Select Committee on Health Minutes of Evidence

Memorandum by the Department of Health (OB 8)

OVERVIEW

  The Government welcomes the opportunity of this enquiry to set out its policy on the prevention and management of obesity.

  Obesity is an international problem, which no country has successfully tackled. There are inequalities in the prevalence of obesity, particularly among women. It is a complex multi-factorial condition which has genetic, social, cultural and behavioural causes.

  The Government is concerned at the impact that obesity has on health and disease and is committed to reversing the current trend of increasing overweight and obesity in both children and adults.

  The prevention and management of obesity are at the heart of many of the Government's priority areas, as set out in the NHS Plan, Cross-Cutting Review on health inequalities, Cancer Plan, and National Service Frameworks, particularly those outlining action on coronary heart disease, diabetes and older people.

  The best long-term approach is prevention. To do so we need to address the main risk factors of diet and physical inactivity. An integrated, cross-governmental strategy is in place to tackle obesity, by improving diet and by increasing physical activity levels. Key to this is the development of the Food and Health Action Plan and the Sport and Physical Activity Board.

THE HEALTH IMPLICATIONS OF OBESITY

1.   Obesity:

—  reduces life expectancy on average by nine years;

—  is responsible for 9,000 premature deaths each year; and

—  increases the risk of a wide range of diseases and illnesses, including heart disease, type 2 diabetes and some cancers.

What are the health outcomes of obesity in society?

Obesity is associated with increased risk of:

—  Premature death

—  Breathing problems

—  Heart disease and stroke

—  Some cancers, including postmenopausal breast cancer and colon cancer

—  Type 2 diabetes

—  Lower back pain

—  Hypertension

—  Complications in pregnancy

—  Angina

—  Increased risk in surgery

—  Gall bladder disease

—  Psychosocial and social problems, including reduced self-esteem and increased risk of depression and social isolation

—  Osteoarthritis

—  Sleep apnoea

  2.  Body fatness is most commonly assessed by body mass index (BMI)—weight (kg) divided by height (m) squared (ie kg/m2). A BMI 25-30 is considered "overweight" and greater than 30, "obese". Mortality rates begin to increase at BMIs greater than 25 and increase rapidly over 30. "Central obesity"—most commonly identified by a high waist circumference or waist hip ratio (WHR)—is also associated with increased morbidity and mortality.

  3.  Risk among some populations, such as Asians, appears to increase at a lower BMI (21-23 kg/m2). The World Health Report (WHO, 2002) showed that, globally, around 58% of type 2 diabetes, 21% of heart disease and between 8% and 42% of certain cancers were attributable to BMI greater than 21 kg/m2.

  4.  In England, the National Audit Office (NAO, 2001) found that obesity is responsible for more than 9,000 premature deaths each year (6% of all deaths) and reduces life expectancy on average by nine years. As well as reducing mortality it is well established that obesity is also associated with increased risk of many serious diseases: 36% of hypertension, 47% of type 2 diabetes, 15% of angina and 18% of myocardial infarction cases are attributable to obesity.

  5. People's exposure to risk reflects, in part, the choices they make about how to live their lives. But these are also heavily influenced by the circumstances in which they live—people do not have equal opportunities to make healthy choices.

What are the economic and social costs?

  6.   The economic costs are estimated at:

—  over £500 million a year to the NHS; and

—  over £2 billion a year to the wider economy.

  The social costs are primarily an increased prevalence of disease.

  7.  The NAO estimated in 2001 that the direct cost of obesity to the NHS is more than £ ½ billion a year. Estimated costs to the wider economy is more than £2 billion per year. The "big three" cost drivers are hypertension, coronary heart disease (CHD) and type 2 diabetes.

  8.  The NAO report was published before the release of guidance on the prescribing of the anti-obesity drugs Orlistat (March 2001) and Sibutramine (October 2001) by the National Institute for Clinical Excellence (NICE). The latest data from the Prescriptions Pricing Authority indicate that there was a three fold increase in the number of prescription items dispensed in the community between publication of the guidance and September 2002 (with associated net ingredient costs—the basic cost of the drugs—increasing to £31 million for the 12 months from October 2001 to September 2002).

  9.  The NAO report predicted that if trends continue at the present rate until 2010, the prevalence of obesity will have increased by around 47% between 1998 and 2010 and the annual cost to the economy would increase by £1 billion, or over a third, to around £3.6 billion, by that year.

What efforts is the Government making to evaluate these?

  10.   The social and economic costs of obesity, and trends in overweight and obesity, are carefully and regularly monitored.

  11.  Trends in overweight and obesity, physical activity levels and their relationship to other cardiovascular risk factors are monitored each year through the Health Survey for England (HSE). The Survey is commissioned by DH to provide reliable information about various aspects of people's health and to monitor selected health targets. The Survey includes physical measurements and the analysis of blood samples. Each year's survey also has a particular focus on a diseases condition or population subgroup.

  12.  Information on smoking, alcohol consumption, health and use of services is also monitored on a yearly basis through the General Household Survey (GHS), carried out by the Social Survey Division of the Office for National Statistics (ONS).

