Oral evidence

Taken before the Health Committee on Thursday 26 June 2003

Members present:

Mr David Hinchliffe, in the Chair
John Austin
Andy Burnham
Mr Simon Burns
Mr Paul Burstow
Jim Dowd
Julia Drown
Dr Doug Naysmith
Dr Richard Taylor

__________

Memoranda submitted by the Faculty of Public Health Medicine

of the Royal College of Physicians of the United Kingdom

and Cancer Research UK

Examination of Witnesses

Witnesses: PROFESSOR SIR GEORGE ALBERTI, President, International Diabetes Federation, DR GEOF RAYNER, Chair, UK Public Health Association, PROFESSOR JULIAN PETO, Institute of Cancer Research, PROFESSOR HUBERT LACEY, Royal College of Psychiatrists, PROFESSOR JANE WARDLE, Health Behaviour Unit, University College London, and DR TIME BARRETT, Consultant Paediatric Endocrinologist, Birmingham Children's Hospital, examined.

Chairman: Colleagues, could I welcome you to this session of the Committee and welcome our witnesses. Before we begin, could I welcome Paul Burstow, who is making his debut at the Committee today: we are very pleased to see you here. I think it is appropriate to pay tribute to your predecessor Sandra Gidley, who was a first-class member of the Committee who was responsible for initiating certain inquiries. We are very grateful for her efforts. I am sure you will follow her lead in many ways. We are very pleased to see you here.

Dr Taylor: May I add my comments. I appreciate her work as a pharmacist. I think in government as a whole there is a lack of professionals in positions of authority.

Chairman: Apart from lawyers, of course!

John Austin: And teachers.

Jim Dowd: Lawyers, lecturers and social workers.

Q169  Chairman: Thank you. Could I ask the witnesses briefly to introduce themselves to the Committee.

Dr Barrett: I am Dr Timothy Barrett. I am a paediatrician at Birmingham Children's Hospital, responsible for a clinic of about 350 children with diabetes and I am a senior lecturer in the University of Birmingham doing research into diabetes and genetics.

Dr Rayner: My name is Geof Rayner. I am Chair of the UK Public Health Association but also representing the Faculty of Public Health Royal College of Physicians.

Professor Peto: I am Julian Peto, Head of Epidemiology at the Institute of Cancer Research and I also have a part-time job at the Ministry of Hygiene and Tropical Medicine.

Professor Lacey: My name is Hubert Lacey. I am Professor of Psychiatry at St George's. I run the St George's Eating Disorder Service. It is not only the largest in the UK but probably the largest in the English speaking world. It deals mainly with anorexia and bulimia nervosa - with a small offshoot into obesity, because of lack of funding.

Professor Wardle: I am Jane Wardle. I am Professor of Clinical Psychology in the Department of Epidemiology and Public Health at University College and I am Director of Cancer Research UK's Health Behaviour Unit there. As part of my role there, I do research into obesity, including beginning to run some treatment studies for paediatric obesity.

Professor Sir George Alberti: I am George Alberti. I am emeritus Professor of Medicine, Newcastle, and Senior Research Fellow at Imperial College. I am also the Trolley Tsar - sorry, the National Director for Emergencies Access, and President of the International Diabetes Federation. I have worked in diabetes for the last several decades, and also ran a very unsuccessful obesity clinic for many years!

Q170  Chairman: Obviously, from the evidence we have had from a range of witnesses, the obesity problem has been something that has been emerging for some considerable time. Why has it taken so long for us to wake up politically to address the issue?

Professor Sir George Alberti: I suppose because it has insidiously crept in. My own experience, talking to an ex-minister while she was a minister, is that she did not want to know. She did not want to tell the public a very simple thing: "Eat less." That did not seem to be a great vote-catcher. Medically I think we have been enormously unsuccessful at altering people's habits and it has just sort of crept in. It is only as we have begun to see epidemics of the consequential diseases that it has really begun to grab hold of people.

Q171  Chairman: You are saying that it is a politically difficult issue for governments to address.

Professor Sir George Alberti: Yes.

Q172  Chairman: For the reasons you gave.

Professor Sir George Alberti: Yes.

Professor Lacey: I think there is another clinical reason, Chairman, which is that as a group clinically they are not liked: people do not find them attractive to work with. They are often subject to stigma, not only from the general population but also, to a degree, from professionals too. I would agree with Professor Alberti, the other reason professionally is that they are very difficult to respond to treatment.

Dr Rayner: I would add that I think it is society looking at itself, really. We are talking about basically the medical consequences. Obesity and super-obesity, but overweight as well, these are consequences of changes in society. We are actually very poor at recognising the powerful cultural change that has happened in this country. And it is happening worldwide. We are not talking just about a UK epidemic. All the reasons that you have been presented with, from changes in dietary patterns to the reduction of physical activity, these are big changes in society. We need big explanations. When you have big explanations which you cannot pinpoint exactly then it is very difficult to see what you can do about it. What do we do about it? If there was a magic pill or bullet or something, but there is not, so we actually have to face up to these big cultural changes and we do not have solutions. We call it a lifestyle illness or lifestyle pattern which explains it, but actually it is our society changing. How do we deal with that?

Professor Peto: In relation to cancer, cancers tend to be studied individually because the causes of different cancers tend to be different. Although it has been known for a long time that breast cancer and endometrial cancer are associated with obesity, it was not until quite recently, when very large American cohort studies, particularly studies of non-smokers, were done, that it was realised what a large contribution overall cancer mortality was making to the effects of obesity, that a whole range of cancers are actually affected. The risks are not huge, and they only emerge in very large studies, but in this particular one, a very large cohort study, it has emerged quite suddenly that among non-smokers obesity was by far the largest avoidable cause of cancer. Heart disease and diabetes obviously have been recognised for a long time, but the realisation that it was a major contribution to cancer has really only emerged quite recently.

Q173  Chairman: We will obviously talk about the public health sector later on and public health steps that might be taken, but, looking back at how the trends have emerged over the years, what ideally might have happened, say, some years ago that could have prevented us being where we are now? What should have happened and at what point? Who should have been responsible for doing something?

Professor Sir George Alberti: I think a massive public education programme - there is one, it has got through to a few people, but I think it has never been emphasised adequately - and tackling the food industry head on.

Chairman: We will get into the specifics later on, so perhaps we should not pursue that further.

Q174  Julia Drown: I want to ask Sir George Alberti about diabetes in particular. Obviously we are seeing huge increases in the number of people with diabetes. Could you briefly outline to us what the evidence is on the role of weight gain in diabetes and whether that is disputed or generally accepted.

Professor Sir George Alberti: Number 1, it is generally accepted. We have seen worldwide, in a number of societies, a parallel increase in overweight, obesity and diabetes. Just as an example, I have studied diabetes and obesity in East Africa - as one does - and in the rural areas there were less than one per cent of people over the age of 15 with diabetes and less than two per cent overweight. Move into the city, and we are up to 20 per cent/25 per cent overweight and 8 per cent diabetes: an eight-fold increase. Some of the populations who have become wealthy very rapidly, like the American Indians in Arizona, where they were given the worst bit of land, as you know, oil wells were found, so they became very wealthy, stopped working, became very overweight, and half the adults in that population have diabetes. It is the same on the South Sea island of Nauru, which was basically a large coral reef of bird droppings, which was mined as fertiliser. Overnight, in the fifties, it became the second richest country in the world and the people are very overweight, life expectancy is falling, and diabetes is the main accompaniment of that. You cannot separate it completely from physical inactivity. Each of them, independently, has a two-, three-, four-fold increase in risk. There was a very good prospective study of nurses in the United States which showed that, if your body mass index was 22 (that is, nice and skinny like I am) and you compared yourself with those people with a body mass index of 35 (which is pretty obese), there was a 92-fold increase in risk of diabetes. I think it is very, very solid. With the additional impact of physical activity, which is probably equally important - or physical inactivity. Society is pushing both physical inactivity and overeating as well, or eating the wrong things.

Q175  Dr Taylor: Could we go back to the links between obesity and cancer, really to Professor Peto - and I must say that the paper we have had from Cancer Research - which is precisely one side of a sheet of paper - is absolutely splendid because it is the sort of length that we can actually digest. This does tell us that about one in eight of cancer deaths in non-smokers is due to being overweight or obese, so it is a real problem. It also goes on,"... the link between obesity and cancer has been poorly acknowledged." Could you give us any idea of the mechanisms of this link? Is that a possible question or just not known?

Professor Peto: One straightforward one is that there is a correlation between obesity and circulating levels of things that are associated with cancer risk. I mean, hormones - oestrogen, particularly in post-menopausal women, which certainly would contribute to breast and cancer of the uterus. Insulin, of course, in relation to diabetes. What its relation to cancer is, I do not know, but IGF-1 insulin, like growth-factor type 1, is emerging as an important circulating corridor to cancer risk for a whole range of cancers. That is correlated with obesity. So there are endogenous processes with obesity which certainly correlate with cancer risk in the general population. In relation to oesophageal cancer, which is quite an important cancer, I regarded that evidence as being inclusive. There is gastro-oesophageal reflux which is likely to increase the risk of oesophageal cancer. Cancer of the gall bladder is trivial, but gall stones are associated with obesity and with cancer, so in that particular site there is a plausible mechanism. One important mechanism is that we are talking about cancer mortality not incidence and the relationship seems to be stronger with the death rate than with the incidence rate. The reason for that is probably that very obese people are diagnosed late. Whether or not, once the cancer is there, it has any effect on the course of the cancer is not known, but they are certainly likely to be diagnosed late - there is direct evidence of that - and, once you have got cancer, you are more likely to die of it if you are obese because you are diagnosed at a more advanced stage.

Q176  Dr Taylor: That brings us back, I think, to the point Professor Lacey raised, that doctors as a whole probably are less interested in the really obese and they are more difficult to examine.

Professor Peto: I think they are more difficult to examine. I do not think doctors do not examine them because they are not interested in them, I think that would be going a bit far. But, I mean, you are a doctor, there is ...

Q177  Dr Taylor: Yes.

Professor Peto: There is one other point which may not be negligible: excess energy. First of all, increased body size. One might expect it to be associated with cancer on arm-waving grounds: cancer originates in a single cell; if there are more cells dividing more quickly, you might expect the cancer rate to be increased. That is an arm-waving argument. It probably has some validity. Of course, in relation to colon or rectal cancer, it is pretty obvious that the chemistry of stools is affected by what you eat and whether you overeat. Again, there is an arm-waving argument. The explanations range from being really rather specific and well-established, to being speculative and plausible. But it is scientifically reasonable.

Q178  Dr Taylor: So you have mentioned the breast, endometrial cancer, oesophageal cancer, colonic cancer. Other cancers?

