestyle combined with changes in eating patterns.[1]

2. Obesity causes much human suffering by contributing to chronic disease and premature mortality, and it entails a substantial cost to the NHS and to the wider economy. A Report by the Comptroller and Auditor General linked obesity to 30,000 deaths a year and a shortening of life by 9 years on average. On a conservative basis, he estimated the costs to the NHS at £0.5 billion a year in patient care and the costs to the wider economy, for example in sickness absence, at £2 billion.[2]

3. As obesity is a lifestyle issue, it is not easy to tackle and the direct influence that the Department of Health can have on the problem is limited. A joined-up approach involving Government departments and local agencies across a range of different policy areas is therefore required. A number of Government departments and agencies are working together on joint initiatives to promote healthy eating and more active lifestyles, with particular emphasis on children and young people.[3]

4. On the basis of the Report by the Comptroller and Auditor General,[4] our predecessor Committee examined witnesses from the Departments of Health, Culture, Media and Sport, Education and Employment, Environment, Transport and the Regions, and the Food Standards Agency, about improving the management of overweight and obese people within the NHS; and developing preventive strategies based on a joined-up approach across government to education, physical activity and healthy eating.

5. In the light of our predecessors' examination, the Committee draws three overall conclusions.

  • Obesity is a major public health concern which is increasing throughout the world and for which there are no easy or short-term solutions. In England, the trend is rising rapidly, with serious implications in terms of human and social costs. Unless effective action is taken, over 20 per cent of men and 25 per cent of women could be obese by 2005, with important consequences for the NHS, the economy and the people involved.

  • The causes of obesity are many, and vary region by region, by gender, by ethnic group and by socio-economic background. The help provided to obese people by the NHS is patchy and it needs to ensure that effective local strategies are put in place in each area of the country to ensure that adequate management and treatment regimes are available in the primary care setting. To provide such help, the NHS first needs to develop a more detailed understanding of the factors affecting bodyweight in different regions of England and in different population groups, and then apply the results through the health improvement programmes being developed locally.

  • Part of the answer lies in helping people avoid becoming overweight and then obese, as much as helping those who are already obese. Long-term changes in people's lifestyle depend on the environment in which we live and the cultural values imparted through education and other key influences, such as the media. Effective, integrated action is needed by those responsible for healthcare, education, transport, sport and recreation, as well as the production, retailing, labelling, and marketing of food. There is some cross-agency working, for example in the development of Local Transport Plans including local strategies for cycling and walking. But it needs to be more systematic and rigorous within national and local strategies for health improvement. The Department of Health should take a stronger lead in co-ordinating this work.

6. Our more specific conclusions and recommendations are as follows.

On improving the management of obesity within the NHS

      (i)  The Department of Health and the Health Development Agency should complete their evaluation of local health authority improvement programmes, and ensure that those for 2002-03 set targets and timetables for taking action to address the needs of overweight and obese people (paragraph 21).

      (ii)  For most people the first point of contact with medical services is general practice, where there is the potential to advise on issues of being overweight or obese. Yet many general practitioners do not see this as their role, and action taken is patchy. Health improvement programmes should set out clear expectations of the role of general practitioners, backed up by guidelines (paragraph 22).

      (iii)  Practice nurses, dieticians, health visitors and school nurses can play a valuable role in identifying patients with weight problems and in providing advice and support on weight control, but practice varies. General practices should seek to engage a wider range of health professionals in this work, including those working in the community and school settings (paragraph 23).

      (iv)  General practitioners are hampered by the lack of evidence-based evaluations and guidance on the range of interventions they might use, ranging from diets, drug therapy, surgery and innovations such as "exercise on prescription". The Department and the National Institute of Clinical Excellence should follow-up their first evaluation and guidance on the anti-obesity drug Orlistat with further evaluations of the range of possible treatments and informative guidance for general practitioners (paragraph 24).

