Conclusions and recommendations
1. The
Clerk's Department Scrutiny Unit has recalculated the total estimated
cost of obesity is £3.3-3.7 billion. This is £0.7-1.1 billion
(27-42%) more than the NAO estimate for 1998. The difference between
the two figures occurs for a number of reasons including higher
NHS and drug costs, more accurate data that have been produced
recently, the inclusion of more co-morbidities and the increased
prevalence of obesity. This figure should still be regarded as
an under-estimate. We note that these analyses are for the 20%
of the adult population who are already obese. If in crude terms
the costs of being overweight are on average only half of those
of being obese then, with more than twice as many overweight as
obese men and women, these costs would double. This would yield
an overall cost estimate for overweight and obesity of £6.6-7.4
billion per year. (Paragraph 66)
2. Given the profound
significance of overweight and obesity to the population we believe
it is essential that the Government has access to accurate data
on the actual calories the population is consuming, including
figures for confectionery, soft drinks, alcohol and meals taken
outside of the home. Although we acknowledge the difficulties
of obtaining accurate data, given the limitations of any self-reported
survey, the current information is very weak and clearly underestimates
actual calorie consumption. We recommend that work is urgently
commissioned to establish a Food Survey that accurately reflects
the total calorie intake of the population to supersede the flawed
and partial analysis currently available. The Food Standards Agency
and Scientific Advisory Committee on Nutrition should advise on
this. (Paragraph 72)
3. The relationship between alcohol consumption
and obesity is too little understood. We recommend that the Department
of Health commissions research into the correlation between trends
in alcohol consumption and trends in obesity.
(Paragraph 87)
4. We were appalled
that a £710,000 campaign, launched by one of Britain's largest
snack manufacturers, deliberately deployed a tactic which explicitly
sought to undermine parental control over children's nutrition
by exploiting children's natural tendency to attempt to influence
their parents. The fact that this campaign was approved by the
Advertising Standards Authority does not exonerate it, but merely
demonstrates the ineffectiveness of current ASA standards and
procedures. (Paragraph 111)
5. The causes of obesity
are diverse, complex, and, in the main, underpinned by what are
now entrenched societal norms. They are problems for which, as
our expert witnesses have emphasised, no one simple solution exists.
However, to fail to address this problem would be to condemn future
generations, for the first time in over a century, to shorter
life expectancies than their parents. A recent report by the Royal
College of Physicians, Royal College of Paediatrics and Child
Health, and the Faculty of Public Health emphasised the need for
solutions to be "long term and sustainable, recognising that
behaviour change is complex, difficult and takes time."
We believe that an integrated and wide-ranging programme of solutions
must be adopted as a matter of urgency, and that the Government
must show itself prepared to invest in the health of future generations
by supporting measures which do not promise overnight results,
but which constitute a consistent, effective and defined strategy.
(Paragraph 153)
6. While the NHS is
clearly central to tackling obesity through providing specialist
health promotion and treatment for people who are already obese,
we believe that the most important and dramatic changes will have
to take place outside the doctor's surgery, in the wider environment
in which people live their lives. And while we recognise that
individuals have a key role to play in determining their own health
and lifestyles, as the main factors contributing to the rapid
rises in obesity seen in recent years are societal, it is critical
that obesity is tackled first and foremost at a societal rather
than an individual level. (Paragraph 154)
7. We feel strongly
that the problem of obesity needs to be recognised and tackled
at the highest levels across government. We therefore recommend
that a specific Cabinet public health committee is appointed,
chaired by the Secretary of State for Health, and that one of
its first tasks is to oversee the development of Public Service
Agreement (PSA) targets relating to public health in general and
obesity in particular, across all relevant government departments.
