Select Committee on Health Third Report

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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