On developing preventive strategies linking education, physical activity and healthy eating across government

      (v)  Achievement of children's entitlement to two hours of physical exercise each week requires an adequate and equitable distribution of facilities. There is, however, a considerable disparity in the opportunities for sport currently being offered to children by different schools. The Department for Education and Skills should move quickly to ensure that this entitlement is delivered in schools and to establish arrangements to monitor and publish progress towards achieving this entitlement in all schools. Departments should gather and co-ordinate the results of local authority audits of sporting and recreational activities, and work with local authorities to address gaps in provision (paragraph 47).

      (vi)  A number of initiatives have been started to improve diet and nutrition, including nutritional standards for school lunches, pilot schemes for free fruit in schools, and community pilot projects to promote fruit and vegetable eating. In line with the NHS Plan, Departments should take action to ensure that the importance of fruit in a balanced diet is promoted in schools and the Food Standards Agency should work with the food industry to improve the nutritional content of the food produced and the way it is marketed, to make it easier for all consumers to choose a more balanced diet (paragraph 48).

      (vii)  Commercial sponsorship schemes may serve to promote the consumption of foods high in fat, sugar and salt. The Department for Education and Skills should issue guidance for schools to interpret locally on how to assess offers from sponsors, and how to evaluate schemes which may for example encourage consumption of snack foods (paragraph 49).

      (viii)  The Food Standards Agency has taken a number of initiatives to promote more helpful labelling of food products. There is still room for concern, however, about the potentially harmful effects of advertising products high in sugar, salt and fat to children. The Agency should work with the food industry to develop a code of conduct with regard to the amount and nature of food advertising aimed at children (paragraph 50);

      (ix)  If national strategies on obesity are to be implemented effectively, there needs to be an emphasis on partnership working between local authorities, local health bodies, charities and the private sector. For example, within their Local Transport Plans local authorities had to produce local strategies for cycling and walking in partnership with other agencies and bodies like schools and health authorities. The Department of Health should promote such partnerships, assess and report on their progress, and disseminate emerging good practice (paragraph 51).

      (x)  The Department for Transport, Local Government and the Regions are working with the charity Sustrans to produce 8,000 miles of cycling paths by the year 2005. They have also issued guidance on the use of cycles on trains, including the provision of safe routes to stations. Noting that in some places Railtrack have established cycle tracks adjacent to operational railway lines, we expect the Department for Transport, Local Government and the Regions to encourage local authorities to explore opportunities to expand these arrangements (paragraph 52).

IMPROVING THE MANAGEMENT OF OBESITY WITHIN THE NHS

7. Obesity leads to much human suffering by contributing to chronic disease and premature mortality; it also entails a substantial cost to the NHS and to the wider economy. Obesity is most commonly defined in terms of the body mass index (weight in kilogrammes divided by height in metres squared). There are different degrees of excess weight, and associated risk, above the range considered healthy (a body mass index between 20 to 25 - Figure 1). A Report by the Comptroller and Auditor General contained the first authoritative estimates of the costs of obesity in England (Figure 2).[5]

Figure 1: Classification of different Body Mass Index values and their relationship with the risk of associated diseases
Body Mass Index
(kg/m2)
Classification
Risk of disease associated with excess weight
Less than 20Underweight Low (but increased risk of other clinical problems)
Over 20 to 25Desirable or healthy range Average
Over 25 to 30Overweight Increased
Over 30 to 35Obese (Class I) Moderate
Over 35 to 40Obese (Class II) Severe
Over 40Morbidly or severely obese (Class III) Very Severe


Source: BMI classifications from the Health Survey for England with additional data on associated risk from the World Health Organisation

Figure 2: The costs of obesity in England
The human cost
The financial cost
The big four diseases linked to obesity
18 million sick days a year £1/2 billion a year in treatment costs to the NHS Heart disease
30,000 deaths a year £2 billion a year to the economy Type 2 diabetes
Deaths linked to obesity shorten life by 9 years on average   High blood pressure
     Osteoarthritis