Professor Peto: Cancer of the oesophagus, you mentioned that. That is an important one. I do not know whether the insulin relationship has anything to do with the pancreas, but pancreatic cancer has emerged consistently in studies as being linked to obesity. The one important cancer where the evidence is, I suppose, dubious and I think it is probably more likely to be due to survival than incidence, is prostrate cancer. There is a significant link with prostate cancer in a big American study, but it is not clear whether that is ... That is not as marked as the other ones, although it is statistically significant. It remains to be seen whether that is a real effect.

Q179  Dr Taylor: Is the link generally with obesity or is there any link with people who suddenly put on a vast amount of weight?

Professor Peto: The data on that are really inadequate. It is not known. There is not very good evidence that losing weight rapidly reduces the cancer risk. I mean, that is irrelevant from a public health -----

Q180  Dr Taylor: Did you say there is or there is not?

Professor Sir George Alberti: There is not. It is pretty clear for obesity and heart disease, so there is no question that people ought to lose weight, but it is not clear that they will abruptly reduce their cancer rate by doing it, because, on the whole, cancer rates tend to go up and down many years after what causes them.

Q181  Dr Taylor: The huge point is you have never to become obese.

Professor Peto: Well, I would be very surprised if 20 years later there was not a huge benefit in losing weight but that has not been demonstrated in prospective studies.

Dr Taylor: Thank you.

Q182  Dr Naysmith: I would like to spend a minute or two with Professor Lacey exploring the link between mental illness, obesity and overweight. I wonder if you could tell us what the link is or what your observations are on that.

Professor Lacey: There is not a direct and obvious link between psychological disorder and massive obesity. If I could specify: with people with a BMI, say, over 40 (which is the usual group that we see) you cannot by clinical examination determine any particular grouping of symptoms that would tend to lead to it. Sometimes from psychological inquiry you can determine why it may have occurred. An example, perhaps, is incestuous abuse or something like that, and by becoming obese you no longer are attractive and you also switch off your own libido too, so within that sort of context. But they are sort of a rare, small-print end of the market. There are significant psychological effects of the obesity itself. That certainly includes depression, it includes phobic symptoms, it includes anger. It also includes a lot of social issues, loneliness and the like. The actual causes, in so far as they can be detected, do not fall into natural major psychiatric disorders but tend to stem from interpersonal or family problems. But that is when you find it. In the majority it is not determinable. There is not a clear link between massive obesity and a pre-existing psychological problem; rather there is evidence of psychological sequelae from the massive obesity itself.

Q183  Dr Naysmith: How serious is this for the National Health Service, for the nation's health?

Professor Lacey: I think it is best to look at it from the individual. I think it is quite marked from the individual. It changes their whole lifestyle, the way people look at them, judge them; their capacity to form relationships; their economic capacity; and of course the other complications are physical complications too, which in themselves have emotional sequelae. It is very, very significant to the individual and to their families.

Q184  Dr Naysmith: What about the relationship between eating disorders and obesity? Is there a clear one?

Professor Lacey: Yes. Within massive obesity there is a significant sub-group who eat by means of binge-eating. Really their presentation - and perhaps I should have made this clear at the beginning - is very similar to bulimia nervosa, except the fact that they are obese rather than normal weight. Broadly speaking, that is behaviourally determined. This is a group that binge-eat but do not vomit afterwards, so their weight continues to go up. They, as a group, can be treated by psychological means. The sort of treatments that have been shown to be effective for bulimia nervosa - which is a very, very treatable condition - both cognitive and focal interpretative therapies, can be used with the bulimic obese to remove the binge-eating symptoms but it does leave them obese. Although that can then perhaps be addressed by dietetic counselling or even by surgical means, it is usually considered a good result if you can deal with the binge-eating and cause some loss of weight whilst leaving them still overweight.

Q185  Dr Naysmith: Could I pick up on something you said earlier which has already been picked up. I just wonder whether any other members of the panel agree with you, this suggestion that overweight people tend to be unpopular with their peers and also with some doctors.

Professor Lacey: I said that because the question was: Why was it not addressed? I think you have to answer the question: Why has their been enormous interest amongst doctors and researchers, myself included, in anorexia nervosa, bulimia nervosa, but not a much more common condition, which is obesity, the subject of this inquiry? One of the reasons, I would tentatively suggest, is that as a group the massively obese do not seem popular. It often gets into these rather spurious debates about self-inflicted injury and such like. When I at a clinical level am attempting, for instance, to get funding to treat patients, I find that they are much more sympathetic at other aspects of eating disorders or psychiatry than the massively obese. Rather they are seen to have brought it on themselves.

Q186  Dr Naysmith: How true do you think that is? Is there a measure of truth in it?

Professor Lacey: Only in the same way that certainly other lifestyles can give rise to cardiological disorders. Or you could make the same argument for a number of psychiatric disorders too. So only in that capacity but not any more than that.

Q187  Dr Naysmith: Is there any evidence of a predisposition towards the condition? Is there a group of the population which can be identified who are more likely to end up this way?

Professor Lacey: Yes. Well, as the papers show, it is something that tends to run in families, there is an increase in certain ethnic groups.

Q188  Dr Naysmith: Then we get the old argument about environment versus genetics.

Professor Lacey: Indeed. Genetic evidence, to my mind, is not satisfactory, so it is really much more in the environmental field.

Q189  Dr Naysmith: Would Professor Wardle like to comment on any of this?

Professor Wardle: I think I would agree with quite a lot of what Professor Lacey said. Generally there is not a very strong association emerging in the scientific literature between psychological disorders and obesity. The same appears to be true even if you look at data from younger age groups, adolescent groups, who you might think would be the group at particular high risk. There tends to be slightly more sign of a psychological disorder when you study clinic populations than when you look at the difference between overweight and non-overweight and obese groups in community populations. Then the effects are lower. That is one thing. A second point which I think seems relevant to the issue - you asked: How much truth is there in this idea that we are talking about something which actually is people's fault and so on? - is that we have to remember that probably 95 per cent of the explanation for the increase in obesity that we see is because the entire population's weight has shifted upwards. We are not talking about something odd happening to some sector of the population; we are talking about a population shift, just the same as we have seen for height, which is generally going up. When you recognise that it is more important to talk about a mean change in BMI (which of course means there is going to be a bunch more people at the top end of things), then it draws your mind to the proper kinds of explanations there might be for this rather than thinking only of, there is this subsect that is increasing. The third thing I would like to say about that is in terms of the stigmatisation issue or social problems which accrue to people who have overweight. The evidence is very strong there in terms of teasing and social rejection, particularly in the adolescent years and in childhood years. A recent study, not yet published but reported at a conference, showed that teachers underestimate the IQ of overweight children more than they underestimate the IQ of normal weight children. There are many studies which show that health professionals have strongly negative views towards the overweight, and, even if they deny them consciously, if you do studies - you use a test called the Implicit Association Test - you can show that the same kind of negative views are held. One of the things though we have to wonder is how these people who suffer prejudice in all kinds of walks of life manage to sustain not being depressed and not having low self-esteem necessarily. It is a testament, I think, to the strength of the human spirit that they make it.

Dr Naysmith: Thank you very much.

Q190  Andy Burnham: Most often people will attribute their own weight gain to their own metabolism rather than lifestyle choices. To what extent is that true? To what extent do some people have a much greater propensity to put on weight because of the way their body functions? Do we need to think more, if people do have that propensity, of what we do with those people?

Professor Wardle: I think this is a very important question. It seems to me that on the whole the evidence supports there being quite a strong genetic influence explaining why within a population some people are at one end of the distribution and some people are at the other end of the distribution. Of course that genetic factor does not explain why the whole population shifted. So I think we do know, and there is lots of other data which you can accrue to make that case. Animal breeding studies show very clearly that you can breed for leanness or you can breed for obesity. Studies of adoption, with people being adopted at birth: people who are adopted into more overweight families, have no increase in their risk.

Q191  Andy Burnham: Part of what I am getting at, though, is do people overestimate - you know, "Well, it is my metabolism" - as a way of not confronting lifestyle choices?

Professor Wardle: They may underestimate the extent to which their weight is modifiable. I think people do have a sense: "That is just the way I am, that is just the way my family has always been, that is not something I can do anything about." I think that to have a fatalistic view about it is inappropriate and incorrect because we clearly know that these things can be changed. I think people's sense that there is some metabolic oddity or mysterious underlying illness is by and large not true. But, for some people, this process, whatever it is, is an awful lot easier than it is for others. If you had to choose between calling them a victim or a criminal so far as their obesity was concerned, then victim is closer to the truth.

Professor Sir George Alberti: But I think it is overestimated. Yes, there is a range of basal metabolic rate. A very simple example of that is that males, by and large, have a bigger caloric intake than females - and I have to keep persuading my wife that she ought to eat less than I do, which she resents! But I think it is used as an excuse often. I always say to patients - I do not know if Professor Lacey does the same thing - "I can guarantee that I can help you lose weight on a particular caloric intake." Once people have it shown to them that they actually can ... That was bringing them into hospital - in the old days, when we actually had beds still in hospital! We used to bring them in, 600 calories for a week, and everyone loses weight, undoubtedly, and then you find the person's own level.

Q192  Jim Dowd: Could I follow up with what I believe to be a related aspect. I am not a medical person, so you will forgive the generalisation. The human body generally develops defensive mechanisms for threats to its well being. Why is it then that so many people seem to like foods that are bad for them and do not like the stuff that is good for them?

Professor Wardle: One explanation is you have to look to our evolutionary past. In our evolutionary past, clearly getting energy intake was crucial, and there were not the kind of designed foods which we see now which have this very unusually high proportion of fat or unusually high energy density. We are talking about an organism that developed in a different food environment, where there would be every reason to expect that it would have been adaptively positive that you should eat when food was available. If food only appears now and then, when the tribe kills a mammoth or whatever, and you say, "I'm not hungry today" ----

Q193  Jim Dowd: It happens in Lewisham all the time!

Professor Wardle: You can see that there would be evolutionary pressures for broadly speaking a genotype which supported energy intake and supported being sedentary when you did not need to be wasting energy. We now find ourselves in a situation where there are technological advances within the food industry, within transport, within engineering and homes, where the opportunities for being sedentary and the opportunities for eating high energy foods are ever present, and we are responding with what people would call our Stone Age genotype to all of this.

Professor Sir George Alberti: It is a thrifty genotype. There is a big hypothesis built round that, which is for intermittent eating: you would need to stuff yourself pretty well and then you would wait another four days. But not many of us do that any more.

Q194  Chairman: Could I come back to Professor Lacey. I was struck by evidence that we had received that obese women are around 37 per cent more likely to commit suicide than women of normal weight. The source of that was the National Obesity Forum. Presumably you would confirm that from your own experience. I wonder whether, in view of the impression we are gaining from all the witnesses who have spoken so far of a kind of lack of interest and urgency in this from the medical profession, perhaps generalising, and government, bearing in mind that suicide reduction is a key health target, is that not a way into doing something about it?

Professor Lacey: I am sorry.

Q195  Chairman: Are the suicide figures I have just quoted not a way into trying to get this issue taken more seriously?