  13.  The White Paper, Saving Lives: Our Healthier Nation (1999) signalled the establishment of the Health Development Agency (HDA) to build the evidence base in public health, with a special focus on reducing inequalities in health. The DH Research and Development Strategy (2001) identified the task for HDA as "maintaining an up-to-date map of the evidence base of public health and health improvement, advising on the setting of standards in the light of evidence, for public health and health promotion practice, and effective and authoritative dissemination of evidence to practitioners". One of the nineteen topics being undertaken by the HDA is weight management.

  14.  Further to the NAO report, the forthcoming Health Technology Assessment Systematic review of the long term outcomes of the treatments for obesity and implications for health improvement and the economic consequences for the health service will provide an assessment of the cost effectiveness of obesity treatments.

  15.  The Chief Medical Officer is expected to publish in the autumn a report describing the evidence for a relationship between physical activity and health.

  16.  The Scientific Advisory Committee on Nutrition (SACN) may consider obesity, particularly the metabolic consequences, within their programme of work. This issue is to be discussed at SACN's horizon scanning meeting in September 2003.

Trends in obesity

  17.   Obesity is rising:

—  the percentage of obese adults has almost trebled in 20 years;

—  the majority of adults are overweight or obese;

—  recent studies show that obesity is also increasing in children.

What are the trends in obesity (including trends among particular groups, by social class, age, gender, ethnicity and lifestyle)?

  18.  The percentage of obese adults has almost trebled in England since the beginning of the 1980s—21% of men and 23.5% of women are now obese, and around 56% of all adult women and 68% of all adult men are either overweight or obese—almost 24 million adults. The latest figures from the HSE (2001) are shown in the table below.

MEN

 

BMI (kg/m2)	1980 *	1993	2000	2001
Mean		25.9	26.8	27.0
	%	%	%	%
Healthy weight: 20-25		37.8	29.9	28.4
Overweight: 25-30		44.4	44.5	46.6
Obese: Over 30	6	13.2	21.0	21.0
Morbid obese: Over 40		0.2	0.6	0.62
*OPCS 1984

WOMEN

BMI (kg/m2)	1980 *	1993	2000	2001
Mean		25.7	26.6	26.7
	%	%	%	%
Healthy weight: 20-25		44.3	39.0	37.6
Overweight: 25-30		32.2	33.8	32.9
Obese: Over 30	8	16.4	21.4	23.5
Morbid obese: Over 40		1.4	2.3	2.5
*OPCS 1984

  19.  The percentage of adults considered to be "centrally obese"—as measured by a high WHR (>0.95 for males and >0.85 for females)—has also increased. Between 1994 and 1998, the prevalence of high WHR increased from 23.5% to 27.5% for males and 18.2% to 19.9% for females.

Age

  20.  In both men and women, mean BMI and the prevalence of overweight and obesity increases with age, reaching a peak in 55-64 year olds. In 2001, 26.5% of men and 30.7% of women aged 55 to 64 were obese compared to 9.5% men and 11.9% women aged 16-24 and 16.0% of men and 19.3% of women aged 25-34.

Inequalities

  21.  The HSE 2001 demonstrated a higher prevalence of obesity in manual compared to non-manual groups for both men and women and that these inequalities have been maintained since 1994 (table below).

	% obese		% obese
	Men		Women
	Non-manual	Manual	Non-manual	Manual
1994	13	15	14	21
2001	19	23	20	28

  Similar trends are observed by social class group, particularly for women. In 2001 14% women and 14% of men classified as social class I were obese compared to 28% of women and 19% of men classified as social class V.

Differences between ethnic groups

  22.  With the exception of the Irish, obesity is less common in men from all other minority ethnic backgrounds than the general population (HSE 1999). The prevalence of obesity in men is lowest amongst those with an Asian ethnic background.

  23.  Among women, the prevalence of obesity among Black Caribbean and Pakistani women is substantially higher than the general population (approximately 50% and 25% higher, respectively). The prevalence of obesity is lowest among women of Bangladeshi and Chinese ethnic backgrounds.

  24.  The HSE (1999) found that the prevalence of raised WHR was highest among Indian and Irish sub-groups and lowest among the Chinese groups. Men in all South Asian groups were half again as likely as the general population to be centrally obese. Among women, the prevalence of raised WHR was higher among all minority ethnic groups than the general population.

  25.  Differences between ethnic groups will again be considered by the HSE in 2004, when ethnic minority groups will be over sampled to allow full assessment.

Children

  26.  There is on-going debate on the definition of overweight and obesity in childhood. Proposed international "cut off" points (Cole et al 2000) have been found to underestimate the prevalence of childhood obesity in the UK. An alternative method—using BMI above the 95th percentile to represent obese and BMI above the 85th percentile to represent overweight—has therefore been used to assess the HSE data. However, all recent studies, no matter which definition is used, have shown that the prevalence of overweight and obesity is increasing in children in England.

  27.  8.5% of six year olds and 15% of 15 year olds are obese (HSE 2001). Between 1996 and 2001 the proportion of overweight children (aged 6-15) increased by 7.0% and the prevalence of obesity increased by 3.5%.