8. In 1980, eight per cent of women and six per cent of men were obese. By 1998, this prevalence had nearly trebled and there is no sign that this upward trend is moderating. Were it to continue, 25 per cent of women and over 20 per cent of men and would be obese by 2005 and overall costs could rise to £3.6 billion by 2010.[6]

9. The increase in obesity reflects changes in lifestyle, the increasing mechanisation of modern life, people being more sedentary, and a diet richer in energy dense foods. Obesity is a world-wide problem, particularly in more affluent societies, but no country yet has developed an effective approach to dealing with it. Although prevalence in England is still lower than in Germany and the United States, there has been a big increase which parallels the trend in the United States.[7]

10. Analysis of the distribution of obesity in England shows that:

  • obesity in the population increases with age;

  • prevalence amongst schoolchildren appears to be increasing;

  • people in lower socio-economic groups have an increased risk of obesity;

  • prevalence is higher among certain ethnic minority groups; and

  • obesity is a growing problem in all regions of England . In 1998, prevalence ranged from 18 to 22 per cent.[8]

11. Our predecessor Committee was told by the Department of Health that there were a number of causal factors and that the mix of factors varied between regions and health authorities. Cross-sectional population surveys, such as the Health Survey for England and the National Diet and Nutrition Surveys, had shown links between the prevalence of obesity and factors such as social class, income, smoking, activity level and alcohol intake. There was, however, a lack of data on the causes of regional variations and the surveys had not investigated the influence of these factors on regional differences. Longitudinal studies assessing the development of obesity from childhood to adulthood had been carried out in the United Kingdom. These had shown that it was not entirely clear why some individuals became obese and others did not.[9]

12. The Department of Health have taken a number of initiatives which address aspects of obesity and its management. These include:

  • the NHS Plan, which states the intention to tackle obesity and physical inactivity informed by advice from the Health Development Agency;

  • the National Service Framework for coronary heart disease, which focuses on local action designed to prevent coronary heart disease through, for example, promoting healthy eating and physical activity;

  • the annual Health Survey for England, which provides an important source of trend data on physical activity, eating habits, height, weight and body shape; and

  • circulation of a framework for developing local action plans to prevent and control obesity.[10]

13. The Comptroller and Auditor General recommended that the Department and health authorities should supplement these actions:

  • by commissioning further research into the effectiveness of interventions for treating overweight and obese people, and by ensuring that the results were reflected in health authority strategies;

  • by setting realistic milestones and targets in health improvement programmes for improving nutrition and diet, promoting physical activity, and arresting the rising trends in the prevalence of excess weight and obesity;

  • by developing indicators of progress in reducing health inequalities through initiatives to target the population groups most at risk;

  • by clarifying the responsibilities of general practitioners and the wider primary care team for identifying people at risk from excess weight, and by effectively disseminating guidelines for the management of overweight and obese people.[11]

14. The Department of Health assured our predecessors that they were now giving obesity higher priority. Obesity was a considerable health issue because prevalence had doubled in a very short time, and it was implicated in a series of major diseases. For example, 70 per cent of Type 2 diabetes was preventable, if it were not for the levels of people overweight and obese. There was also the significant cost. There were two approaches: clinical measures for patients when they are obese, and working across government on prevention.[12]

15. Over 80 per cent of health authorities had identified obesity as an issue in their health improvement programmes as at April 1999. The extent to which these authorities had developed and implemented relevant strategies varied considerably, but some had set quantified and measurable targets for reducing obesity and others for increasing physical activity and improving diet.[13] Under the NHS Plan, however, by April 2001 every health authority should have a strategy that included plans for dealing with overweight and obese people. The Health Development Agency had started an evaluation of these plans, so that the Department of Health could gauge what was going on and spread good practice.[14]

16. General practices are important in the management of obesity, as they are often the first port of call for those seeking help. They are where 95 per cent of people come into contact with medical services and where there is the potential to tackle issues of being overweight or obese, possibly as part of a consultation not initially related to weight problems. In addition to general practitioners, practice nurses, dieticians, health visitors and school nurses can play a valuable role in identifying patients with weight problems and in providing advice and support on weight control.[15]