Professor Lacey: Yes. I think that is the case. At the coal face it is very frustrating. Obesity clinics are needed for the massively obese and they are few and far between. In fact, most of the staffing necessary is there. Usually a very small amount of funding is needed, or will, or managerial skills - often the latter, and we so often undervalue the need for managerial skills in the NHS - actually to bring the relevant multi-disciplinary team together. Because I would strongly argue that to deal with the massively obese is not one individual clinician; it is rather a multi-disciplinary team that would involve surgeons, physicians, psychiatrists, and much more, occupational therapists, dieticians and the like. It is the way in which those teams are managed and brought together for the benefit of the patient, and we lack skills in dealing with that. Apart from those skills, often very small amounts of money are required - or perhaps little at all. The big expansion, for instance, in my own service for eating disorders, stems from the internal market: then, the money could be made available. With the lack of that, what seems to be needed is another way of dealing with it. I mean, it caused a lot of problems, etcetera, but it did, for certain specialist areas, allow considerable expansion to the benefit of patients. What is now needed, within our current structure, is a way of getting very small amounts of money to the required place. If it is given generically (or whatever the word is), almost certainly it will get lost, for the reasons and the prejudices that I have indicated. Some way in which some ring-fenced money can be got to the point of need would open up services. Much of the skills are there.

Professor Sir George Alberti: I would add that managers do not like putting money into services which are not particularly successful - so we have trouble explaining to them. You should not underestimate how difficult it is, as a doctor, to see recurrently a group of patients, most of whom actively are not helping. That is what really gets at the professionals. You need the oddballs, like my colleague here, who continue to be enthusiastic regardless - and there are a few of us around.

Professor Peto: If I could make a general comment. The massively obese are not the problem, because they are less than one per cent of the population. The overweight are not the problem; they are half the population. The bulk of the excess mortality occurs in the obese, who are 20 per cent of the population. I think it is important to focus on that. The NHS cannot provide detailed clinic services or intensive clinic services for 20 per cent of the population. For cancer, for example, the obese account for two-thirds of the excess mortality. The overweight, who are a much larger proportion of the population, are at an increased risk but not much of an increased risk. Obviously a campaign that puts pressure on obese people to lose weight will in fact spill over into the overweight. Although what Jane says is true, there has been a shift in the entire weight distribution and that has had the effect of increasing the upper end, which is where the mortality risk is, I think that is where the focus should be. It is neither the top half a per cent nor the 70 per cent who are overweight, but it is the 20 per cent who are obese who have to be focused on. And somehow or other you have to stigmatise them unfortunately. That is the real difficulty that everybody is skirting round. The way Californians gave up smoking was because smoking became socially unacceptable. That is a real problem. I have a young patient who was obese and had been since being a teenager. Finally, in her twenties, her boyfriend told her she was too fat and within a year she had lost a great deal of weight. And she has actually been much happier ever since. So I am not sure that stigmatisation is a bad thing but I think that has to be addressed. This is not really a medical problem.

Dr Barrett: In childhood obesity there is an interest from paediatricians in the subject, together with mounting apprehension as to what is happening. Obesity-related illness is not supposed to be a problem in childhood and it certainly was not until up to, perhaps, five or six years ago. From about 2000 onwards we have started seeing children with obesity-related diabetes (which has never really been described in this country before) such that now it accounts for about six per cent of all children presenting with diabetes in our clinic. Out of the 20 children with diabetes this year, six of them have obesity-related diabetes. The youngest one I saw four weeks ago was an eight-year old girl who had developed some symptoms. She would come into the super-obese category because of her diet and because of her snacking at school. We do not know what is going to happen in the future, because it is a new problem, but one would anticipate that the complications of diabetes have a whole lifetime to develop. My colleagues in North America, in Winnipeg in Canada, have followed up the first 50 or so teenagers with Type 2 diabetes over 12 or 15 years. They presented last year in America. Of the girls who got pregnant, about one-third of them had miscarriages. So they had about a 30 per cent miscarriage rate with Type 2 diabetes in their twenties, but, also, some of these 50 who had gone on into their twenties were on kidney dialysis machines and had retinopathy as well. The complications of Type 2 diabetes are going to occur in the twenties and thirties if we follow the pattern in North America.

Chairman: We will be exploring the issue of children in a moment or two in a bit more detail. I am grateful for that comment.

Q196  Mr Burns: Could I turn to the economic impact of obesity. The NAO has recently put a conservative estimate that the cost to the NHS is about £2.6 billion in 2001. I was wondering if you would like to comment on that figure, whether you think it is a valid one or whether it is an underestimate or an exaggeration.

Dr Rayner: I think the NAO would say it is a starting-place figure. I think that is the problem. We are always looking backwards and we need to look forwards. We need to see the picture in 20 years time and then come backwards. I prefer to look at the American data, which is more complete, in a way, and gives a much bigger picture on how overweight and obesity issues are driving costs. One of the points of that is that obese and overweight patients - set aside the overweight - seem to generate higher treatment costs than people with alcohol problems or tobacco problems. We need to think not just of the costs for the health services but of the costs for the general economy, for the driving of jobs. Obviously there are some benefits to this: the manufacturers of slimming food products are doing very well out of these things. To look at the complete picture, you have to go beyond just the costs to health services. One of the figures I put in front of you is that by 2011 the US health care costs are going to be in the region of 17 per cent: more than 17 per cent of their GNP spent on health care. The biggest cost push within that, I would argue, is the general area of non-communicable disease, and this is a prominent part of them. So, yes, these costs are rising. I think what needs to be looked at again - I think the NAO report was a starting place - is the total social costs, economic costs to the economy, to the people themselves, in terms of affecting their employment, and so on. We need to look far more at that. I think the NAO report was particularly good - coming back to the point of the Chairman - because it actually dramatised issue and brought it to government, but I would like to see further research on that and obviously that there will continue to be interest. I think this is the Treasury's problem as well. It is not just the Department of Health. I am pleased to see that Derek Wanless, who did the study for the Treasury looking at health care costs, actually has come back to looking at the fully engaged scenario; that is to say, the difference between really effective engagement with the public about these non-communicable diseases and the ineffective. I think that is the research that needs to be done: more modelling about what the costs might be in the future, from some of the trends that our colleague here has identified, in terms of the younger age groups. We are still talking about the conversion of costs in older groups and, actually, when you start looking at these problems appearing in younger age groups and then generating the costs ahead, the figures start to get very large.

Q197  Dr Taylor: Could we turn to the costs of diabetes - and really this is a question for Professor Alberti. We have been told that diabetes consumes something like 10 per cent of the NHS budget. Is that right? Can you give us a breakdown? Which bits of those are savable?

Professor Sir George Alberti: Certainly, the estimates that have been made based on data from Wales - I do not know if you are allowed to take evidence from Wales! - and also from East Anglia - and it is a fairly universal figure actually worldwide - is 10 per cent of healthcare budgets. The biggest proportion of that is the complications of diabetes. Certainly, if we have this evidence which we have of younger people developing Type 2 diabetes, which is the big burden here younger, we are already seeing in the South Asian population in this country that something like approaching 20 per cent of adult South Asians have diabetes, another 25 per cent have impaired glucose tolerance. So virtually half are either diabetic or at high risk of heart disease. We are going to see a lot more vascular disease early. That is where the big costs are coming, together with renal replacement therapy. That is going to burgeon and is savable (i) if we can deal with the obesity problem, and (ii) if we treat diabetes better, of course.

Dr Taylor: Thank you very much.

Q198  Julia Drown: I want to pick up on the comments that Time Barrett made about the emergence of Type 2 diabetes in children. Is that largely due to obesity or are there other factors as well? In so far as it is obesity, when you are talking to the parents involved, is there real worry about eating disorders which stops parents dealing with the first signs of obesity? Other people may want to come in on that as well, but I am particularly interested in your view on it.

Dr Barrett: We have tried to do a national survey through our own professional body of how common obesity-related diabetes is in children. Nationally, it is probably still less than one per cent, but those children are all in the obese or super-obese category.

Q199  Julia Drown: That is one per cent ...

Dr Barrett: Of all children with diabetes have obesity-related diabetes across the country on a first survey. But locally, in areas where there is a more cosmopolitan population, such as Birmingham, the figure is up to six per cent. So we are seeing an increased proportion in inner city areas and that reflects differences in population. All of these children with Type 2 diabetes are obese or more obese than that, super-obese again, so there appears to be an association with that. It does appear to affect children of South Asian origin disproportionally, as Professor Alberti was alluding to, and I think this is because they have extra susceptibility factors on top of the obesity that make them prone first, which may be genetic or may be racial but probably reflect the increased prevalence of diabetes in the adult Asian population.

Q200  Julia Drown: But overall it is small in terms of diabetes.

Dr Barrett: Nationally, it is small at the moment. The level in the UK is where it was in reports from Cincinnati in Ohio, North America, about 15 years ago. The only model we have to go on really is what has happened in North America over those 15 years, and the reports from North America now show that up to 45 per cent of all children with diabetes have Type 2, and they have clearly associated that with the prevalence of obesity.

Professor Sir George Alberti: There is still a much smaller number than in adults, of course, but it is worrying. The people we need to focus on today are the ethnic minorities: Afro-Caribbeans, people from the Mediterranean basin, people of Arab origin, where it is going like that (indicating up)as well in their own countries and even more so in the immigrant populations in the States and here.

Q201  Julia Drown: Are parents not dealing with the first signs of obesity because they are worried about eating disorders?

Dr Barrett: It is a lifestyle issue, the way they are living their lives and their families are. Quite commonly, the obese child comes along with an obese mother or an obese father, so it is a family thing often.

Professor Wardle: There have been a number of studies attempting to look at the extent to which parents are worried about their children developing eating disorders. It looks as though, within the parent population, fear of the development of eating disorders is much higher than fear of the development of obesity. The issue of control - you know, limiting things and saying no about things and denying their children things - is a very difficult thing for parents to do, partly because of caring parenting but also because of fears that that is going to result in eating disorders. A study which was carried out in a number of European countries reported that parents did not say anything, they did not do anything for a very long time. It was only when they realised - you know, something would happen, like they would see their child on stage at a school play compared with the other children and realise that it was not just that he was a "big" boy but that there was something thoroughly wrong - that they were sort of shocked and panicked and desperate to get help for it. But it had gone on a long time. If you look at surveys showing how many parents are accurate in detecting whether their children are overweight or obese - if you measure the kids and ask the parents to make a judgment - parents grossly underestimate the prevalence of overweight and obesity in their children.

Q202  Andy Burnham: It is a natural instinct, though, is it not? I used to go to university laden down with 20 flapjacks and things. Your mum and dad want to feed you.

Professor Wardle: Absolutely.

Q203  Andy Burnham: Their worst fear is that you might be under-eating. That is their great fear, is it not?

Professor Wardle: Yes.