  28.  Children's weight tends to "track" from childhood to adulthood and children who are overweight or obese are at high risk of being obese in adulthood. Obesity in childhood is an important risk factor for adult obesity, but of course the majority of obese adults were not obese children. This suggests that factors throughout the lifecourse have an impact on the development of obesity (Parsons et al, 1999).

  29.  There is some evidence that the prevalence of overweight and obesity in British children may increase with increasing social deprivation (Kinra et al, 2000), but this has not been shown consistently (Parsons 1999).

Lifestyle

  30.  The impact of lifestyle on obesity is discussed under the section What are the causes of the rise in obesity in recent decades (see paragraphs 39 to 55).

What is the relationship between obesity and other health inequalities?

  31.   There is a strong correlation between obesity and health inequalities.

  32.  Inequalities in obesity tend to be reflected in the prevalence of the chronic diseases with which obesity is associated. For example, less affluent people also have a higher than average risk of type 2 diabetes and, among women, levels of high blood pressure increase as income decreases. Disadvantage is also associated with:

—  lower consumption of healthier food options;

—  poor access to sports facilities;

—  higher rates of inactivity in some groups; and

—  less physical activity outside work and less participation in sport—for example 31% of men and 24% of women with the lowest incomes participate in sports compared to 55% of men and 45% of women with the highest incomes (HSE 1998).

  33.  Risk factors for disease tend to cluster. Government action to tackle chronic conditions such as obesity therefore take a broad, lifecourse approach with a focus on tackling inequalities in health.

  34.  The Acheson Independent Inquiry into Inequalities in Health (1998) noted that "Improvements in the diet of girls and women are likely to bring improvements not only in their own health, but in the health of their children. Avoidance of obesity similarly benefits both the mother and child. The effects of mother's nutrition on their children's health will take more than one generation to alter. An approach which starts with both mothers and children is likely to bring the most rapid benefits".

What are the international comparisons? (EU, OECD, USA)?

  35.  Obesity is an international problem—virtually all population surveys have shown an increase over the last two decades.

  36.  In 2001, the OECD reported that obesity levels have risen sharply in recent years in many countries, for example:

—  Australia—7.1% in 1980 to 18.7% in 1995.

—  England—7% in 1980 to 20% in 1999.

—  US—23% in late 1980s/early 1990s to 31% in 2002 (Flegal et al, 2002).

  37.  Obesity is more common among women than among men in two-thirds of OECD countries, and such problems also tend to be more common in lower socio-economic groups (OECD, 2001).

  38.  It has been suggested that the prevalence of obesity in England (and the rest of the UK) is rising faster than in other European countries. However, as the table below shows, while the UK has the highest rate of self-reported obesity in the EU, measurement-based sources show the prevalence of obesity in the UK to be below the EU average. Many countries rely on self-reported values, which will underestimate the true prevalence. Monitoring of trends in overweight and obesity is particularly good in England—measured yearly through the HSE.

PREVALENCE OF OVERWEIGHT AND OBESITY IN THE EUROPEAN UNION, BY TWO DATA SOURCES

		Measurement-based sources2
	PAN-EU1		Men		Women
European Union	BMI 25-29.9	BMI >30	BMI 25-29.9	BMI >30	BMI 25-29.9	BMI >30
Members Country	Overweight	Obese	Overweight	Obese	Overweight	Obese
Austria	32	10	48	12	29	17
Belgium	31	9	49	15	36	20
Denmank	31	8	44	11	25	10
Finland	33	10	50	18	38	20
France	24	7	49	12	30	17
Germany	35	11	53	17	35	20
Greece	35	11	50	13	40	22
Ireland	31	8	47	11	32	17
Italy	30	7	48	15	36	21
Luxembourg	27	9	45	14	33	18
Netherlands	29	10	45	11	31	11
Portugal	33	9	45	14	39	21
Spain	33	11	58	9	44	24
Sweden	33	7	45	10	29	12
United Kingdom	30	12	46	11	36	15
EU	31	10	50	13	35	19

1  Self-reported data from a European Union survey by the Institute of European Food Studies, Trinity College, Dublin, 1999.

2  Measured data from MONICA CINDI and other studies as compiled by Bergstrom et al (2001).

Source: European journal of Clinical Nutrition page 202.

What are the causes of the rise in obesity in recent decades?

  39.   Without periods of increased energy intake and / or decreased physical activity, individuals will not gain weight, no matter what their genetic make up.

  40.  International trends in obesity have been too fast to be due to genetic factors alone. However, there may be an interaction between individual genetic make up and environment.

  41.  Changes in lifestyle observed in many developed countries are likely to have contributed to trends in obesity. Factors associated with the development of obesity are discussed in paragraphs 42 to 55.

What has been the role of changes in diet?

  42.  The National Food Survey (NFS, 2001) shows that average energy (calorie) intakes have been falling since the 1950s (graph below). However, the graph below also shows that total fat intakes have remained relatively constant, and have not fallen in line with energy intake. Foods which are high in fat are less "satiating" than lower fat foods, and so a diet high in fat can lead to "passive" over consumption.