17. The Comptroller and Auditor General found that the majority of general practices promoted healthy eating and physical activity through general information. Many, but not the majority, sought to identify those patients at risk from obesity. The National Service Framework for coronary heart disease includes, however, plans for general practitioners and primary care teams to identify all people at risk from cardiovascular disease, including those at risk because of their weight, and to offer them appropriate advice and treatment to reduce those risks. Most general practitioners thought they had a role in treating patients with excess weight and in referring obese people to specialists for treatment. But while 60 per cent said that promoting a healthy lifestyle was the role of the primary care team as a whole, 30 per cent saw it as a role for health authorities or the Government.[16]

18. The Comptroller and Auditor General found many examples of good practice within general practices, with the adoption of a "whole practice" approach, through advice and monitoring for obese patients, and by offering innovative programmes such as exercise on prescription. There was, however, uncertainty amongst general practitioners about the effectiveness of the different interventions at their disposal.[17]

19. The Department of Health acknowledged that they had not made enough effort to equip general practitioners with adequate resources and information to deal with the problem. Under the plans each health authority now had to have in place for tackling those who were overweight and obese, the main people who would be delivering that part of the strategy would be in primary care. The process would involve all primary care trusts, all primary care groups and through them all general practitioners in tackling these issues. It would require more general practitioners to take a pro-active approach to the management of those who were overweight or obese.[18]

20. Additional research was needed to establish what worked or what combination of factors worked, and the Department of Health needed to do more to provide guidelines and advice. The National Institute of Clinical Excellence had produced guidance on the first drug treatment and the Department had published guidelines on referrals for physical exercise. Further work was necessary, for example on the effectiveness of surgery, and the Department would be looking with the National Institute of Clinical Excellence at whether to provide more comprehensive guidelines.[19]

Conclusions

21. The Department of Health and the Health Development Agency should complete their evaluation of local health authority improvement programmes, and ensure that those for 2002-03 set targets and timetables for taking action to address the needs of overweight and obese people.

22. For most people the first point of contact with medical services is general practice, where there is the potential to advise on issues of being overweight or obese. Yet many general practitioners do not see this as their role, and action taken is patchy. Health improvement programmes should set out clear expectations of the role of general practitioners, backed up by guidelines.

23. Practice nurses, dieticians, health visitors and school nurses can play a valuable role in identifying patients with weight problems and in providing advice and support on weight control, but practice varies. General practices should seek to engage a wider range of health professionals in this work, including those working in the community and school settings.

24. General practitioners are hampered by the lack of evidence-based evaluations and guidance on the range of interventions they might use, ranging from diets, drug therapy, surgery and innovations such as "exercise on prescription". The Department and the National Institute of Clinical Excellence should follow-up their first evaluation and guidance on the anti-obesity drug Orlistat with further evaluations of the range of possible treatments and informative guidance for general practitioners.

DEVELOPING PREVENTIVE STRATEGIES LINKING HIGHER EDUCATION, PHYSICAL ACTIVITY AND HEALTHY EATING ACROSS GOVERNMENT

25. The Comptroller and Auditor General found a substantial amount of cross-departmental work in areas central to addressing the rising prevalence of obesity - principally education, physical activity and diet. Much of this activity was targeted at schoolchildren, and both promoted the adoption of healthy lifestyles in childhood and subsequently throughout adult life, as well as addressing a section of the population in which obesity was becoming increasingly prevalent.[20] It includes:

  • the provision of education on the risks of being overweight, and the benefits of a healthy diet and physically active lifestyle;

  • the improvement of nutritional standards in schools, including through initiatives to increase levels of fruit and vegetables consumed;

  • equipping children with important skills such as cooking and the technical skills to enjoy sport and physical exercise;