Q204  Andy Burnham: They really want to see you eating well. They like to see you overweight rather than underweight. It is quite difficult, is it not, to -----

Professor Wardle: It is extremely difficult. In the childhood obesity treatment programme that we are running, we get lots of calls from people who want to have a preliminary discussion but do not think they can really face addressing the issue with their child because of the family conflict that will be produced and so on.

Q205  Jim Dowd: How much of a difference between the attitude, as you said, towards obesity and eating disorders may lie in the fact that anorexia and bulimia are manifestations of something else, whereas obesity or "overweightness", if you like, is just a condition of itself?

Professor Wardle: I think people are very muddled about that whole issue. I think parents feel very responsible for anything that develops with their children. I think parents feel exceptionally responsible if their children develop eating disorders. I think probably they feel slightly less responsible if their children develop obesity, even though that may not be the justifiable allocation of responsibility.

Q206  Julia Drown: I think this is certainly something the Committee is going to have to address. Maybe Professor Lacey may be interested in commenting. Are parents right to be so fearful? I pick up from parents that they think, as soon as the child has an eating disorder, "It is hopeless and hardly anything can be done for them," and we hear of the children who die, of the desperate situation they get into, whereas, with obesity, people still think, marginally, "I can change this over time." Are parents right to be so worried or are there some things which the Committee can suggest which might actually try to rebalance this somehow.

Professor Lacey: I think the answer to that is no. You are right, of course, that anorexia nervosa is a very serious condition. It is the psychiatric disorder with the very highest mortality - far more than alcoholism or schizophrenia or such like. It is a very high mortality. The latest Swedish study is showing 20 per cent of girls dying between 15 and 40. That said, certainly bulimia nervosa is highly treatable - that is much more common: five per cent of the relevant population - and, with anorexia nervosa, in treatment round about 50 per cent can have a full and normal life. The answer is: yes, we should instill hope that treatment can help them. It is an interesting phenomena - and I do not want to be guilty of broadening the brief of your question - that in the papers that have been submitted there is a lot of evidence, for instance, on the use of the media in emphasising the dangers of obesity, and of course there is enormous evidence and enormous pressure in the media for women to lower their weight, and we do see the casualties of those. So it is an area, using media for the manipulation of food, which does have its dangers as well as its obvious desirabilities.

Q207  Jim Dowd: I want to examine excess weight and tobacco to see if there are any parallels. This is principally, I suppose, a question for Dr Rayner to start with. Can you quantify the relative risks of excess weight as opposed to, say, smoking? How is the epidemiology of obesity comparing to the early days, say, of when smoking was recognised to be the considerable risk to public health that it is?

Dr Rayner: I am not going to give you an answer in terms of the sets of illnesses or diseases that go with either smoking or overweight. I would say, just to reiterate my previous point, that there are about three studies which have computed the difference in terms of the medical inputs to those and they are coming in with quite consistent findings. It is all American data. In terms of smoking, that smoking is reducing in the US; that obesity levels are going up - so that they have come to a cross-over point at some time; that there are, if you like, economic benefits of smoking for health services, in that it actually attenuates life at an earlier point. With obesity, as treatments come in, people's weight is reduced and so on, but those are generated in terms of medical costs as well, so that the costs are going to be higher the more this is established as an area of inquiry, the more that the services start responding, but there is not the benefits, if you like, from smoking. If you remember, a year or two ago one of the tobacco companies was saying that the beneficial aspects of having tobacco in the economy was that it will pop off people earlier in their lives, saving the country in pensions payments. This is going to be different from that, but I am saying basically that there are analogies between the tobacco epidemic and the obesity epidemic and I think there are things we should be learning from the way tobacco has been dealt with. Professor Peto mentioned California, for example, and restrictions upon smoking and so on, but also examination of all the costing data, which is not the same level over obesity. I think we can learn from what has happened in tobacco and apply that. Food is not tobacco, but there are similarities. I think, to go back to my basic point, we actually should be doing more research in this area. I have mentioned three studies which have looked at the cost issues and I think they should be extended and developed, going back to my earlier point about much more modelling of the impact of this as we look ahead.

Q208  Jim Dowd: Smokers also pay large sums of tax while they are around as well.

Dr Rayner: Indeed. It may be a point you want to take up later, of course, but there is differential taxation in the food area, VAT and so on. Taxation is still on the luxury side of eating. The issue of taxation on high fat foods or high salt foods or high sugar foods is to be considered, certainly. More work needs to be done on looking at the impact. Again, the analogy is with smoking because smoking is now very much concentrated among the poorer groups and therefore taxation is being levied on the poorer groups. You need to look at those issues, because you do not want regressive taxation on people who spend a large proportion of their income on the food budget. So that has to be considered as well.

Professor Peto: In relation to smoking, smoking is such a health catastrophe that, if you smoke, then in a sense it is silly to worry about anything else - particularly in relation to cancer or to heart disease. It is such a massive cause of cancer that, if you are a smoker, to worry about any other lifestyle risk factor is silly until you have given up smoking.

Q209  Chairman: You know Mr Dowd is a smoker, don't you?

Professor Peto: It is very important to split the population into smokers and non-smokers.

Q210  Jim Dowd: But not as bad as Burns - Burns is out having a fag now!

Professor Peto: I do not know whether there were references with that CRUK document. Are there references at the bottom of that document? Yes. Is number 1 an article in Nature two years ago? I mean, there was a table in there which actually looks at percentages of cancer caused by various factors and it splits smokers and non-smokers. It is quite an important division because, amongst smokers, 60 per cent of cancer deaths are caused by smoking and everything else is trivial, but, amongst, non-smokers, obesity is far and away the most important avoidable cause. The majority of the population are non-smokers, so, for the majority of the population, the message that has to get across is: This is the central health issue. It really is. Cancer Research UK produces this leaflet on lifestyle and cancer and it lists all sorts of things that you should give up. You should take more exercise, avoid the sun, avoid alcohol, even safe sex, the use of condoms, will stop you catching HBV and getting cervical cancer. Obesity is listed in the middle of all that lot. Those are all 10 times less important than obesity. I mean, none of those accounts for more than one per cent of cancer mortality among non-smokers, but obesity causes something of the order of 10 per cent -1 in 8, 1 in 10. It is 10 times more important than any of those things and it is twice as important as all of them put together. That is a very important message to get across. It is not just another thing to make a fuss about. It has emerged quite suddenly, partly because the evidence has suddenly crystallised and partly because now we are beginning to crack smoking. Most people are non-smokers - at least, if they do not take it up again.

Q211  John Austin: Not in terms of mortality but costs to the NHS, in one of the papers that Dr Rayner has given us, he has given us figures that in the next eight years in the United States health care spending as a proportion of GDP will go from 13 to 17 per cent and 60 per cent of expenditure is likely to be on cardiovascular disease. I appreciate that smoking is a contributor to that as well as overweight and obesity, but it does appear, in terms of costs to the health service, that obesity may be as big a cost factor as smoking.

Professor Peto: Oh, no, smoking is a benefit. That is quite clear. I pointed this out 25 years ago. It kills retired people. Every time somebody dies of a smoking-related disease - four out of five smoking-related deaths are after retirement - they stop eating food and living in houses. And they do not pay tax, they go on living off us. If you kill retired people it is a uniform benefit to the economy. I think the economic argument is not really the point. We are talking about quality of life. I mean, if being fat kills you, it also makes you miserable. It happens that the economic argument also supports it. I mean, the economic argument also supports taking obesity seriously, but, if you take that to its logical extreme, you would encourage smoking because in that case it does not.

Q212  Jim Dowd: Before I come to Professor Wardle, referring to that list of things you said that people should give up, I think, if you did give them all up, you would not actually live any longer, it would just seem like it!

Professor Wardle: People are very interested in the question of how these different hazards to our health add up relative to one another. It is of course always difficult to make estimates. If you look for one disease type, then one can be much more important than the other and so on. But a paper published earlier this year from the Framingham Study, a long-term follow-up study in the US in adults, did a life-table analysis of years of life lost associated with obesity. In female non-smokers who are obese, it is seven years shorter life-expectancy. In female smokers it is 7.2 years less life-expectancy. The seven years is quite an interesting number actually, because seven years is also a figure which is often given in connection with the years of life lost through a lifetime of smoking. I think that, along with a number of other different strands of evidence, is pointing to currently comparable kinds of effects, and, if smoking is going down and obesity is going up, then, in terms of population attributable risk, the situation will get worse, and the proportion of health care expenditures which are related to obesity.

Q213  Jim Dowd: A lot of smokers would claim that one of the disincentives of giving up, apart from the fact that they are addicted, is fear of gaining weight.

Professor Wardle: There is no doubt about that. The problem is that they should not have started in the first place, but I know it is a bit difficult to tell them that.

Jim Dowd: It is also of limited impact at the time.

Q214  Dr Naysmith: Is there any evidence of synergy? There must be a few obese people who also smoke.

Professor Wardle: The life-table analysis, which is the first one that has been produced for obesity, as a matter of fact does not show that synergy. But this is going to be the first among a number of analyses, so I do not think we should take it as definitive in this case.

Q215  Jim Dowd: To what extent is it a help or a hindrance to describe obesity as an epidemic?

Professor Sir George Alberti: I think it is helpful in terms of getting it across to the general public. We have been talking about diabetes as a world pandemic: we are going rapidly towards 300 million people with diabetes, which makes an awful lot of the so-called epidemics look very small. I think obesity is running alongside ... I mean, they are running together: an epidemic or a pandemic. People think of epidemics as infectious diseases. Perhaps pandemic is even better because you do not carry the infectious connotation. I think anything which draws attention to the size - wrong word - of the problem is a benefit. I think we have to get it across.

Q216  Jim Dowd: I think you have just answered my next question, which was going to be: If the levels of obesity continue to rise, what effect will this have on the numbers suffering from diabetes?

Professor Sir George Alberti: I think we have some very good predictions there. Even without much rise in obesity, there will be an increase in diabetes as the population ages and survives longer. But, looking at the trends in obesity, we are reckoning that the number of people with diabetes, which was roughly 180 million worldwide last year, will hit 300 million in somewhere like 2020, and the number of people with this condition, impaired glucose tolerance, where you have a 50:50 chance of then getting diabetes and you are already at increased risk of heart disease, is approaching 300 million as well. These are enormous numbers. Going back to the point about when you should die. It is probably best when you have just stopped being productive and paying tax. Our problem now with the younger onset of diabetes is that people are getting heart disease and we are much better at keeping them alive now, and that is a continued expense. They are getting that in their 30s and 40s, and we were seeing that in different parts of the world as well.

Q217  Jim Dowd: It is not just a change of numbers, it is the profile?

Professor Sir George Alberti: You have a four or five times greater chance of having a heart attack if you have diabetes, that is one of the big impacts of obesity.

Q218  Dr Taylor: Dare I ask Professor Alberti if he think that MPs are being productive?

Professor Sir George Alberti: That depends on how much you are being paid!