  43.  While providing valuable information on trends, the ability of the NFS / EFS to track trends in average caloric intake is to some extent limited. The Survey does not fully account for foods eaten outside the home. Furthermore, as the prevalence of obesity has increased, so the extent of under reporting of food intake may have increased. People who are overweight or obese are more likely to selectively mis-report what they eat.

  44.  The WHO report on Diet, Nutrition and the Prevention of Chronic Disease (2003) suggests that, unless individuals are very active, fat intakes above 30% of calories could increase the risk of obesity (WHO 2003). A high fat diet may undermine the normal mechanisms regulating energy balance in humans and predispose to weight gain (Prentice and Jebb 1995). Most countries which have experienced increases in obesity, such as those observed in the UK, have fat intakes above 30-35% of calories. The National Food Survey (NFS, 2000) and preliminary data from the Expenditure and Food Survey (EFS, 2001/2) (DEFRA 2003) suggest that average fat intakes are around 37% of total calories. The forthcoming National Diet and Nutrition Survey (NDNS) on adults will provide more detailed information on macronutrient intakes in adults in England (expected June 2003).

  45.  There is evidence to suggest that:

—  People are snacking more (borne out by industry surveys showing continued rise in sales) and drinking more carbonated drinks. (In the UK, the recent National Diet and Nutrition Survey (2002) showed that consumption of carbonated drinks by adults age 19-64 years has almost doubled during the past decade, with young adults consuming, on average, six cans per week. Most of the increased consumption in carbonated drinks for adults overall is attributable to an increase in the consumption of diet drinks. However, for young adults half the increase is attributable to non diet drinks containing sugar. This style of eating is an international phenomenon.

—  There has been an increase in the number of meals people eat out (see graph below). Meals and snacks eaten outside of the home tend to be higher in fat (NFS 2001) and may also be higher in calories and sugars than foods eaten at home.

—  Evidence from the US (Nielson et al 2002) suggests that portion sizes are significantly larger now than they were in the 1970s, especially for high calorie snacks and fast foods. The "supersizing" of fast foods and snacks has also occurred in the UK and may make it easier for people to inadvertently overeat.

To what extent have changes in lifestyle, particularly moves to a more sedentary lifestyle, been influential? How much is lack of physical activity contributing to the problem?

  46.  Physical activity levels in developed countries appear to have fallen due to a combination of factors. For children and adults in developed countries, factors contributing to lower activity levels compared to previous generations include (Epstein et al 1995, 2000):

—  greater use of cars for short journeys;

—  sedentary occupations;

—  lower sports participation;

—  parental reluctance to allow children to play outdoors;

—  increased pressures on time available for school sport and physical education; and

—  greater access to television and computers and other sedentary activities—reduced TV viewing has been shown to result in decreased adiposity and percent overweight in children.

  47.   The present UK physical activity recommendations (HEA 1995) are as follows:

—  Adults: 30 minutes of moderate intensity physical activity, at least five days a week.

—  Young People: participate in physical activity of at least moderate intensity for one hour per day.

  48.  In England, six out of 10 men and seven out of 10 women are not active at recommended levels (HSE 1998) and four out of 10 boys and six out of 10 girls are not meeting the recommended hour a day physical activity for children (NDNS 2000).

  49.  The chart below shows that between 1994 and 1998 the percentage of men who were achieving physical activity recommendations remained unchanged (HSE 1998). For women there was an increase in the percentage who were "active for health" from 22 to 25%. The increase in the numbers of men and women classified as sedentary are likely to be due to changes in the HSE questionnaire—housework or manual work/DIY of less than 20 min duration was classified as a "medium" activity in 1994 but a "low" activity in 1998.

  50.  In England, the National Travel Survey (2000) demonstrated that both walking and cycling have declined since 1975/6. Total miles travelled per year on foot was reduced by 27% and the miles travelled by bicycle by 25% (DETR 1999). However, data from the GHS (ONS 1998) reports that adults are more like to walk over two miles and go swimming and cycling for leisure. Taken together these surveys present an increase in the proportion of people taking occasional physical activity but a decrease in physical activity in daily life.

Other possible lifestyle factors contributing to trends in obesity

  51.   Alcohol consumption has increased in women and young men in England over the last ten year (ONS 2001, table below). Alcohol provides almost as many calories as fat. Although epidemiological research on the association between alcohol and obesity is equivocal (BNF 1999), Wannamethee and Shaper (2003) recently reported that, among a prospective cohort of middle age men, heavy alcohol intake contributed directly to weight gain and obesity.

PERCENTAGE OF ADULTS WITH HIGH ALCOHOL INTAKES

	1990	1998
Men > 21 units per week
All adults	27	27
18-24 year olds	32	39
Women > 14 units per week
All adults	11	15
18-24 year olds	17	31

  52.   Breastfeeding rates—There is some evidence that long term breastfeeding may help mothers lose the excess weight they gain during pregnancy, and children who are breastfed may be at lower risk of becoming obese later in childhood. Breastfeeding rates remain low in many developed countries, particularly among lower social groups. For example, in the UK 43% of women in higher social groups and 17% in lower social groups breastfed for at least four months (IFS 2000). The prevalence of women who breastfed in England at four months increased from 28% to 29% between 1995 and 2000 (IFS 2000).