(Paragraph 159)
8. We recommend that
the Government should consider either expanding the role of an
existing body or bodies, such as the Food Standards Agency or
Central Council of Physical Recreation (or linking these), or
consider the creation of a new Council of Nutrition and Physical
Activity to improve co-ordination and inject independent thinking
into strategy. (Paragraph 160)
9. We strongly endorse
the Wanless Report's recommendation that the Government must assign
clear responsibility for the health educational role, previously
played by the Health Education Authority, a fact made clear in
correspondence from the Department to the Committee. (Paragraph
169)
10. We were very surprised
that despite its occupying 'joint top priority' on the Government's
public health agenda, there have been no health education campaigns
aimed at tackling obesity. Although we acknowledge its benefits,
we do not accept the Government's view that the Five-a-day fruit
and vegetable promotion campaign is either designed for, or capable
of, addressing the nutritional aspects of obesity. In recent years
the Government has funded health education campaigns around, amongst
other things, smoking, teenage pregnancy and sexually transmitted
infections. The order in which other public health issues have
been addressed, and the exclusion to date of obesity from this
list, make the Government's actions in this area appear haphazard
rather than strategic. (Paragraph 170)
11. If the Government
intends seriously to address obesity through health promotion,
it must adopt a health education campaign dedicated exclusively
to tackling obesity, which should follow the model used in the
recent anti-smoking campaign, plainly spelling out the health
risks associated with being overweight or obese, and also highlighting
those nutritional and lifestyle patterns which are most conducive
to weight gain. It should specifically identify 'high risk' foods
and drinks, and should also emphasise the fact that consuming
alcoholic drinks, like any other high-calorie food or drink, can
also be conducive to unhealthy weight gain. At the same time,
it should highlight the importance of physical activity both in
preventing obesity and reducing weight levels. Part of the campaign
should emphasise the crucial links between obesity and diabetes,
and between obesity and cancer (which we have heard is barely
known by the public as a whole). We recommend that such a health
promotion campaign should be launched as soon as possible, with
the Food Standards Agency advising on the nutritional content
of such promotion, and the Activity Co-ordination Team, if this
remains operational, or alternatively Sport England through its
links with Move4Health advising on the physical activity dimension.
(Paragraph 171)
12. Understanding
the importance of healthy eating is meaningless without the skills
to put these messages into practice. The huge demand for initiatives
such as the Focus on Food Cooking Bus is a testimony to the extremely
limited opportunities for cooking and food training within schools,
and also to the desire of both pupils and teachers to have access
to this type of training. While we fully support these initiatives
and acknowledge the good work they are doing to bring this training
back within reach of school pupils, we feel that learning about
how to choose and prepare healthy meals should be an integral
part of every young person's education, not an optional extra
delivered only periodically. This is currently not the case. We
recommend that the Government takes steps to reformulate the Food
Technology curriculum, so that children of all ages receive practical
training in how to choose and prepare healthy food which they
can put into practice in their daily lives. As well as practical
cookery lessons and classroom lessons about nutrition, children
should also be taught how to understand food labelling and how
to distinguish food advertising and marketing from objective fact;
they could put their knowledge to the test in visits to a local
supermarket. Healthy Schools initiatives have demonstrated the
additional value of engaging children in projects to grow their
own fruit and vegetables, fostering an understanding of where
foods come from as well as reinforcing their motivation to eat
more healthily. This should also form part of the food curriculum
in schools. In order to achieve this, steps will need to be taken
to strengthen teacher training in these areas. (Paragraph 174)
13. We recommend that
delivery of the Food Technology curriculum should be rigorously
inspected by Ofsted. (Paragraph 175)
14. Health promotion
campaigns, as the recent anti-smoking advertising campaign has
demonstrated, can play a successful role in raising awareness
of the risks associated with particular behaviours, and to this
end we have recommended that a health education campaign targeting
obesity is launched as soon as possible. However, our evidence
suggests that obesity has increased rapidly despite the fact that
the benefits of a healthy diet have been well known for over 20
years. While we accept that individuals have the right and the
responsibility to make choices about their own health and lifestyle,
and we accept the importance of health education in enabling them
to do so, we believe that to tackle obesity successfully education
must be supported by a wider range of measures designed to remove
the key barriers to choosing a healthy diet. We therefore recommend
that the Government should concentrate its efforts not solely
on informing choice, but also on addressing environmental factors
in order to, in its own words, make healthy choices easier to
make. (Paragraph 181)
15. While we would
clearly support an expansion in the promotion of healthy foods
to redress the balance which currently lies entirely in favour
of unhealthy foods, this alone seems to be an idealistic and ill
thought-through notion, one which we are surprised that the Secretary
of State for Culture, Media and Sport was prepared to espouse.