  • encouraging school sport, including the provision of improved facilities; and

  • encouraging and providing the means for children to travel safely to school on foot or by bicycle.[21]

26. The Comptroller and Auditor General recommended that the Department of Health reinforce existing joint working by establishing a cross-departmental advisory group to co-ordinate all research on obesity and measures to prevent it.[22]

27. The witnesses confirmed that a considerable amount of cross-governmental work was going on in these areas, particularly in sport. Specific examples included the New Opportunities Fund, Round 3 for PE, and Sport in Schools. The Departments of Health and Culture Media and Sport were also planning to appoint a joint departmental adviser. Those arrangements were intended to ensure that, whatever machinery of government changes there were and whatever the boundaries between departments, there was a proper health element within the overall sporting strategy, with no cracks between them.[23]

28. Against this background, our predecessors examined in particular issues surrounding physical activity and diet.

Physical Activity

29. The Comptroller and Auditor General recommended that the Department of Health should lead the development of a new cross-Government strategy to promote the health benefits of physical activity. This initiative should include work to develop and support alternative approaches for groups where there were specific barriers to physical activity, such as those imposed by poverty, culture or fears about personal safety. He also recommended:

  • continued encouragement to adopt local targets for cycling and walking;

  • joint work between central government and local agencies to develop targets to increase the number of school journeys undertaken by bicycle, on foot or on public transport;

  • consideration of targets to increase participation in sport and physically active leisure activities, building on the strategic target set by the Department for Culture Media and Sport to raise significantly, year on year, the average time spent on sport and physical activity by those aged 5 to 16;

  • continued encouragement to schools to achieve the stated aspiration of at least two hours physical activity a week for all pupils.[24]

30. The Government has established an inter-ministerial group specifically on physical activity for children. The Department of Health told our predecessors that they were waiting for information from that group before taking a definitive decision on providing a strategy for all age groups.[25]

31. Every child between the ages of 5 and 16 has a statutory entitlement to physical education. The Government had introduced into the curriculum personal, social and health education. It had also made a commitment that every child would have an entitlement to two hours of physical exercise a week at school. There were pressures on curriculum time, and the target covered time spent both in the curriculum and outside. Over the past five years, there had been a reduction in physical education within the curriculum, but an increase in exercise taken outside it: in 1994, 74 per cent of children had been engaged in after-school exercise and this had risen to 79 per cent in 1999. At the same time, participation in lunchtime exercise had also risen by 5 per cent. There was, however, a mixed pattern around the country in terms of making sure all children had opportunities to take part in sport after school. For example, there was a wide range in the number of children able to swim 25 metres at the end of Key Stage 2, and some of that diversity depended upon where they were going to school. In particular, some of the poorer neighbourhoods, because they were under such pressure, were not providing the same opportunities.[26]

32. The Department for Education and Employment were therefore working with other departments on how best to meet every child's entitlement to two hours physical activity a week. There had been a substantial investment in initiatives like schools sport co-ordinators, where they were spending £120 million and expected to have 1000 in place by 2004. They had also invested in Champions, where well known sports people went to schools to encourage people to participate and raise the level of participation up to two hours a week.[27]

33. The Department for Culture, Media and Sport had deliberately focussed additional money and attention on opportunities for sport and exercise for young people in schools, not least because in the school environment they could have most control over how children spent their time. However, the Government's sports policy went much wider and dealt with the enhancement of sporting facilities for use by all ages including Sports Council and Lottery funding. They were investing, with the Department for Education and Employment in a very substantial programme of multi-purpose arts and sports facilities across the country. There was also a joined-up initiative to increase the amount of time people spent travelling to school by foot or bicycle, which had included guidance on school travel entitled A Safer Journey to School. The Department for Education and Employment said that in two or three year's time, they hoped to have improved their performance quite considerably.[28]