  53.   Smoking cessation is associated with a mean gain of 3-4.5kg (a range of 0-20kg has been observed) and people who stop smoking are at high risk of becoming overweight or obese. In 1998, 31% males and 21% of females in England were ex regular smokers, compared to 24% males and 11% females in 1974 (ONS 2001).

  54.   Inappropriate dieting strategies—"Yo-yo" dieting and inappropriate dieting strategies may make it harder to maintain a healthy weight in the long term. Concern about body image is common in developed countries, particularly among young women. In England, around half of all 20-24 year old females (and 22% of males) claim they are trying to lose weight (HSE 95-7), yet less than 11% of 16-24 year olds are obese (HSE 2001).

  55.   A wide range of other factors have been hypothesised as contributing to international trends in BMI and fat distribution, including such diverse factors as increased levels of stress (which may be associated with poorer dietary habits or other behaviours which predispose to weight gain or adverse fat distribution); an increase in the incidence of infants with high birthweight; holiday weight gain and divorce.

WHAT CAN BE DONE ABOUT IT?

  56.   It is recognised that a wide range of environmental factors need to be addressed in order to tackle trends in obesity—including access to sport and leisure, family life, access to healthier diets and education/information.

  57.  To make an impact on obesity and halt the upward trend action needs to follow two general strategies:

—  Prevent future generations of people becoming obese—through action to tackle inequalities and improve diet and increase physical activity, particularly among children and young people.

—  Management of overweight and obesity—a number of themes are emerging on what strategies are most effective for treating obesity (HDA 2002). These include:

—  diet, physical activity and behavioural strategies for adults in combination where possible;

—  reduce sedentary behaviour in obese children and family therapy;

—  maintenance strategies eg continued therapist contact;

—  drugs; and

—  surgery for morbidly obese.

    A gradual, incremental stepwise approach in weight reduction seems to have the most beneficial long-term effect.

  58.   For obese individuals, even a modest weight loss can have substantial benefits. A 10kg loss is associated with a 20% fall in total mortality and a 10% reduction in total cholesterol (WHO 1999).

What is the range of levers and drivers (food industry, marketing, education, family life, genetics, drugs, surgery)?

  These are addressed separately as follows:

What is the range of levers and drivers —food industry? Within that range what role can the food industry play?

  59.   Industry has a responsibility to make it easier for consumers to choose a healthy diet, remove some of the barriers that can make it difficult to do so and provide clear and consistent information about their products.

  60.  The food industry—producers, manufacturers, retailers and caterers—provide all the food we eat and therefore play a crucial role in the determination of dietary intakes.

  61.  Preference, price, availability and convenience are major factors in consumer decisions about what to buy and cook. It is ultimately up to consumers to choose a diet that will improve their chances of better health. However, industry has a key role in ensuring that healthy choices don't require extra effort, time or expense, and that consumers have the information they need to make sound choices.

  62.  Changes in lifestyle in England have resulted in the food industry having an increasing impact on dietary intakes:

—  There is increasing consumer demand for convenience food, snacking and eating on the move, and eating alone. Between 1990 and 2000 alone, purchases of convenience foods rose by 24% (NFS 2001).

—  There is less demand for formal meals, and for cooking from scratch. For example, industry research by Geest indicates that the average time taken to prepare the evening meal has fallen from 90 minutes in the 1980s, to around 20 minutes.

—  Eating outside the home is more common—25% of respondents to the Consumer Attitudes Survey (FSA 2002) said that they regularly used some form of fast food or takeaway outlet.

What is the range of levers and drivers—marketing? Within that range, what role can marketing and advertising play? What are the responsibilities of the food industry in respect of marketing?

  63.  The Food Standards Agency (FSA) is currently funding a systematic review of research into advertising and the promotion of food to children (expected July 2003). This will review and critically appraise the available evidence on the effect of a range of promotional activities on the eating behaviour of children and seek to draw conclusions on their effect relative to other influences on eating behaviour.

  64.  The key issues are that:

—  Independent research on the link between food promotion and eating behaviour is currently lacking.

—  Industry surveys show that advertising spend on food products is reflected in increased sales, but the impact on food category as opposed to brand sales is unclear.

—  Food products such as confectionery, drinks and snacks are among those most commonly advertised, particularly to children.

—  Advertising to children includes TV and print advertising, as well as indirect forms of advertising such as food promotions to schools.

—  Advertising to children is banned in Sweden, but the impact is difficult to assess. This is because the ban relates only to terrestrial TV, while non-terrestrial viewing figures are greater.