(Paragraph 185)
16. Given the scale
of the public health hazard the country is confronted by, it would
seem appropriate to employ a precautionary approach where evidence
is contradictory. As we have said previously, we are committed
to long-term solutions to the problem of obesity. The Hastings
Review offered stark evidence of the extent to which advertisers
of less healthy foods were saturating broadcasting slots targeting
children, who are often watching without any adult present. While
we would not want to go so far as to call for an outright ban
of all advertising of unhealthy food, given the clear evidence
we have uncovered of the cynical exploitation of pester power
we would very much welcome it if the industry as a whole acted
in advance of any possible statutory control, and voluntarily
withdrew such advertising. There is clear evidence that the majority
of parents do not favour such advertisements during children's
television. (Paragraph 192)
17. In one crucial
sense, however, we share a concern about the effectiveness of
banning or controlling television advertising: as noted above
it is only a small part of the enormous food marketing effort
that is aimed at children. If television advertising were to be
banned, the marketing effort would simply be displaced to other
areas—money previously spent on television advertising would,
for example, be diverted to point of sale or internet promotion.
(Paragraph 193)
18. We gather that
the Secretary of State for Culture, Media and Sport is in discussion
with OFCOM over the marketing of less healthy foods. We would
like her to review the whole marketing function. In particular,
we would like her to address some of the issues the Irish Broadcasting
authorities are looking at, namely the impact of product endorsement
of less healthy food by sports stars, and other celebrities; guidance
on how these products can actually fit into a healthy diet, perhaps
linking into nutritional information; and their impact on the
energy equation in terms of the activity needed to displace the
calories they add. Assuming the food and advertising industry
is genuine in its desire to be part of the solution, a starting
point for this would be for companies to agree clear public health
targets. (Paragraph 194)
19. As we noted earlier,
we were disturbed at the ineffectiveness of the Advertising Standards
Authority, which is an industry self-regulation system. We recommend
that OFCOM be asked to review the role of the ASA with a view
to improving its effectiveness. This is not the first occasion
on which the Health Committee has found the performance of the
ASA to be disappointing. (Paragraph 195)
20. We feel that the
school environment can have a strong influence over children's
developing nutritional habits, and that the Government must not
neglect this crucial opportunity to promote healthy eating to
children and help them develop sound lifelong habits. Healthy
eating messages learnt through the national curriculum and Government
healthy eating initiatives such as the schools fruit campaign
will be contradicted and undermined if, within that same school
environment, children are exposed to sponsorship messages from
unhealthy food manufacturers, and given access to vending machines
selling unhealthy products. There is evidence that parents are
keen to see unhealthy influences removed from schools, with recent
research finding that as many as 70% of parents were in favour
of banning vending machines in schools. Recent research by
the FSA also indicates that children are willing to purchase healthier
drinks from vending machines when they are given the option. Given
the worryingly steep rise in levels of childhood obesity, we feel
that parents, teachers and school governors must all be fully
engaged in tackling it, and that obesity should command a high
priority on school board agendas. (Paragraph 199)
21. We therefore recommend
that all schools should be required to develop school nutrition
policies, in conjunction with parents and children, with the particular
aim of combating obesity, but also of improving nutrition more
generally. In conjunction with this, the Government should issue
guidance to all schools strongly recommending that that they do
not accept sponsorship from manufacturers associated with unhealthy
foods or install vending machines selling unhealthy foods. If
Government insists that this is a matter for local determination,
we believe that governors should permit such practices only if
these are shown to be supported by a clear majority of parents.
The guidance should also give firm support for the replacement
of existing vending machines with ones selling healthy foods and
drinks. (Paragraph 200)
22. Nutritional labelling
is intended to help consumers make sound nutritional decisions
when buying food, but the current state of such labelling seems
to be having, if anything, the opposite effect. We have repeatedly
heard the argument, both from the food industry and from the Government,
that there are no such things as good or bad foods, only good
or bad diets. However, both the food industry and the Government
have embraced the concept of labelling certain foods as 'healthy'
with great enthusiasm, inviting the obvious conclusion that other
foods must be, by definition, less healthy. (Paragraph 214)
23. The Government
must accept the clear fact that some foods, which are extremely
energy-dense, should only be eaten in moderation by most people,
and we therefore recommend that it introduces legislation to effect
a 'traffic light' system for labelling foods, either 'red—high',
'amber—medium' or 'green—low' according to criteria
devised by the Food Standards Agency, which should be based on
energy density. This would apply to all foods. Not only will such
a system make it far easier for consumers to make easy choices,
but it will also act as an incentive for the food industry to
re-examine the content of their foods, to see if, for example,
they could reduce fat or sugar to move their product from the
'high' category into the 'medium' category. (Paragraph 216)
24. Bearing in mind
Derek Wanless's suggestion that greater effort needs to be made
to measure the effectiveness of different interventions, we believe
that this recommendation would lend itself well to objective assessment.