34. Our predecessor Committee was concerned that the sale of school playing fields and pressure on the provision of recreational facilities by local authorities would hamper the planned increase in physical exercise in schools. The Department for Education and Employment had not collected data on the number of school playing fields, although local authority Asset Management Plans would in future provide a clearer picture. Nor did they have data centrally on the disposal of playing fields before 1998, although they estimated that before 1998 disposals were running at up to about 40 fields a month. However, Section 77 of the School Standards and Framework Act 1998 was intended to protect school playing fields. From October 1998, local authorities or governing bodies of maintained schools had to obtain the Secretary of State's consent to disposal or change of use. Since then, 81 applications to dispose of sports pitches (about three a month) had been approved.[29]

35. The Department for Education and Employment expected local authorities and schools to recognise the importance of providing playing fields and opportunities for young people to participate in sport, and to fill any gaps that existed at local level. All local authorities had agreed to produce local sports strategies, and in the Government's Plan for Sport, there were propositions for each authority to audit the sporting and recreational facilities in their areas. Through the National Lottery and the New Opportunities Fund, the Department for Education and Employment and the Department for Culture, Media and Sport were providing a very substantial additional investment, which could be used for sports and arts facilities of all sorts, including playing fields. Since 1995, £1.2 billion had been spent, coupled with the new Sport in Schools initiative. In the view of the Department for Culture, Media and Sport, the provision of sporting activities throughout the country was undergoing a transformation as a result of these initiatives, encouraged by and normally in partnership with local government.[30]

36. In addition, the Department of the Environment, Transport and the Regions were consulting on draft planning policy guidance on sport, open space and recreation. This guidance would set out a new systematic approach for local authorities in establishing provision and need for open space and recreational facilities. The starting point was an assessment of need in each area, having regard to the standards of provision recommended by sports governing bodies, the National Playing Fields Association and other interest groups. Local authorities would then set standards of provision to reflect local circumstances and make provision in their local development plans, and these would be the primary consideration in considering planning applications.[31]

37. A key aspect of the Department of the Environment, Transport and the Regions' work related to strategies for encouraging walking and cycling across all ages. Within their Local Transport Plans local authorities had to produce local cycling strategies and local walking strategies in partnership with other agencies and bodies like schools, health authorities and so on. There had been a history of partnership working and the Department had collaborated in the publication of a document called Making T.H.E Links to try to emphasise the links between transport, health and education. Local authorities were required to report on progress and this would give the Department more information.[32]

38. As regards cycling, the Department of the Environment, Transport and the Regions told our predecessors they had doubled the resources in 2001-02 and provided a stable funding framework for the next five years in the local transport plan settlement. They had asked local authorities to consider giving cyclists and pedestrians priority in their road planning, and had given them powers in the Transport Act to designate home zones and quiet lanes. They had probably underestimated, however, the amount of investment needed in cycle paths, in separate cycle lanes on highways and in traffic calming measures, which were important because of high fatality rates among cyclists, especially young children. As a result, they would probably not meet their target of doubling the level of cycling trips by 2002, which was a key part of the national cycling strategy.[33]

39. In addition, the Department of the Environment, Transport and the Regions were working with the charity, Sustrans (Sustainable Transport), to produce 8,000 miles of cycling paths by the year 2005. They had also produced guidance on the use of cycles on trains, including the provision of safe routes to the stations. In some places Railtrack had established cycle tracks adjacent to operational railway lines, with secure separation between cyclists and the railway, and it was open to local authorities to explore such opportunities with Railtrack.[34]

Diet

40. On issues relating to diet, the Comptroller and Auditor General recommended:

high priority be given to implementing the initiatives on nutrition listed in the NHS Plan, working with the food industry, including manufacturers and caterers, to improve the balance of diet;

  • work to establish ways of monitoring the overall impact of initiatives to improve the nutritional quality of food provided in schools;

  • strengthened guidance to schools on commercial sponsorship to ensure that they take full account of the potential disadvantages of participating in schemes that might run counter to key messages on healthy eating.[35]