  65.  The Broadcasting Act 1990 requires the ITC to publish a Code governing standards and practice in television advertising. Compliance with the Code is a condition of television broadcasters' licences. The ITC Code of Advertising Standards and Practice contains guidance on the content of individual television adverts, in the case of food advertising guidance exists to prevent harm, notably from that which misleads, makes unsubstantiated health claims or disparages good dietary practice. For example, the Code states "advertising should not undermine progress towards national dietary improvement by misleading or confusing consumers or by setting bad examples, particularly to children." The code also states that advertisements must not "encourage or condone excessive consumption of any food" or "disparage good dietary practice". Non-broadcast advertising must comply with regulations against misleading claims.

  66.  Qualitative research carried out by COI Communications on behalf of the Food Standards Agency (FSA, October 2001) indicated that parents' main concerns were around mis-leading information, for example being led to assume that fruit "drinks" were pure fruit juice. Misleading labelling is being addressed by the FSA through its labelling action plan.

What is the range of levers and drivers—education? Within that range, what role can schooling play?

  67.  Action in schools—combining dietary advice and exercise—has been shown to be effective in preventing obesity (Story 1999). Integrating regular activity into the daily life of children has also shown to be effective (and maintained at two year follow up) and more so than structured aerobic exercise (Epstein 1998).

  68.  The NHS Centre for Reviews and Dissemination Effective Healthcare Bulletin on the prevention and treatment of childhood obesity (2002) states that "Currently there are a number of government initiatives specifically targeting schools and there is some evidence that school-based programmes that promote physical activity, the modification of dietary intake and the targeting of sedentary behaviours may reduce obesity in children, particularly girls."

  69.  The Health Development Agency evidence base on obesity highlights that while there is a the lack of high quality evidence on the treatment and prevention of obesity within school settings, findings from less rigorous research are encouraging.

  70.  See paragraphs 145 to 154 for more information on the role that schools can play.

What is the impact of family life, genetics, drugs and surgery on obesity?

Family life

  71.  A wide variety of factors within families may have an indirect impact on obesity rates, including:

—  changes in family eating patterns and leisure activities;

—  reduction in opportunities for active outdoor play;

—  changes in the way children and their parents travel to and from school and work;

—  pressures on parental time, including the increase in female employment and single parent families; and

—  increase in access to labour saving equipment.

  72.  Many parents, especially those who are overweight themselves, may not recognise overweight and obesity in their children.

  73.  The NHS Centre for Reviews and Dissemination Effective Healthcare Bulletin on the prevention and treatment of childhood obesity (2002) stated that "Family based programmes that involve parents, increase physical activity, provide dietary education and target reductions in sedentary behaviour may help reduce childhood obesity." The HDA evidence base on obesity is in agreement with this conclusion.

  74.  For more information on the role of family life, see paragraphs 120 to 123.

Genetics

  75.  See paragraph 40.

Drugs

  76.  Appropriate use of obesity drugs results in greater weight loss than placebo. Furthermore, patients who lose weight using obesity drugs are more likely to maintain the loss when the drug use is extended than those who rely on diet and exercise alone. For more information on the use of obesity drugs, see paragraph 119.

Surgery

  77.  Surgery is usually reserved for the extremely obese patient with life threatening disease. It has been shown to be effective (Glenny 1997) and NICE has concluded that surgery is the recommended treatment for morbidly obese people (BMI > 40 kg/m2), providing certain criteria are fulfilled—for example, that all appropriate and available non surgical measures have been adequately tried but have failed to maintain weight loss. More information on surgery is in paragraph 119.

What is the range of levers and drivers—transport? Within that range, what role can transport play?

  78.   There has been a reduction in active transport in many developed countries.

  79.  The British Medical Association (1997) have confirmed the links between transport and health—including inactivity and obesity.

  80.  In the UK, 59% of 5 to 16 year old school children walked to school in 1985-86 compared to 48% in 1997-99. Children transported to school by car over the same period increased from 16% to 30%. Virtually no primary school children cycle to school, and among secondary school children, the figure has fallen from 6% in 1985-86 to 2% in 1997-99 (DfT 2000).

  81.  The Social Exclusion Unit's report Making the Connections: Final Report on Transport and Social Exclusion (2003) examines the links between social exclusion, transport and the location of services. The report highlighted that people living in disadvantaged communities may have limited access to shops offering healthy and affordable food and suffer disproportionately from the effects of road traffic, through pollution and pedestrian accidents, particularly among children.

  82.  More information on transport is in paragraphs 124 to 127.

How influential is the media?

  83.   The impact of the media on issues related to overweight and obesity can be positive or negative.

  84.  The media can be a source of conflicting information and inappropriate advice on weight management. It has also been blamed for increasing concerns about body image. A British Heart Foundation Survey (2002) found that most adults who diet do so for cosmetic reasons. Furthermore, most adults view "dieting" as a short term activity despite the fact that successful weight loss is accomplished by making positive sustainable changes to long term eating habits and physical activity patterns (BDA 2002).

  85.  In the UK, the media—TV, newspapers, radio—are the most commonly cited sources of information on food and food safety (FSA 2002). The same is likely to be true for issues around weight management and obesity.