If the scheme we propose is accepted, it would be relatively simple
to measure the impact on the range of relatively healthy and unhealthy
foods offered by supermarkets, and any shift in the patterns of
consumption from relatively unhealthy to relatively healthy products.
(Paragraph 217)
25. We note the Government
has made efforts to date to reduce salt levels in foods, but we
feel that urgent attention should also be given towards tackling
obesity. We recommend that, rather than targeting sugar and fat
separately, the Government should focus on reducing the overall
energy density of foods, and should work with the Food Standards
Agency to develop stringent targets for reformulation of foods
to reduce energy density within a short time frame. While we expect
that reformulation could be achieved through voluntary arrangements
with industry, and while we believe that the introduction of legislation
in respect of labelling will encourage industry to make the entire
product range healthier, the Government must be prepared, in the
last resort, to underpin this with tougher measures in the near
future if voluntary measures fail. (Paragraph 222)
26. The notion of
taxing unhealthy foods is fraught with ideological and economic
complexities, and at this stage we have not seen evidence that
taking such a significant and difficult step would necessarily
have the hoped-for effect of reducing obesity. We recommend, instead,
that the Government should keep an open mind on this issue, and
monitor closely the effect of fat taxes introduced in other countries.
We also recommend that the Government should take steps to address
the anomalies in the current arrangements for VAT on unhealthy
'treat' foods as it is clearly ludicrous that VAT is levied on
ice cream and fizzy drinks but not on Bourbon biscuits or cakes.
(Paragraph 228)
27. We hope that as
the Government and food industry work together to reduce the energy
density of foods, the need for 'healthy' options will be gradually
reduced, with standard versions of foods being healthy as a matter
of course. However, as this is likely to be a phased process,
we recommend that in the short term the Government must work with
the food industry to ensure that 'healthy' versions of foods,
with reduced calories and fat, are available at an affordable
price. (Paragraph 230)
28. As a matter of
urgency, the Government must redouble its efforts to reform the
Common Agricultural Policy as part of the public health agenda,
and the future UK presidency from July 2005 will afford an opportunity
for this to be done. Obesity is, after all, a growing problem
in almost all EU countries. The issue of agricultural policy presents
a perfect opportunity for the Government to demonstrate that it
is committed to tackling public health issues in a joined-up way,
an opportunity which in our view it has to date entirely neglected.
However, as noted above, progress on the CAP will be extremely
difficult unless public heath is given much greater emphasis in
Europe. We therefore call on the Government to use its influence,
and its forthcoming presidency, to encourage the Commission to
reconsider the Treaty of Rome and put public health on an equal
footing with trade and economics. (Paragraph 237)
29. In the interim,
the Government, led by the Treasury should emulate the Swedish
Government and produce a Health Audit of the CAP, and build
a stronger alliance of Health Ministries to combat other interests
protecting the status quo in public policy. (Paragraph 238)
30. During this inquiry
we have heard repeatedly that industry is keen to be 'part of
the solution'. If this desire is to be translated into reality,
then supermarkets should adopt new pro-active pricing strategies
that positively support healthy eating, rather than acquiesce
in the view that their duty to their customers goes no further
than simply providing the range of foods which they want to buy.
As part of their healthy pricing strategies, supermarkets must
commit themselves to phasing out price promotions that favour
unhealthy foods, and also stop all forms of product placement
which give undue emphasis to unhealthy foods, in particular the
placement of confectionery and snacks at supermarket checkouts.
Alongside this, all sectors of the food industry should collaborate
in the phasing out of super-sized food portions. We expect that
the food industry will be keen to capitalise on the significant
commercial opportunity that introducing these policies will present,
and indeed much good work has already been done in this area.