41. He noted in particular that consumption of fruit and vegetables by young people between the ages of 4 and 18 was well below World Health Organisation recommendations. In the NHS Plan, the Department of Health had announced a series of proposals to improve diet and nutrition by 2004. From April 2001, Regulations introduced nutritional standards for school lunches for registered pupils in all schools maintained by local education authorities in England. The Regulations set out compulsory minimum standards, including fruit and vegetables. Alongside those standards, the Department for Education and Employment had introduced a requirement for schools to provide school lunches where parents wanted them.[36]

42. In addition, the Department of Health had been piloting a free-fruit-in-schools initiative in over 500 schools. These pilots were looking at "gate to hand" issues in 33 schools in Leicester, Hackney and Southwark & Lewisham and "farm to gate" issues in 510 schools across England. Evaluations of these pilot projects would be available in the summer and would be disseminated widely. Early results indicated that the scheme was being extremely well received. Further pilots would focus on "hand to mouth" issues. There were also several community initiatives to promote fruit and vegetable eating. There was a striking difference in the consumption of fruit and vegetables across the regions. For example, in the North East region average fruit consumption was 827 grams per person per week, whilst in the South East it was 1,252 grams. A number of factors could contribute, such as access to shops, availability of produce, and price. Pilot projects were looking at the feasibility of increasing consumption by a number of interventions.[37]

43. A key issue in giving people information and choice about what they eat is the way food is marketed and labelled. The Food Standards Agency have a variety of initiatives designed to promote, on a voluntary basis, more helpful labelling for customers and to ensure that advertising conveys a proper picture of the results derived from eating the product. The Agency were seeking to persuade the food industry of the real market benefits and public demand for products that were more healthy because they had less fat and less salt. For example, there was evidence from Scandinavia that products could be changed from high to low in saturated fats, whilst retaining their appeal to customers. And they had been in discussion with the catering industry about the desirability of offering lighter options.[38]

44. One concern was that much advertising aimed at children on Saturday mornings appeared to relate to foods high in fat, in sugar and in salt. Another was that schools were getting into sponsorship deals, for example with Walker's crisps, which could run counter to the emphasis on healthy eating. Both the Agency and the Department for Education and Employment emphasised that the individual foods were not harmful, and it was not a question of banning particular foods or advertising. It was the balance of diet, both in childhood and later, that mattered.[39]

45. The Agency were seeking a voluntary agreement with the food industry on advertising. The Department were trying to educate children on the choices available and the implications of a badly balanced diet for their health. They were also trying to educate parents at a much earlier stage, through initiatives such as the Sure Start programme, to understand the importance of these choices. As regards sponsorship in schools, the Department believed it was for individual governors and schools to decide whether or not they were content for particular products to be sold to their children or content to accept particular forms of sponsorship.[40]

46. Finally, our predecessors asked about the barriers to participation in healthy living and healthy lifestyles, including poverty and personal safety. The Department for Education and Employment had targeted education initiatives on providing more resources in disadvantaged areas, including education action zones, excellence in cities, and the cooking for kids schemes. There was also a concern that some of the poorer neighbourhoods were not providing the same opportunities for sport after school. Through the Sports Council, the Department for Culture, Media and Sport were monitoring the use of sports facilities by those who in the past considered themselves shut out or discouraged, including women's and ethnic minority groups and the poorer members of society. The Department of the Environment, Transport and the Regions had asked local authorities to take account of personal safety issues like good lighting in local walking and cycling strategies.[41]

Conclusions

47. Achievement of children's entitlement to two hours of physical exercise each week requires an adequate and equitable distribution of facilities. There is, however, a considerable disparity in the opportunities for sport currently being offered to children by different schools. The Department for Education and Skills should move quickly to ensure that this entitlement is delivered in schools and to establish arrangements to monitor and publish progress towards achieving this entitlement in all schools. Departments should gather and co-ordinate the results of local authority audits of sporting and recreational activities, and work with local authorities to address gaps in provision.