  86.  The US Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity (2001) states that "The media can provide essential functions in overweight and obesity prevention efforts. From a public education and social marketing standpoint, the media can disseminate health messages and display healthy behaviours aimed at changing dietary habits and exercise patterns. In addition, the media can provide a powerful forum for community members who are addressing the social and environmental influences on dietary and physical activity patterns."

How can the amount of physical activity being undertaken be increased?

  87.  Details of how physical activity can be increased are addressed in paragraph 106 to 117.

To what extent can and should Government, at central and local level, influence lifestyle choices?

  88.   The role of Government is to ensure that all people can make informed choices and that they have proper access to healthier options. Government also has an important role in developing the evidence base and monitoring.

  89.  A range of government departments—including those with responsibility for health, transport, food and sport—have an important role in preventing and managing obesity.

  90.  Government can influence choice by:

—  working with a wide range of stakeholders—at national and local level—including industry, health professionals and NGOs, in particular, to address issues around access to healthier options;

—  providing guidance and implementing legislation, as appropriate;

—  providing clear, consistent information to aid informed choice;

—  working with a broad range of partners to ensure consistency in all relevant policy areas, including health, transport, food, education, sport; and

—  ensuring that the interventions are evidence based, regularly monitored and evaluated.

How coherent is national and local strategy?

  (also see paragraphs 98 to 119)

  91.  DH is working with other Government Departments (OGD) to ensure co-ordinated action to tackle health inequalities, to address healthy eating at every stage of life and to increase mass participation in physical activity and is driving local action through the NHS. Regional Government Offices (RGO), Primary Care Trusts (PCTs), Strategic Health Authorities (SHA), Public Health Networks (PHN) and Local Strategic Partnerships (LSP) provide the mechanisms for effective co-ordination of local policies and influences.

  92.  There are three main strands to DH's programme of work:

—  developing the evidence base—for example:

—  the HDA maintains the evidence base for a number of public health topics including obesity, physical activity and transport.

—  research and development activity related to diet, nutrition and obesity.

—  implementation of service provision and national policies—for example:

—  DH has set out standards for the NHS through a series of National Service Frameworks (NSFs).

—  Regional Directors of Public Health and their teams are uniquely positioned to work with OGDs in the regions to build a strong health component into regional programmes in areas such as transport, environment and urban regeneration.

—  monitoring and evaluation:

—  see What efforts is the Government making to evaluate these?, paragraphs 10 to 16, and What is the role of the Department of Health?, paragraphs 98 to 118.

What is international best practice?

  93.   To date, no country has successfully tackled the problem of obesity.

  94.  The WHO report Obesity: Preventing and Managing the Global Epidemic (1999) highlighted that there has not yet been any well evaluated, properly organised public health programme aimed at the population management or prevention of obesity. Furthermore, very few countries have a comprehensive population wide national policy or strategy to deal specifically with the problem of overweight and obesity.

  95.  A number of countries have recently made moves to implement national policies to tackle obesity, including:

—  America—in 2002, committed $250 million in federal spending for programmes including local obesity prevention and exercise promotion projects, and federal studies into the effectiveness of weight-reduction programmes for children.

—  Australia—developed a strategy in 1997 with a broad range of approaches such as safe bicycle paths and healthier food choices in schools (however a Lancet editorial 2001 stated that it had still to be implemented).

—  New Zealand and Denmark—both launched strategies in 2003.

  To date, no information is available on the impact of these policies.

  96.  The WHO has identified the features of successful public health programmes as:

—  adequate duration and persistency;

—  slow and staged approach—changes to diet and physical activity need to be realistic;

—  legislative action may be useful in some instances;

—  education required to encourage and support changes in behaviour;

—  advocacy from respected elements within all sectors of society has been a key feature of the decrease in smoking rates; and

—  shared responsibility by consumers, communities, food industry and government.

  97.  The WHO are in the process of developing a Global Strategy on Diet, Physical Activity and Health, which is to be launched in May 2004.

ARE THE INSTITUTIONAL STRUCTURES IN PLACE TO DELIVER AN IMPROVEMENT?

  98.   An integrated, cross-governmental strategy is in place to tackle obesity, by improving diet and by increasing physical activity levels. Key to this is the development of the Food and Health Action Plan and the Sport and Physical Activity Board.

What is the role of the Department of Health? How coherent is national and local strategy?

  99.  The aim of the DH is to improve the health and well-being of people in England. DH is responsible for driving forward change and modernisation in the NHS and social care, as well as improving standards of public health. DH also develops policies, sets national standards and ensures that these are being met.

  100.  Addressing the prevention and management of obesity is key if Government priorities in England are to be met, as highlighted in the NHS Plan, Cancer Plan and the NSFs, particularly those outlining action on CHD and diabetes. Action on obesity, diet and nutrition is included within the DH-led cross-cutting health inequalities strategy and supports the public service agreement target to reduce inequalities in health outcomes.

  101.  In addition to the specific initiatives and programmes delivered by DH, there are many relevant programmes being run by Healthy Living Centres and Sure Start local programmes.

Action on Diet

  102.  There is a need to ensure co-ordination of policy on diet and nutrition at national and local level and to ensure clear and consistent messages. Work is in hand to achieve this through the development of a Food and Health Action Plan.