Several supermarkets have already committed themselves to banning
the placement of confectionery at checkouts, and Kraft and McDonalds
have begun to limit the availability of super-size portions. We
commend fast-food outlets for offering fruit and salad options,
though we request that these should be promoted more effectively
than at present. Those companies who do not comply with Government
guidance on healthy pricing, including product placement and super-sizing,
should be publicly named and shamed. (Paragraph 241)
31. We recommend that
the Department for Education and Skills extend the scope of the
FSA review of the implementation of nutritional standards, with
a view to developing appropriate nutrient based standards for
school breakfasts. (Paragraph 248)
32. Furthermore, we
recommend that the Department for Education and Skills takes steps
to ensure that all children eat a healthy school meal at lunchtime,
both through improving the provision of attractive and palatable
'healthy' options, and through restricting the availability of
unhealthy foods. The Government should shift from the current
'food-based' standards towards the 'nutrition-based' standards
being introduced in Scotland. The quality of school meals should
also be taken into account by Ofsted inspections. (Paragraph 249)
33. We commend the
wide range of measures and substantial funding being directed
by the Government towards physical activity, particularly in schools.
While we have reservations about the effectiveness of measures
taken to date, we wish to pay tribute to the efforts that have
been made in the last two years and to acknowledge the substantial
funding that has been provided. (Paragraph 268)
34. We regard it as
lamentable that the majority of the nation's youth are still not
receiving two hours of sport and physical activity per week. While
we very much welcome the DCMS/DfES target to have 75% of school
children thus active by 2006 we do not believe that this goes
far enough. We have reservations about the quality of much of
the activity undertaken, since little work has been done to establish
what the two hours involves, and whether it includes, for example,
time taken in travelling to and from facilities. Moreover, even
the two hour target puts England below the EU average in terms
of physical activity in school, despite the fact that childhood
obesity is accelerating more quickly here than elsewhere. (Paragraph
275)
35. We recommend that,
given the threat of obesity to the current generation of children
and taking account of the proven contribution of physical activity
to academic achievement, the aspiration should be for school children
to participate in three hours per week of physical activity, as
recommended by the European Heart Network. (Paragraph 276)
36. Relentless pressure
on the curriculum has served to squeeze out school sport and PE.
However, there is ample evidence that being physically active
benefits children's academic performance, and many schools in
the independent sector offer four or more hours of exercise per
week. We know that the Government is monitoring closely the Brent
project but that it has been less than forthcoming with supportive
funding. We believe that this is a fascinating pilot project and
would like to see it rigorously evaluated. Given its potential
importance as a model, we also think it would be helpful if the
Department's favourable initial appraisal of the scheme were supported
by funding. (Paragraph 277)
37. We recommend that
the Curriculum Authority should address ways of diversifying organised
and recreational activity in schools to embrace areas such as
dance or aerobics to broaden the appeal of PE and to counteract
the elitism, embarrassment and bullying that the changing room
sometimes creates. (Paragraph 278)
38. We do not think
it appropriate that the activity of a school in delivering the
physical activity agenda should be extrinsic to any evaluation
of its overall performance. Physical activity is not—or
should not be—a second order consideration. Not only is
it crucial to children's health but it also directly benefits
academic performance. So we recommend that the Ofsted inspection
criteria should be extended to include a school's performance
in encouraging and sustaining physical activity. (Paragraph 279)
39. We recommend that
the Department for Education and Skills, as part of its wider
work to improve self-esteem and self-confidence amongst school
children, should ensure that each school, as part of its policy
against bullying, remains alert to the particular issue of bullying
of children who are overweight or obese. Teachers should receive
training in children's diet, physical activity levels, and how
to help obese children combat bullying, without further stigmatising
them. (Paragraph 280)
40. We believe that
providing safe routes to school for walking and cycling, adequate
and safe play areas in and out of school is very important in
the battle against obesity. (Paragraph 284)
41. The measures proposed
by the Environment, Transport and Regional Affairs Committee in
its report Walking in Towns 2001 strike us as sensible
and persuasive and we are sorry so little action has been taken
to implement them. (Paragraph 287)
42. Given the profound
impact increased levels of activity would have on the nation's
health, quite aside from the obvious environmental benefits, it
seems to us entirely unacceptable that successive governments
have been so remiss in effectively promoting active travel. (Paragraph
288)
43. We regard the
failure of the Department for Transport to produce a National
Walking Strategy over a period of almost ten years as scandalous.
This very inactivity clearly demonstrates that the priorities
of the Department lie elsewhere. We would be extremely disappointed
if concerns about political embarrassment had indeed obstructed
such an important policy. One way of defusing any political embarrassment
would be to incorporate the walking strategy into a wider anti-obesity
strategy. (Paragraph 292)
44. We believe it
would be helpful if commercial firms issuing pedometers also issued
guidance agreed with Sport England and the FSA, on the recommended
activity levels per day and on the correlation between steps taken
and calories consumed. (Paragraph 297)
45. We welcome the
funding the Department of Health has provided to a pilot project
on the use of pedometers. We recommend that the Department co-ordinates
inter-departmental activity with a view to achieving wide-spread
use of pedometers in schools, the workplace and the wider community.