Q219  Dr Taylor: How important is salt in the increase in palatability and in the attraction of convenience food? Can you expand on the place of salt?

Dr Rayner: The suspicions about salt over the years are now sort of condensed - I suppose the opposite of that. I think that just taking the manufacturers' point of view, they see it as very important. I would not want to say that people speak better about the physical effects on you of consuming so much salt. I would say from the point of view of food producers they are going to add salt to food and towards the processing of foods. It is the change in our diet. To give you an example in terms of the States, again the data there is better, from 1977 to 1978 the proportion of snack foods in our diet was round 12 per cent - this is the Harvard Institute of Economic Research - then looking at 1994 to 1996 there is an increase to 21 per cent. You have this transition in your diet towards snacks foods which have higher levels of salt and often higher levels of sugar as well, while the daily calories increased from 1,800 to 2,000 the big change was really in the snack food area, which are the higher salt varieties of food. That is where the change comes, it really has been in that. There has been the argument over portion size, and so on, and the evidence is now changing towards snack food with a high salt aspect.

Q220  John Austin: I want to go back to the issue of children, Dr Barrett has told us of the impact on children's health if the trends continue, both on the physical and psycho-social side, what I would like to ask is how much the pediatric profession is alert to the issue of obesity?

Dr Barrett: The Royal College of Pediatrics and Child Health have issued some issue guidance on the management of obesity, distributed to all health professionals, it offers general advice about separating out the medical cause from life-style and offering life-style advice to improve this. We have also had assistance from publications by Time Cole and others of body mass index charts for children, you can plot them properly and get some measure of fatness, or at least some very crude estimate anyway. Currently we are trying to put in a pediatric surveillance unit to get some accurate figures on the prevalence of obesity related illness, presenting each month over the next couple of years.

Q221  John Austin: To what extent do you think GPs are able to deal with problems of overweight children?

Dr Barrett: The problem is too great for one group, it is a life-style change rather than a medical problem until they get the obesity-related complications.

Q222  John Austin: Doctor Rayner, in the submission that came from the Facility of Public Health Medicine there was a reference to a toolbox for local partnership action, clearly this needs to be tackled across the board, not only for the impact on children's health immediately but its long-term impact that we have heard about. If we are really going to tackle this surely the focus must be on children and changing life-style and habit?

Dr Rayner: I think so. That is precisely the point that other people have made. Unless we address the issue of children's diets we will be looking at what is - I hate to use this expression - the tip of the iceberg. We project these things ahead and you have to change behaviour because children's diets solidify early on, our colleague will explain this in terms of dealing with children in the clinic. Unless you tackle a child's diet fairly early on then you are going to have a lifetime of dietary problems. If a child takes up smoking they can give it up again but once you acquire food problems early on they are going to be with you for a long time. I think the issue is also about understanding the needs of children. We are very protective of children. In terms of the surveys of parents looking at the impact of advertising, for example, there is a very high score all of the time from parents who see that it is there need to protect their children from food advertisers. I think the issue of children is not just for its own sake, it is also a way of having these arguments and having the education taken on within the adult population as well so that you can get to the parents through the children. I think it is one where the debate of the nanny state, and all that, whoever complains. I never hear complaints about the nanny state but our papers are full of it. People do accept that there is a role for the nanny state in protecting children, so child health protection is a legitimate area and I think it is the one that we should be pursuing.

Q223  Chairman: Following this point about the nanny state, one of the things that struck me in last week's session was the way in which we appear to have lost the ability to monitor the health of children in a school environment. I recall being at school, certainly at primary school, and we used to have height checks, weight checks, eyesight tests, teeth, nits, you name it. Talking to head teachers in my own area we do not appear to be able to address this issue in a school environment, particularly obesity. One of the head teachers I spoke to recently his personal, anecdotal evidence was children are less fit than they used to be. In this inquiry should we be looking at mechanisms to reinstate a school Health Service? I think it was Professor Peto who made the point that stigmatising might be a positive thing rather than a negative thing. One of the objections that I picked up on the question of obesity and lack of fitness in a school environment was we should not stigmatise children through any process we introduce to monitor health. Dr Barrett, I do not know if you have any thoughts on that, what should we do?

Dr Barrett: The issue I feel that needs tackling is the exercise that children undertake and the diet they have. The school Health Service has been cut back over a number of years, largely through Professor David Hall and the reports there because of a lack of evidence that different aspects of that service had in improving a child's health. At the moment the school nurse will weigh and measure children at school entry and screen them at that stage and if there are any problems they will be referred on for medical causes. Of course obesity is not a medical illness per se, it is more of a life-style issue. That goes back to the issue of children having opportunities for exercise and children's diets, both in school and in the home. Those are the areas, the exercise and the diet, that would be very helpful for you to address.

Q224  John Austin: On the exercise issue we are talking about a lack of self-confidence and the low self-esteem of people who are grossly overweight. If we are talking about the children and the need for exercise often the exercise which is provided within the school framework is even more humiliating for the overweight child and adds a further humiliation. How do we introduce programmes of encouraging people to engage in activity?

Dr Barrett: The school development plans try and build exercise into that. There are school health buses that can go and visit schools and educate children on these things. The problem is the school timetable is quite taken up with national curriculum targets, as they should be, for numeracy and literacy and exercise opportunities are being squeezed out of that timetable, so children are doing less. Fewer children are walking to school and almost no child cycles to school nowadays because of traffic concerns and child protection issues, so there are lost opportunities there. When children get home there are lots of opportunities to watch television or play on Game Boy rather than riding out on their bicycles. These are major issues to do with child obesity.

John Austin: In my generation we did not have television and there was a bomb site on every street corner. We now have Game Boys and computers and televisions.

Jim Dowd: We were happy.

Q225  John Austin: I know that Dr Rayner's organisation produced Getting Active, a local guide for partnership action. I am wondering whether there are any examples of success that you can point to that we as a Committee might go and look at?

Dr Rayner: I can submit you with a list, I am very happy to do that. There are examples of things. My colleague is right, we are talking about small remedies, I mentioned the cultural changes, these are the changes which are the full extent of the explanations from a society which feels insecure about their children walking to school, about cycling, we also have the school tuck shop, a central income generator for the school. Going back to the point about the school nurse service, there is a sea of trouble, if you like, which is pointing towards a more inactive, more snacking culture and I do not think one service is going to address that. We need to have a complete, whole school perspective and we need more local action. Some of the things we suggest in our documents, and I am very happy to send you a list and to take you round places, I think are good examples. The issue is that the schools are doing them on an independent basis. There are troubles in having these things sponsored by confectionary companies - you may wish to go into this issue - and it is about the school creating an environment where good, healthy food is accepted as the norm rather than this aspirational food which comes out of a world which is peddled by footballers, or whoever, and actually emphasising the basics. We are not talking rocket science here, it is about the world in which young people live and understanding the things that confront them now which our generations did not have to confront, when things were looked at as treats rather than the mainstream. The world has changed. We have to look at it from the young people's perspective.

Q226  John Austin: We did raise the issue when the Minister was here of Coca-Cola machines in schools or the association of Pepsi Cola in sponsoring activities of an educational type. The Minister's view was that this was a matter for local school governors and parents to determine and not one for the nanny state to intervene. Your view would be?

Dr Rayner: In which case we have a very bad nanny, do we not? I think it is the responsibility of the state to protect children with parents and with schools. The children are in a state institution and the state has the responsibility to protect them while they are there. It is funny that we can give guidance on many matters but we cannot give guidance on this. The question is, why? We need a response by the state which is proportional to the problem. It is lacking in proportionality towards the growing problem.

Professor Sir George Alberti: I can comment on that, I have a very good example from one of my pediatric diabetes colleagues in Los Angeles who led a public campaign to have sugar containing drinks banned from schools in the public sector and succeeded, and that was done on a popular public vote, they always add things on to their votes, and they have gone. That was done by one determined individual. I think the state ought to pick up on this and take responsibility and not get the brush off I have had from the Public Health Department saying, we cannot interfere with people's liberty.

Q227  John Austin: Can I ask one final question on trends, if the current trends continue are we going to see a substantial increase in the number of children who will pre-decease their parents?

Dr Barrett: We cannot predict the future but we can look at the pattern that has happened in North America over the last 20 years, the evidence is that obesity-related diabetes in North American illness was about five per cent in about 1982, and some centres are reporting up to 45 per cent in parts of Texas in the year 2000. The problem has ballooned. These people are getting cardiovascular complications in their late 20s.

Professor Peto: The idea of measuring just height and weight and perhaps hip and waist measurements in children perhaps once every year in school would be enormously helpful for several reasons. It would have a considerable publicity value, it would draw attention to the fact that it is seen as a problem. It would also have the immediate benefit that children and their parents would know where they were on the scale and they would also know which way they were moving over a couple of years. It would be enormously helpful because this is a problem that creeps up and children are very fat by the time their parents notice. It would be a huge help to research in the short-term because to have that data at a national level as a basic framework within which you can do more detailed studies, given that this is a major public health problem you have to support the research of it, and this is a huge contribution that costs nothing at all. You do not need a school nurse to measure height the teachers can do it. This does not have to all be done on one day, you can measure every child during the course of a school year, that would be quite sufficient.

Q228  Chairman: Why have we not done it already?

Professor Peto: The long-term effects are probably more serious than the short-term effects and although you will wait 35 years to do it in 35 years' time it will be an enormous bonus to an epidemiologist to have that data. If you do recommend that you should also recommend that the data be available to medical researchers. Lord Falconer said that such records are confidential because of the common law of confidentiality, I think he is technically wrong. This has to be addressed because otherwise the data is not worth having. We have to be able to look at them to be able to use them.

Q229  John Austin: I know it is important for babies to gain weight but has there been too much emphasis on weight gain and too much emphasis on bonny bouncy babies? Does that have an impact?

Dr Barrett: It is hard to know. There is good research being done in Cambridge looking at the rapidity of weight gain in relation to the later development of obesity, it seems the thinner babies that gain weight the fastest are the ones that end up in trouble. Continuing the Government programme to promote breast feeding is a very positive thing that would help against that.

Q230  Mr Burstow: I just want to pick it up on the point about data collection and ask whether there are other examples where there are gaps in data collection that would be relevant to ensuring that we have a good understanding and information on which we can base policy in the future and whether there are any other research gaps? It would be useful to know where there are problems with not have systematic collections of data that would be useful to informing future policy and indeed research.

Professor Peto: We do not have a huge cohort like the American cohort. The American Cancer Society has done these studies seriously since 1960s and they have been incredibly helpful and we do not have a huge national cohort of that sort. The bio-bank project may or may not get going, it is just in the process of being launched, but that does not include anybody under the age of 45. To establish a huge, national cohort where you have measurements of this sort on all children and then on a volunteer basis you get them and their parents to fill out questionnaires on things like smoking, drinking, dieting and exercise would be an amazing resource for national health monitoring. The other thing about that is you get a chance to address questions, you ask questions about weight gain versus weight and you do not know the answer, the data is not there. That data would simply be there for nothing if you used up this national cohort and within a very short time you would have a goldmine to addressing these questions.