48. A number of initiatives have been started to improve diet and nutrition, including nutritional standards for school lunches, pilot schemes for free fruit in schools, and community pilot projects to promote fruit and vegetable eating. In line with the NHS Plan, Departments should take action to ensure that the importance of fruit in a balanced diet is promoted in schools and the Food Standards Agency should work with the food industry to improve the nutritional content of the food produced and the way it is marketed, to make it easier for all consumers to choose a more balanced diet.

49. Commercial sponsorship schemes may serve to promote the consumption of foods high in fat, sugar and salt. The Department for Education and Skills should issue guidance for schools to interpret locally on how to assess offers from sponsors, and how to evaluate schemes which may for example encourage consumption of snack foods.

50. The Food Standards Agency has taken a number of initiatives to promote more helpful labelling of food products. There is still room for concern, however, about the potentially harmful effects of advertising products high in sugar, salt and fat to children. The Agency should work with the food industry to develop a code of conduct with regard to the amount and nature of food advertising aimed at children.

51. If national strategies on obesity are to be implemented effectively, there needs to be an emphasis on partnership working between local authorities, local health bodies, charities and the private sector. For example, within their Local Transport Plans local authorities had to produce local strategies for cycling and walking in partnership with other agencies and bodies like schools and health authorities. The Department of Health should promote such partnerships, assess and report on their progress, and disseminate emerging good practice.

52. The Department for Transport, Local Government and the Regions are working with the charity Sustrans to produce 8,000 miles of cycling paths by the year 2005. They have also issued guidance on the use of cycles on trains, including the provision of safe routes to stations. Noting that in some places Railtrack have established cycle tracks adjacent to operational railway lines, we expect the Department for Transport, Local Government and the Regions to encourage local authorities to explore opportunities to expand these arrangements.


1   C&AG's Report (HC 220, Session 2000-2001), paras 1- 2 Back

2   ibid, para 3 and Figure 1 Back

3   ibid, paras 4-8 Back

4   C&AG's Report Back

5   C&AG's Report, para 3 and Figure 1 Back

6   C&AG's Report, paras 2.5-2.6, 2.31, and Appendix 3 Back

7   Qs 1-3 and 158-159 Back

8   C&AG's Report, para 2.9 Back

9   Qs 152-157 and Evidence, Appendix 3, p27 Back

10   C&AG's Report, para 3.3 Back

11   C&AG's Report, para 17 Back

12   Qs 15, 138-139 Back

13   C&AG's Report, paras 3.7-3.14 Back

14   Qs 4-5, 142-143 Back

15   C&AG's Report, para 3.15 Back

16   ibid, paras 3.21-3.28 Back

17   ibid, paras 3.29-3.57 Back

18   Qs 6, 21-26, 86-93, 140-141 Back

19   Qs 6, 86-93, 140-141 Back

20   C&AG's Report, paras 18 and 4.32 Back

21   ibid, paras 4.33-4.62 Back

22   ibid, para 20  Back

23   Qs 36-43 Back

24   C&AG's Report, para 20 Back

25   Q7 Back

26   Qs 9-10, 79-84 Back

27   Q9 Back

28   C&AG's Report, para 4.44 and Qs 7, 9, 44, 81-83  Back

29   Qs 67-69, 164-165, and Evidence, Appendix 4, p28 Back

30   Qs 70-76, 148 Back

31   Qs 71-72, 167 Back

32   Qs 7, 11-12 Back

33   Qs 51-55 Back

34   Qs 56-63 and Evidence, Appendix 1, p25 Back

35   C&AG's Report, para 20 Back

36   ibid, paras 4.31 and 4.57; Qs 33, 168-173, and Evidence, Appendix 4, pp 28-29 Back

37   Qs 64-66, 146-147 and Evidence, Appendix 3, pp 26-27 Back

38   Qs 13-14, 32, 50, 103-120 Back

39   Qs 31-33, 120-129, 133-135 Back

40   Qs 31-33, 120-129, 133-135 Back

41   Qs 8, 84-85, 144 Back


 
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