(Paragraph 299)
46. It would not be
appropriate for us to spell out the individual measures required
to achieve the Government's ambitious cycling targets, although
we were particularly impressed by the segregation of cyclists
from road traffic we witnessed in Odense. If the Government were
to achieve its target of trebling cycling in the period 2000-2010
(and there are very few signs that it will) that might achieve
more in the fight against obesity than any individual measure
we recommend within this report. So we would like the Department
of Health to have a strategic input into transport policy and
we believe it would be an important symbolic gesture of the move
from a sickness to a health service if the Department of Health
offered funding to support the Department for Transport's sustainable
transport town pilots. (Paragraph 316)
47. There will be
profound economic as well as health costs to be paid if the current
obesity epidemic continues unchecked. Major planning proposals
and transport projects are already subject to environmental impact
assessment; we believe that it would be appropriate if a health
impact assessment were also a statutory requirement. This would
enable health to be integrated into the planning procedure and
help bring about the sort of creative, joined-up solution which
is required. This may seem a cumbersome and drastic step but we
believe that only such strong measures will help reverse the dramatic
decline in everyday activity that has occurred in recent decades.
(Paragraph 321)
48. We recommend that
the Department of Health, in conjunction with the Department for
Work and Pensions and the Department of Trade and Industry first
organises a major conference to promote awareness of obesity in
the work-place and then engages in an ongoing process of consultation
to see how measures can be taken to address sedentary behaviour.
We recommend that these Departments consult with the Treasury
to see what fiscal incentives can be provided to promote active
travel. (Paragraph 328)
49. We also recommend
that the public sector looks to set an example in finding creative
ways of encouraging activity in everyday life, and that this is
built into a PSA target for each Department. (Paragraph 329)
50. We welcome the
creation of the Activity Co-ordination Team though we regret it
took so long for it to begin its work. Anything that co-ordinates
Government activity in this complex and challenging field is worthwhile.
We await with interest the publication of its first report. We
recommend that its reports explicitly link its activity to the
Government's specific targets on activity both in schools and
in the community. (Paragraph 334)
51. The Department
agreed that Strategic Health Authorities (SHAs) should have information
about local work on obesity at their fingertips, and we recommend
that a survey of action on obesity, both at PCT and SHA level,
should be undertaken as part of the ongoing work on the forthcoming
White Paper on public health. (Paragraph 337)
52. We feel strongly
that Primary Care Trusts should be taking a more active role in
preventing obesity, and urge the Government to ensure that PCTs
have the capacity, competency and incentive to fulfil their crucial
obligation to safeguard the public health of the local communities
they serve. We also endorse the recommendation of the Wanless
report that the Healthcare Commission should develop a robust
mechanism for assessing performance of both PCTs and Strategic
Health Authorities with respect to public health. (Paragraph 343)
53. We feel that this
country's well developed network of primary care providers, local
GPs, provides a unique resource for health promotion and for the
identification and management of patients who are overweight or
obese. However, managing weight problems sensitively and successfully
requires specialist skills, and we are concerned by suggestions
that obesity is viewed by many clinicians as a lifestyle issue
rather than a serious health problem requiring active management
to prevent dire health consequences. We deplore the low priority
given to obesity by the new GP contract. We hope that NICE guidance
on the prevention, identification, evaluation, treatment and weight
maintenance of overweight and obesity, currently expected in Summer
2006, will go some way towards increasing the priority of obesity
within general practice, as well as helping primary care practitioners
develop and improve the services they provide in this difficult
area. The Government should also ensure that within each PCT area
there is at least one specialist primary care obesity clinic,
probably supported by a range of different health professionals,
to which GPs can refer any patients they identify as needing specialist
support to address a developing or existing weight problem. (Paragraph
355)
54. We recommend that,
in establishing primary care obesity clinics, PCTs should fully
explore the possibilities of using less traditional models of
service delivery, involving clinicians from across the professional
spectrum, from nurses to pharmacists to dieticians. The full range
of interventions available to treat obesity includes diet, lifestyle,
medical treatment and surgical treatment. (Paragraph 356)
55. We also took some
interesting evidence from commercial slimming organisations. We
recommend that the NHS examines whether their expertise can be
brought to bear in devising strategies to combat obesity holistically.