Professor Sir George Alberti: For getting blood pressure, glucose, the waist circumference, we have to keep remembering that it is central obesity that is the really damaging one in terms of diabetes and heart disease compared with total obesity. There are one or two smaller cohort studies but nothing like big enough to give us this continuing trend so that we can say, okay if we take action now, we are always running behind ourselves.

Dr Barrett: Can I say there is a very big gap in the research area in terms of interventions to prevent obesity at an early stage. There are one or two studies in the United Kingdom but the vast majority of it is coming from North America. There is a big area of getting funding for studies to prevent obesity in the early years when you could do something about it, and that needs to be addressed.

Q231  Mr Burstow: What is the reason? If this is so blindingly obvious what are the main pressures and reasons that this has not been something that has been done to date?

Professor Wardle: Can I add to that point, maybe this relates to problems, I think what we have to say on prevention studies for childhood obesity, which I agree are really critical, is we are talking about studies which will very likely have very small effects which are only going to be measurable over quite long periods of time and therefore they are expensive, so they have to be large studies. There is also no funding organisation, we do not have the equivalent of the National Heart, Lung and Blood Institute which takes responsibility for the obesity issues. Given that almost everyone would agree this is the single largest new health problem that we now have it seems to me there ought be recognition of that in terms of funding organisations.

Professor Sir George Alberti: It does not feature on the MRC's list of priorities much to the annoyance of us who are in this sort of more practical physiological type of research.

Q232  Andy Burnham: This issue about data collection, do think generally that civil liberty concerns in this country play far too much of a role in balancing public health. Do you think we do not have this balance right, we are too obsessed on privacy and not taking enough sensible action?

Professor Sir George Alberti: Yes.

Professor Peto: It is asserted, as I said Lord Falconer famously asserted it, he said the common law of confidentiality such as medical records are confidential and you have to get then cleared under section 60 to approve the study before you can look at medical records. It was routine for people doing medical research to look at medical records without informing patients until two or three years ago, when the MRC guidelines were officially changed, it was written in the MRC the guidelines, once an ethics committee reviewed it. Confidentiality is absolute, if we breached it we would lose our jobs. We never, ever did. In 35 years I have never known a case to breach confidentiality from that sort of work. If you stop people in the street and say: "Should medical researchers be able to see your GP records without telling you?" 90 per cent say "no", but if you explain the question 95 per cent say "yes". There was a meeting last November organised by the All-party Parliamentary Group on Cancer, where I gave a little 15 minute talk on epidemiology and how wonderful it all was. At the end of it I explain what a disaster this was for our work. I put up a proposed law which simply said that consent is not required for medical researchers to look at medical records and 93 per cent of the audience voted for - because the audience had little buttons - and because I gave a 15 minute talk explaining what the question meant 93 voted yes. I think we have been hijacked by a ludicrous campaigning minority. All medical researchers agree with what I am saying and more than 90 per cent of the general population do as well when they had the question explained to them. The damage to research is unbelievable, it is not the subject of this meeting, it is an absolute catastrophe for English medical research and for some reason we are doing it more enthusiastically than any other country in the world. It has no basis in law. It is an absolute disaster for medical research.

Q233  Andy Burnham: Can I ask a question to anybody who would like to comment, to what extent is the epidemic a class issue? To what extent is it an issue that effects the lower social groups we were talking about?

Dr Rayner: Yes, it is a social class issue and it is also an issue of ethnicity, as we have pointed out. Certain groups are effected more than others. Again my explanation is culture, you have to look at the background of where people have come from, obviously there is a genetic importable invariable there too. It is a class issue and it is about where people live, how they shop, what is available in the local store, if you walk to the shops, it is about the changes we have had of some people taking cars. It is about what is in your pocket to be able to buy the healthier foods as well.

Q234  Andy Burnham: Is it rising affluence of the lowest social groups? Is it the cost of food in supermarkets? Going back 30 years in this county it would not have been the same, it is rising fastest for the lowest social group, what is it that has changed?

Dr Rayner: I would like to look at the marketing materials of some of the food companies to see who they are targeting. It is clear that children are being targeted for some sort of products, that lower income families are targeted for some products.

Q235  Andy Burnham: That is possibly slightly patronising because it is suggesting that people on lower incomes are more susceptible to advertising messages?

Dr Rayner: There is no denying advertising has an effect, it has an effect on me, you and everybody, they would not it do otherwise. Your green-grocer shops have closed down locally, look at the social exclusion units studies of retailing in poorer districts. Simply the access issues are quite pertinent here. Also if you go to the shops which are there it is the long-life products which are on the shelves, the snacking and so on and so forth. People are vulnerable. One of the consequences of being poor and socially excluded is that you can become more vulnerable to advertising, it is not patronising to point it out I do not think.

Q236  Andy Burnham: Most people have access to a large supermarket within reasonable distance these days and the margins on some food sales is very, very low and the price is in proportion.

Dr Rayner: The margins on fruit and vegetable in supermarkets are the highest margins in the supermarket.

Professor Lacey: It is a class issue, it is a sexual issue, it is a racial issue, but it also is an epidemic, it effects all social groups, both sexes and all ethnic groups too. I think that we should not lose sight of concentrating down in certain particular areas unless we are looking at sub groups deliberately. It is far better to see this as an issue that effects the whole population.

Professor Sir George Alberti: I would agree with that. One of the interesting things is that in the developing world it is the reverse, obesity is hitting the well-off people and that is because the poor people really have such bear subsistence foods available to them, it is what they grow and till on the whole and they are still exercising vigorously to get the food. We have reversed all that. In our society it has gone the other way round, the chattering classes tend to be the ones that go jogging and perhaps trying to do something about it but it is effecting all tiers of society, yes, there may be more in certain tiers but it is there all of the way through.

Q237  Jim Dowd: Where is the crossover?

Professor Sir George Alberti: We are beginning, just beginning, to see it in Africa, when the balance of food availability and cash in hand, just catching up, we are seeing it in the urban areas, improved bus services, people walking less, it is all just beginning to turnover in the urban areas.

Q238  Andy Burnham: Quite simply, as society has developed we get fatter. We have to understand that and start to ---

Professor Sir George Alberti: We have to work at it as a society. This is not a medical problem, this is a societal problem, as several of my colleagues have said. Yes, there are the medical bits of it that we all play with.

Q239  Andy Burnham: You are picking up the pieces of changes in society really. There the key is the schools, it is transport, it is ---

Professor Sir George Alberti: We have done a societal experiment with a group of South Asian immigrants in East Africa, we took the whole community, who had 25 per cent diabetes in the adults, and the only messages we gave, because I do not believe in all of this complicated dietetic stuff, because it boring, was walk more eat, less, eat less, walk more. They set up their own walking clubs. It is that sort of thing. Okay they were overweight but they could walk and they walked and that became a social phenomenon. After six years everything had got a bit better, the weight had gone down a bit, nothing dramatic, but diabetes had gone down by 70 per cent.

Q240  Dr Taylor: Changing the subject and going to Professor Lacey, it is probably a relatively small question, it is known that anti-depressant drugs contribute to weight gain, how significant is this?

Professor Lacey: It is, particularly with the newer ones. I think the answer to your question is a significant issue in the treatment of depression, yes. Compared with the enormity of obesity in the whole population of course it is comparatively small. Whilst I recognise that prevention is clearly a very important role of this Committee we have to recognise that there is a clinical problem out there and there is a great need to develop treatment, programmes that can affect those that are currently sufferers.

Q241  Dr Taylor: Right.

Professor Lacey: The skills are there. The techniques have been used in our other populations. I think what is particularly exciting for those that are massively obese is the interplay between surgery and psychological and behavioural techniques. This is very exciting and showing perhaps the first glimmers of hope for this massive obese population.

Q242  Dr Taylor: Are there guidelines for psychiatrists, particularly for coping with weight gain associated with the anti-depressant drugs?

Professor Lacey: No. It is worth just noting that obesity is not a part of the curriculum for the memberships of the Royal College of Psychiatrists, and indeed it is worth noting that even the study of anorexia nervosa is not part of the curriculum of the membership of the Royal College of Psychiatrists.

Q243  Dr Taylor: Obviously the latter two should be, should ordinary obesity be?

Professor Lacey: Yes, I think so. I think increasingly psychological techniques, behavioural techniques and the sort of multi-disciplinary teams that psychiatrists have brought to perfection, perhaps more than our general medical colleagues, is probably the way forward for those people that are very overweight.

Dr Taylor: I cannot help commenting on something that Professor Alberti said earlier, that he used to recommend 600 calorie diets, whenever I tried to do that I got into terrible trouble from my dieticians because dieticians seem to have a rule that anything less that 800 is positively dangerous for you. That was only a comment.

Q244  Mr Burns: Professor Wardle, there has been a huge increase in obesity in England and paradoxically the best-seller lists are littered with books on dieting, what do you think is going wrong there?

Professor Wardle: One of the great paradoxes, there are several in relation to obesity and it has proved quite hard to find evidence that people's own attempts at weight control, following the advice of diet books, make a substantial difference to their weight gain over time. I think one explanation for this may be that your typical diet book is promising something which it cannot deliver, namely there is something that you can do, just for six weeks or twelve weeks or ten weeks which is going to produce some marvellous outcome and either it does not or even if it does if you then revert to your usual life-style then all the same problems are going to reemerge. I think that the diet book and the diet industry has been based on something which is attractive to consumers, which is quick-fixes, and the obesity problem has not come from and is not going to be resolved by quick fixes.

Professor Lacey: If I can add to that, a lot of the diet books are not aimed at people that are even overweight.

Q245  Mr Burns: Absolutely. Young people are constantly been presented with stereotypes in magazines of models and celebrities who are super thin, glamorous and beautiful, can you comment on the impacts, such as it is, on the behaviour of young people?

Professor Lacey: I think it is quite mild. All advertising has an effect, as my colleague on my right said. It seems that in fits particularly with the susceptibilities of young girls. The reasons for this are complex but, of course, women are fattier than men and it is there for sexual reasons and therefore they are particularly likely to be affected by such images. There seems to be a great deal of pressure on women particularly to be slim. Interestingly enough there is no evidence that men prefer women to be slim but every evidence that women prefer women to be slim. The evidence from men, if anything, is that a more Rubenesque figure is more attractive.

Q246  Andy Burnham: Can we come on to health promotion and health education professionals and possibly a question for Professor Lacey and Dr Rayner, to what extent do we need to improve health promotion advice and eating advice we are giving at a primary care level? It seems to be a bit flat. People are becoming much more interventionist, do you have any thoughts on that?