(Paragraph 357)
56. Obesity is a serious
medical problem. Although in common with other illnesses, its
prevention and some first-line management can be delivered within
a primary care setting, patients with more entrenched or complex
problems need prompt access to specialist medical care. Childhood
obesity is a worrying and increasingly common subset of this illness,
and children in particular need specialist care. Yet specialist
obesity services seem to be an almost entirely neglected area
of the NHS, apparently exempt from Government initiatives to push
down waiting times despite their obvious importance in preventing
a large range of other debilitating and costly diseases. We therefore
recommend that the Government provides funding for the large scale
expansion of obesity services in secondary care, underpinned by
careful management to ensure that the service provision is matched
to need. The Government's maximum waiting time targets must apply
to all of these services. (Paragraph 363)
57. We were appalled
to learn of the desperate inadequacy of treatment and support
services for obese children. Steps must be taken to ensure that
obese children and young people have prompt access to specialist
treatment wherever they live. (Paragraph 366)
58. We recommend that
throughout their time at school, children should have their Body
Mass Index measured annually at school, perhaps by the school
nurse, a health visitor, or other appropriate health professional.
The results should be sent home in confidence to their parents,
together with, where appropriate, advice on lifestyle, follow-up,
and referral to more specialised services. Where appropriate,
BMI measurement could be carried out alongside other health care
interventions which are delivered at school, for example inoculation
programmes. Care will need to be taken to avoid stigmatising children
who are overweight or obese, but given that research indicates
that many parents are no longer even able to identify whether
their children are overweight or not, this seems to us a vital
step in tackling obesity. (Paragraph 369)
59. We were dismayed
to hear that a specialist GP who devoted much of his time to trying
to tackle obesity in his local population was being put under
pressure from his local PCT to reduce his prescribing of drugs
to tackle obesity, despite these drugs having received approval
from NICE, with the corresponding obligation on PCTs to provide
funding for them. We were told by the same doctor that in 15 years
of practice he had never received communications questioning his
prescribing rates for drugs to treat heart disease or diabetes,
two illnesses frequently caused by obesity. This provides a telling
exposé of current attitudes towards obesity, whereby it
is regarded by NHS decision-makers as a lifestyle problem for
which treatment is an optional extra. We recommend that the Government
takes urgent steps to tackle this subtle deprioritisation of obesity
wherever it occurs in the NHS. (Paragraph 372)
60. Bariatric surgery
is in no way a panacea for the current obesity epidemic. Rather
it is a high-risk, invasive surgical procedure that represents
a last line of defence for people with life-threatening morbid
obesity. However as the number of people suffering from morbid
obesity in England looks set to increase, it is an option that
needs to be made available to all those who need it, and it is
unacceptable that in some parts of the UK patients with a life-threatening
condition are having to wait as long as four years for bariatric
surgery. We hope that the measures we have recommended to improve
provision of specialist obesity services in both primary and secondary
care will help to address the problem that many patients are not
referred for bariatric surgery simply because their local doctors
are not aware that it is an option. However, the NHS needs also
to ensure that adequate service capacity is in place fully to
meet need, which is patently not the case at present. The Government
must devote protected resources to ensuring that bariatric surgery
is available to all those who need it, and should issue guidelines
for the strategic development of services across the country,
to eliminate the current postcode provision of obesity surgery.
(Paragraph 379)
61. We feel it is
vital that advances in medical and surgical treatment of obesity
should be supported by equivalent development of services to address
the psychological and behavioural aspects of obesity. All those
receiving treatment for obesity, whether in a primary or in secondary
care setting, should have access to psychological support provided
by an appropriate professional, whether this is a psychiatrist,
psychologist, psychotherapist, counsellor, or family therapist.
(Paragraph 382)
62. The evidence we
received during the course of this inquiry has convinced us that
despite its overwhelming importance, obesity remains a low priority
for the majority of service commissioners and providers in the
NHS. The National Health Service has a responsibility both to
take strategic action to prevent obesity, as part of its public
health remit, and to provide adequate treatment for those already
suffering from overweight or obesity, as it would for those suffering
from any other medical condition. It appears to us to be failing
in both of these areas, and this needs to change as a matter of
urgency. (Paragraph 393)
63. We are fully aware
that obesity is mentioned in existing NSFs, but we believe that
these scant mentions are woefully inadequate to provide a strategic
framework through which to tackle what has been described as 'the
biggest public health threat of the twenty-first century'. We
also understand that a public health White Paper will be published
in the summer, but again we fear that the extent and seriousness
of the obesity problem will be lost by including obesity only
as part of a wider umbrella of general public health initiatives.
(Paragraph 394)
64. We note the Government's
reservations about committing to further National Service Frameworks,
which they voiced in response to our report on Sexual Health.
However, the current structure of the National Service Framework
programme places too great an emphasis on tackling discrete disease
areas, focusing on downstream consequences at the expense of the
upstream contributors to these diseases, including obesity. Indeed,
we heard compelling evidence that many general practices are unable
to devote time to tackling obesity because of their obligation
to meet targets in the Coronary Heart Disease and Diabetes NSFs,
even though, ironically, many of these 'competing' disease areas
can be directly improved by tackling obesity. And while it is
clear that general public health problems, such as smoking, can
be addressed within disease-based NSFs, the lack of obesity targets
has led to this area being systematically neglected. (Paragraph
395)
65. It is essential
that, as part of the Government's wider strategy to tackle obesity,
a dedicated framework document is produced to emphasise to a largely
sceptical NHS the full scale and seriousness of this problem.
The complexity of the challenge facing the NHS in this area, including
the need to develop services and care pathways across all tiers
of service delivery in a rapidly changing area of medicine, as
well as to take the lead on prevention and health promotion, makes
a detailed strategic framework vital. This document should build
on existing work in this area, drawing together and emphasising
the obesity measures already set out in the National Service Frameworks,
and linking in with the ongoing work of NICE. Crucially, it must
re-introduce realistic but stretching targets for reducing the
prevalence of obesity and overweight over the next ten years,
underpinned by more detailed, service-based targets, in particular
bringing waiting times for specialist medical and surgical obesity
services in line with all other NHS specialties. PCTs should be
stringently performance-managed on their delivery of these targets.
(Paragraph 396)
66. It would be very
difficult to disaggregate the possible impact of any of the recommendations
we make. We have argued for a coherent package of measures, addressing
both sides of the energy equation. We believe they would have
more chance of being effective if implemented in full rather than
in a piecemeal fashion. However, it is clearly important that
some steps are taken to monitor the effectiveness, and the cost-effectiveness
of what we propose, in line with the recommendations of the Wanless
report on public health. The National Audit Office undertook an
influential and ground-breaking report on obesity in 2001. We
know that they have maintained an interest in the subject thereafter.
So we would like the National Audit Office to conduct further
work on the value for money implications of measures taken to
combat obesity, since this will be one of the greatest pressures
on NHS resources over the coming decades. In calling for this,
we also note the point made in the Scrutiny Unit analysis annexed
to our report that there is a "severe lack" of official
estimates of the costs of diseases relating to obesity. We recommend
that the Department undertakes urgent work to establish better
estimates of the cost of treating diseases to allow it to manage
its resources more effectively. (Paragraph 403)
67. Overall in our
report we have looked for positive solutions. We have noted the
example of Finland, where the force for change came from a grass-roots
consumer response which took Government with it, rather than vice
versa. We have at several junctures recommended voluntary agreements
rather than regulation. We have chosen to accept the word of many
representatives of the food industry that they wish to be part
of the solution as well as part of the problem. Our belief is
that this is a line worth pursuing, not only because it is politically
far easier, but also because it could achieve results more quickly
than a protracted battle to implement regulation. (Paragraph
409)
68. Other pressures
will be brought to bear on the food industry. Consumers may start
to demand healthier products once unhealthy ones are properly
labelled. Litigation—which is already happening in the USA—may
alter the products available and customers' perception of those
products. The greatly increased media attention to the problem
of obesity may ripple through society and produce a change in
behaviour. (Paragraph 410)
69. This is an optimistic
way of looking at the future. However, the recent past trends
in the growth of obesity and overweight across the population
must temper such optimism. Our concluding thought is that the
Government must be prepared to act and intervene more forcefully
and more directly if voluntary agreements fail. We recommend that
the Government should allow three years to establish those areas
where voluntary regulation and co-operation between the food industry
and Government have worked and those where they have failed. It
should then either extend the voluntary controls or introduce
direct regulation. (Paragraph 411)
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