Dr Rayner: We have to make sure that we understand that it is a holistic model, it is about not changing people's ideas. If it was just about changing people's ideas the diet books would have been successful. The fact that there are so many diet books it proves they are all not very good. If we are competing in a terrain where there is so much advertising, so much discussion of food continually and yet we have this emerging problem it is clearly not going to be an approach that is merely going to be competing with all of the images out there round the same topic. You have to look at a perspective which, as I said, protects children, I think, which looks at the settings where people are, which understands why people are doing physical activity less and construct to help promotion strategy round creating normal activity. The mention of getting people to walk more, and so on. In towns it may be the construction of urban walks to make walking something which is natural rather than getting into your car.

Q247  Andy Burnham: Those messages are well understood by the public. If you tested those ideas about tackling obesity you would get high recognition about and exercise diet, people understand them. Changing behaviour is the key, the question I really want to get out of you is, is there enough sophistication about understanding the needs of patients and what will trigger a change in behaviour? It is all very well having the messages do we have to educate health professionals more so they can trigger those changes?

Professor Lacey: I now understand your question, there is a dearth of knowledge amongst many different professional groups. I have indicated in my own profession on the sort of advice that should be given to patients, so I think it is an issue. I think that often the advice is to go on some sort of diet, sometimes a crash diet, as Dr Taylor was commenting on a moment ago, and of course the dangers of this are often not fully recognised. It is probably the best way of a young adolescent to develop a binge eating pattern, and then you go off not into obesity immediately but via bulimia nervosa you go into obesity later. I do not think advice is well formulated, not only is it not well known I do not think that the professionals in the area that do know have properly formulated it for their general and professional colleagues.

Professor Sir George Alberti: We really do not know how to achieve behavioural change. We do not actually know what advice to give. When I chaired a national nutrition research programme in the United Kingdom the top three priorities people chose for further work were all to do with behavioural change, because we did not have the tools and the knowledge to do this. We are scratching round but we are not good at it.

Andy Burnham: With smoking and drink there is a clear, if you carry on you will die, that clearly does change people's behaviour. With food it is not quite the same.

Q248  Jim Dowd: Why are food manufacturers so good at promoting behavioural change?

Professor Sir George Alberti: We have tried to ask them to help us do research into this but they were not keen.

Professor Wardle: There has been limited research on the extent to which the public really understand the association between life-style and weight gain. One of the things that comes up time and time again when you work with people who are overweight is their misunderstanding of portion sizes and the amount. The message about trying to eat lower fat foods has got through fairly well. You can see the saturated fat intake has gone down and overall fat intake is not going up. Portion size knowledge, certainly when we see families with overweight children and we show them what the recommended portion sizes are for children of that age group they are totally stunned. You know when you buy a little small packet of cereal time and time again people say to me how does somebody have that amount, I always have to have two. This relates to the super-sizing issue in fast food places that is giving people the message that these are normal portion sizes. I think that is one thing that is very important.

Q249  Andy Burnham: Do you think we are losing that kind of shock, for example when you go to America and get a coke in the cinema it is absolutely massive?

Professor Wardle: You can see it all happening here.

Q250  Andy Burnham: It is going that way.

Professor Wardle: Some of the new cinemas are selling their popcorn in what look more like buckets than anything else. I think the comment earlier, which has come up several times, nanny state and multi-sectorial influence in trying to get changes in health education, one of the reasons that I think it would be really important that school food should be healthy is not just the impact that will have on children's diets but the impact that has on the message that we are giving out about the critical importance of this. It is the message that it is okay in schools to have soft drink machines and sweet machines. Likewise in hospitals, St George's have opened a Burger King in their foyer. What message does that give about what health professionals think?

Q251  Andy Burnham: It is much easier to give people a positive message, say to children, "do more exercise", intervene in that way and give more positive opportunities rather than come in with messages about banning drink machines in school. The side of the equation where we can change behaviour is increasing physical activity and doing that through providing better sports facilities, prescribing exercise at a primary care level, giving people walking counters to wear, that kind of thing. Going heavy on the other side, banning advertising, maybe that ---

Professor Wardle: You are comparing going heavy there with not going so heavy on the activities side. I think it would be completely wrong if you reached the conclusion that we should intervene on the energy expenditure side and not be thinking of intervening on the energy credit side. All the evidence suggests that the two things work together. The energy density of the diet is a crucial influence on obesity change, epidemiological studies show that. It would be a mistake to say that. As a matter of fact, we have not yet had a single intervention study in schools which has produced good outcomes in terms of weight change in children. Yes, I think we should be trying to do these things for lots of reasons, but it is not an obvious and simple answer and you can forget about the input side. I would say there was zero chance of significantly impacting on the obesity epidemic if you take one side of the equation and ignore the other.

Q252  Andy Burnham: My local PCT has just had a small amount of funding to promote physical exercise. Would you favour that being used to promote exercise?

Professor Wardle: As part of the interventions for overweight and obese people, absolutely. I think at the public health level you have to think about how we shift the average level of physical activity back up again. Where it has slumped over the past 50 years we will have to think about how to push it back up. The answers there do not just lie in what you do in schools or in health education, they also lie in the design of environments, in the design of buildings and in the design of workplaces, it all has to work together.

Q253  Dr Naysmith: I have heard a professional in this area say - and it is quite obvious I am not going to agree with Andy here - that it is just a waste of time going for the exercise bit unless you also do the other half of the equation we are talking about. Is that an extreme view?

Professor Sir George Alberti: I think anything helps.

Professor Wardle: I was taking the view that the Committee should not say one thing or other.

Professor Sir George Alberti: The Department of Health's view was to go for the exercise and the dos rather than the don'ts and that is very much what you were getting at too.

Q254  Dr Naysmith: And if you just do that then you are fooling yourself, are you not?

Professor Sir George Alberti: I think so, yes. A lot of people will get a modest impact from exercise but I think you need the other message as well. It is about the quality of food, which Jane was mentioning, as well as the actual quantity.

Professor Lacey: Can I just say, to coin a phrase, obesity is a big subject. With massive obesity exercise as a form of treatment has comparatively little to give, frankly, because of breathlessness and joint problems, it does not have a big role at all.

Q255  Andy Burnham: Are there not a whole range of practical steps we could be taking on either side of the equation that we are not taking at the moment?

Professor Lacey: Yes.

Q256  Andy Burnham: That could have an impact within five or ten years.

Professor Wardle: It has been multiple small changes in society which have contributed to the changing population weights and we are going to have to intervene in multiple ways to push it back down again, there is not one simple answer.

Q257  Dr Taylor: We had an excellent presentation last week from our advisers which really brought home the enormity of the problem and that is the fact that it is behavioural change that we are aiming for. I have to remind the Committee of a quote I have already used once before. A member of the station staff at home who was picking up fag ends said, "We might be able to change policies, it's a job to change people." I thought that was very apt. It says in Dr Rayner's evidence that the market for biscuits, chocolates and sugared confectionary alone added up to £7.43 billion in 2001. Somehow we have got to change the behaviour of people so they do not want to buy that sort of food and the producers produce the food that they ought to be eating. How do we do that?

Dr Rayner: I think we are actually having to consider these issues for the first time and going back to the dearth of research in this area, starting with smoking, where you have a similar situation, where you want to change behaviour. What tools do you have for doing that? One of them is the taxation system. Another one is telling them they should not do it or giving incentives for not doing it. There is a whole set of things and I think these still have to be properly explored in terms of the impacts. We have differential taxation on tins of beer according to the alcohol content. I think we should apply similar reasoning in terms of certain types of foods. You could look at some ways of controlling the marketing of foods. It may be that we want to introduce taxation. At least we should be exploring these things. We do not have enough information to say what the impacts will be on these things. I think there are big public policy issues in modelling the impacts both on the industry and on individuals from doing this sort of work. It is early days, but I do think it needs to be done, I think that work needs to be commissioned. Whether it is the Department of Health or the Treasury or someone else, the sort of work that is being done in the tobacco field needs to be applied in this area.

Q258  Dr Taylor: Any other thoughts from any of the other members of the panel on how we change behaviour?

Professor Peto: Following the analogy with tobacco, some of the information that you have heard today could be condensed on little labels and go on packets of biscuits. It is not clear what effect the health messages on packets of cigarettes have but they have had some effect. The other thing is people ought to know what their BMI is. I do not know what my body mass index is. I have always assumed it is not too big. People talk about obesity, but most people do not even know whether they are technically obese. Maybe we should be finding out about what proportion of people die of heart disease and cancer and diabetes above levels of 25, 30 and 35 and so on and putting on the packet, "Do you know your BMI?" If you put that on a packet of biscuits and stick ten per cent in tax on it, it would have some impact. It has the merit of saving money as well. Teachers weighing children and recording it and sticking messages on packets of biscuits while you increase the taxation, Gordon Brown would love all that because you would get huge benefits from the expenditure.

Q259  Dr Taylor: So food labelling is something we should address?

Professor Peto: Yes, because the information is just lacking. Even educated people do not know this. I am sure a lot of people in this room did not know all these facts until a week ago. It is not common knowledge.

Q260  Dr Taylor: I have been looking at food labelling for a salt debate yesterday and on some packets of crisps and things it is in seven different languages, but the bit you need to know is almost illegible because it is so small, so it really is something to tackle.

Professor Peto: It needs to say "kills" in letters three foot long.

Q261  Jim Dowd: It is also a question of the usefulness of that information. On sweet packets they have how many kilojoules there are in it and various numbers referring to magnesium, but these things just do not mean anything to anybody. Is 2,000 a big number, is it a small number, should it be more, should it be less, it is information but it carries no meaning.

Professor Peto: If it said what the death rate was above certain levels of body mass index I think that would concentrate the mind. If people could talk about that in the pub I think it would help.

Chairman: It was 38 inches and it has come down to 36 this week. Some of us are getting a bit worried!

Q262  Dr Taylor: That sort of measurement is what we like because it is so easy to comprehend.

Professor Sir George Alberti: Can we take any of this on until you take the food industry on? I am just thinking about what they have done in the States recently. After a very sensible WHO statement the food industry then attempted to get Bush to withdraw the United States' support for the World Health Organisation. That was just overt behaviour of the sort we have had in a covert way in this country for a very long time.

Q263  Dr Taylor: This was very much the message from last week, that we have got to change the behaviour of people so the demands on the food industry change and that is the crucial thing.

Professor Lacey: You might consider trying to change the behaviour of the food industry where it is likely to do so, which is a means that increases their profits. You have already said, perhaps with some disparagement, about the idea that there is a greater margin on fruits and vegetables than there is on other products, but maybe that is something we should be encouraging.

Q264  Andy Burnham: We have focused in this debate on food. What role is alcohol playing in this drive? People do not really think about the calories as much when they are drinking, but there is a huge calorie intake when you go out for a few beers. Are we thinking enough about this?

Professor Wardle: I think it is an important issue. It seems to be poorly regulated. Whereas to some extent calories from food will suppress your urge to eat more calories within the next little while, calories from alcohol do not seem to have such a suppressant effect. It is certainly being argued that children often put on a substantial amount of weight while they are at university which, as everyone has said, is extraordinarily difficult to get off again. They are not becoming obese at that age, they are just accelerating their trajectory and there is quite a lot of suggestion now that the high levels of alcohol in student life is contributing to this.

Professor Peto: I think the quantity of this is important. The fact is that drinking small amounts of alcohol reduces overall mortality and it reduces mortality from heart disease. The real danger in all these things is that you are being seen as the killjoy nanny state. Excessive drinking is very dangerous. Moderate drinking is actually beneficial to health. If that message goes across at the same time it would make the package more attractive. To target alcohol in this context is a mistake, I do not think it is the point. Heavy drinkers may get fat but that is not the fundamental reason for obesity in the population.

Q265  Andy Burnham: Surely there are people who eat a fairly moderate and balanced diet but drink a lot of beer and they are overweight because of their drinking.

Professor Peto: Excessive drinking is dangerous just as excessive eating is dangerous. There is a danger with alcohol because it is such a part of the social fabric and because in small quantities it is beneficial. Most people are moderate drinkers. The proportion of the population who drink dangerously is really quite small.

Q266  Dr Naysmith: That view is not accepted by everyone, the fact that moderate drinking is not harmful and it may even be helpful.

Professor Sir George Alberti: Three units a day added up over a year is an awful lot of calories. People have at least to know - and many people do not - that there are actually calories in beer, wine, etcetera, that is an educational thing, it is part of your daily calories.

Professor Wardle: From a population point of view, if you calculate how many excess calories per person per day have to be consumed to shift the weight up like that, we are talking about very small amounts of calories. So people have got to learn. It is thought that probably the average over-consumption is 100 calories a day. Most people cannot tell subjectively the difference between a meal which has 500 and 600 calories.

Q267  Andy Burnham: I am sorry to labour this point, but it seems to happen in the States that "lite" beers are very common and we do not have that at all here. Have we not picked up on this issue at all or has it been in a much less developed way?

Professor Wardle: I think not.

Q268  Mr Burstow: I wanted to move on from the issues around influencing behaviour which we have been talking about to broader strategies for change and try to get from all of you some steer as to those small incremental changes that Professor Wardle was talking about. We have had small changes that have led to where we are now, we need to step back through a series of small changes. The NAO published a report in 2001 on these issues and it outlined initiatives that were being taken. Dr Rayner, can you say whether or not you feel the package of measures that is already in place both locally or nationally of itself will be sufficient to make a difference over the next few years, or do we need to do other things as well?

Dr Rayner: There are some initiatives which are highly commendable. One is putting fruit into the hands of school children. That is a particularly important strategy, developed by the Department of Health and paid for by the New Opportunities Fund. I think that is critical. The trouble is that these are often isolated things. I think I have said a couple of times they need to look at whole systems and not just elements within things. It is getting a reconnection and a cultural change towards an acceptance of fruit and vegetables, which is an absolutely critical issue. Going back to other things, they need to be supplemented by the protection side. We cannot always have positives without dealing with the negatives. That is the area which governments do not like dealing with and they do not like dealing with it because they are subject to the "nanny state" criticism. We were just talking about issues of alcohol a moment ago but the issue of carbonated drinks in schools is particularly important. I do not know that it is about banning it, it is protecting children from a drink that is 50 per cent sugar. I prefer to see it in those terms. To give an example, there are certain cereals on the market which are aimed at children when actually you should not be calling them cereals, you should call them sugar products with added cereal ---

Q269  Mr Burstow: And salt.

Dr Rayner: And salt. So it is not just the fruit in school issue, which is one initiative which is commendable, it is the total package of joining up that is essential.

Q270  Mr Burstow: Could you signpost any other countries where they have gone down a much more aggressive route in terms of labelling to raise awareness of those sorts of points?

Dr Rayner: If you look around Europe certainly the Swedes would be a good example of people who are thinking about those things and they are thinking about it both from one side of it, which is protecting children from food advertisements, right the way through to the investigation of the impact of the Common Agricultural Policy. So here is a society that is concerned about those things and it is showing in terms of their general health indicators, which are superb where health inequalities are much smaller (almost tiny in comparison with the UK) although obviously they have made their expenditures on health services too. So there are good examples. Mention has been made of California. California is interesting because the problem there is so large that the states and communities and individuals are driven to take action. So, if you like, there is one set of examples where societies want to be ahead of things merely because they have a very mature response to things, and there are other examples of societies merely by the size of the problem saying, "We have to do something." In California in schools there are charters to protect children, they have nutrition, they are stopping the "sweetheart" deals between the vendors of carbonated drinks, and so on. I think there are lots of other examples around Europe as well. What we do know in terms of Europe is there is not enough serious, good quality research pulling these things together. One of the bits of added value that the European Union should be doing is pulling together good examples of health promotion around Europe. In England at the moment the Health Development Agency is putting an evidence base around obesity and that will be available soon, I have not seen it in draft yet. Clearly it would be useful for the Committee to visit places around Europe and the US and to see the two dimensions, both the prospective where they are looking ahead and also these emergency actions where the communities are taking efforts into their own hands.

Q271  Mr Burstow: Thank you for that. I want to ask a question which might be useful for all witnesses to answer. What do you all feel should be the key priorities for government that we ought to be considering in terms of the report, in terms of what should be done first or next, in terms of where we are now? What should be done next as a key priority? What would be the things you are recommending?

Dr Barrett: From a child health point of view increasing opportunities for children to undertake organised exercise in schools and raising the priority of exercise on the curriculum in primary schools would be very helpful. And, secondly, warning on dietary products aimed at children of the health dangers of obesity from them would also be very helpful.

Dr Rayner: I would reiterate some of the points I have already made. First of all, this Committee's work is very, very important because we are now taking the issue very, very seriously. That means we cannot just have bits of intervention, we need a total whole society perspective. Therefore, we need information and we need a change of attitudes in the general public. We need to be more assertive in the way we deal with manufacturers. That needs to be a joined-up across government. We cannot have one department of government undermining another department, the Department of Health for example, by relationships with food manufacturers. In the Department of Education, for example, people have mentioned things like "free books for schools", you need consistency across government.

Q272  Mr Burstow: There has been a change for lead responsibility now in terms of children's policy and it is now within the DfES under Margaret Hodge. Is that a good thing, bad thing or completely neutral in terms of what you are talking about?

Dr Rayner: It should be very positive, if she takes up the issues seriously. The problem was we have been force fed, if you like, the head side of education. It has become cerebral and we have had this body of "mind jewellers" and it is all about children's heads, cramming as much in as possible. We actually now should be attending to their bodies.

Professor Peto: I would recommend that children are weighed and measured every year or two at the school and a leaflet sent home to their parents saying what their body mass index is with some information on what the long term implications of that are. We should also have the change compared to the previous year because it is very important that people see which direction they are moving in.

Professor Lacey: A recognition of the importance of providing adequate treatment for those that are severely affected, a recognition that there are treatments that have been shown to be effective in adjacent conditions, and a recognition that the harnessing of these in multi-disciplinary teams is probably the best way forward, including surgical techniques for those that are severely affected, those that are massively obese. I would like to append that comment onto what was just said because we were talking about very active approaches in how to deal with food. I think it is very interesting that Sweden, where they have laid a great deal of emphasis, as we were talking about on the danger of gaining weight and also weaning school children off sugars, is also the country which has seen the most rapid increase in eating disorders over the same period of time, so we have to be careful on how it is done.

Professor Wardle: At the risk of reiterating, I guess I would agree with a whole number of things which people have said already, Professor Peto's point about surveillance is tremendously important and what one needs is continuing surveillance because when you see about age 10 BMIs progressing upwards then it is very unlikely that is going to spontaneously remit by that kind of age. Secondly, engaging with industry in the idea that what we are trying to produce in a safer food environment for the whole society is important. It is not engagement by what we are going to ban or not going to ban, whether it is providing information or modifying constituents of food, it is this notion that part of the world that we are all responsible for is not just emissions from cars and safety of water, it is also the broader food supply to which people are exposed. Similarly I think the same issue applies to physical activity. We need health impact assessments on all kinds of environmental changes which look at the extent to which they either depress or facilitate physical activity. For the most part the physical activity of the future that is probably going to change things is not going to gyms, it is the amount people walk or the amount they cycle. Of course these things are on everybody's agenda but I think we would all agree they should be increased. Lastly, I would agree we need to have specialist clinical services because what you want is an approach which recognises the need to treat people who have already become obese as well as a need to prevent obesity in those that have not yet got there.

Professor Sir George Alberti: Again agreement with quite a lot of the things. Starting in schools is absolutely vital and doing more there. When you get to our stage of life the odds of behavioural change are limited. Even if our Secretary of State managed to stop smoking, not many of us do manage that. So schools, adult physical activity, more emphasis on better facilities for it are all very important. I think better education of health professionals is important. It is something that does not come through well in medical schools or in post-graduate teaching at all. I think that needs to come in. Food labelling, but with the associated information so people know what it means. I think we have got to get our heads round that and it is important. I did wonder as a slight tease whether perhaps we should performance manage our strategic health authorities on the rates of obesity or rates of increase in obesity on their patches and they lose a star if they are not doing well. That really focuses the mind.

Q273  Mr Burstow: That has been very helpful. One final thing, the thread that has come through in the discussion so far has been this issue of stigma, whether it is a good thing or bad thing and I thought it might be useful to get witnesses' views about whether to stigmatise or not to stigmatise as a way to address this issue?

Professor Lacey: As a representative of a profession that has had to deal with stigma, particularly in medicine with psychiatric illnesses, I would be very vehemently against the whole notion of stigma. What we have heard is that the responsibility of the individual is only one part of it, parents, et cetera. If we are to be effective we have to work with the grain and I do not think you do that by pointing fingers at any particular group and you certainly do not get it by pointing fingers at parents. They often feel guilty enough as it is. They need education and guidance, they do not need to be pilloried.

Professor Sir George Alberti: Certainly medically it is anti-Hippocratic to stigmatise a patient and it is anathema as far as I am concerned. Over and over again you find if you treat something positively rather than negatively you stand some chance of success. We are all around to help our fellow men and I think we should be helping not labelling.

Q274  Chairman: Thank you very much indeed, it has been a very interesting and informative session this morning and I would like to say thank you to all our witnesses. If there is anything you want to add to what you have said in writing or ---

Professor Peto: I would like to add something with a diatribe about data protection. It is something that absolutely essential to British medical research and particularly essential to an issue like this where you want to monitor the population and see what happens. I would very much welcome a general comment about the damage that is being done to medical research by data protection, particularly medical confidentiality legislation. It is an extraordinary innovation, it has transformed the work we do in a catastrophic way. I do not know if other people would agree

Q275  Chairman: I see some nods of agreement from some of your colleagues but it is verbally on the record and it will be in the minutes. If there is nothing further ---

Professor Peto: I was asking you to headline it.

Chairman: --- Thank you very much for your attendance.