  103.  The development of the Action Plan was announced as part of the Government's Strategy for Sustainable Farming and Food (December 2002), which builds on Sir Don Curry's Independent Policy Commission report. The Plan will aim to achieve a healthier diet for the people of England and will include clear policy objectives on nutrition, setting out the arrangements for future co-ordination of nutrition work across Government and other sectors at national, regional and local level. The Plan will address not only those policies where nutrition is the key aim, but policies across Government, particularly other elements of the Sustainable Farming and Food Strategy, such as regional and local food strategies and public procurement of food.

  104.  The Plan's development is being led by DH in collaboration with FSA, DEFRA and OGDs. However the Plan will not be for Government alone. It will present a framework for action for bodies outside Government, including industry, setting out the key responsibilities and opportunities.

  105.   The Food and Health Action Plan will pull together all action on diet and nutrition. Current action takes a lifecourse approach, is predominantly based on commitments outlined in the NHS Plan (2000), and includes:

—  Reform of the Welfare Foods Scheme (WFS) to use the resources more effectively to ensure children in poverty have access to a healthy diet and increased support for breastfeeding which is accepted as the best form of nutrition for infants to ensure a good start in life.

—  Action to promote breastfeeding, including the funding and evaluation of 79 "best breastfeeding practice" projects and support for an annual National Breastfeeding Awareness Week. The aim is to increase the rates of breastfeeding, both initiation and duration, particularly among disadvantaged groups. This is a goal shared by all Sure Start initiatives (see paragraphs 121 and 122).

—  Action in schools, including the Food in Schools Programme, the National School Fruit Scheme and the National Healthy Schools Programme—see paragraphs 143 to 152.

—  Eating more fruit and vegetables instead of foods high in fat and/or sugar, can help in the maintenance of a healthy weight (Biing-Hwan et al 2002). The 5 A DAY programme aims to increase consumption of fruit and vegetables through work at a national and local level. The programme has 5 main strands of work, including:

—  National School Fruit Scheme (NSFS) (see paragraph 147)

—  Local 5 A DAY initiatives—national evaluation of the 5 A DAY pilot initiatives demonstrated that community initiatives can produce important changes in people's knowledge, access and intake of fruit and vegetables. Overall, the intervention was found to have had a positive effect in people with the lowest intakes—this is important for addressing inequalities in health. Those who ate less than 5 a day at baseline increased their intakes by 1 portion over the course of the study. The New Opportunities Fund (NOF) has made £10 million available to support the establishment of 66 new initiatives, led by PCTs. These will also be fully evaluated. Guidance on delivering evidence-based interventions has been developed and is informed by lessons from the pilot initiatives.

—  A communications programme (see paragraph 137, 138)

—  Work with the food industry (see paragraphs 133 to 138)

—  Work with national and local partners, such as: cross-government and health, education and consumer organisations.

    Evaluation and monitoring underpins the programme. At a national level consumption, attitudes and awareness of fruit and vegetables will be monitored annually through the HSE, the EFS, the FSA Consumer Survey and ad hoc surveys.

—  Initiatives with the food industry (including manufacturers and caterers) to improve the overall balance of diet including salt, fat and sugar in food, working with the FSA (see paragraph 135).

Action on physical activity

  106.  The Government's aim is to significantly increase levels of sport and physical activity, particularly among disadvantaged groups by 2020. In practical terms the target is for 70% of the population (currently 32%) to be reasonably active by 2020. In this context, "reasonably active" means 30 minutes of moderate exercise five days a week or the equivalent.

  107.  In December 2002, the Prime Minister's Strategy Unit and DCMS jointly published Game Plan: a strategy for delivering the Government's sport and physical activity objectives. The report recommended the creation of a Sport and Physical Activity Board (SPAB) to work with a wide range of partners to develop mass participation policies. The scope within Whitehall for encouraging greater participation in sport and physical exercise is wide-ranging. There is also a broad range of organisations outside central government—in local government and in the sporting, health, charitable and other sectors—with important delivery and policy roles.

  108.  The practical steps that SPAB will take will be to:

—  innovate, introducing change where there is supporting evidence and available funding—this should give early impetus to the work;

—  pull together evidence and present it—jointly with outside sporting and health organisations—as part of a positive communication strategy, disseminating evidence and best practice;

—  test and evaluate interventions where evidence is not strong, including other externalities of increased participation, such as crime reduction—where the timescale might be longer;

—  identify sources of funding; and

—  gather comprehensive data on participation and fitness regularly.

  109.  A progress report on this work will be made in 2004. The report will identify areas where work is underway and set out existing evidence. It will also contain proposals for improving data collection and running pilot schemes to increase long-term mass participation, as envisaged in Game Plan.

  110.  DH hosts the National Alliance on Physical Activity (NAPA) which provides a forum for policy makers, experts and practitioners to share experiences and learning on strategies, plans and projects that aim to promote increased participation in physical activity. It includes representatives from DfES, DfT, DCMS, Qualifications and Curriculum Authority, Sport England, and the LGA, as well as academics and representatives from the NHS and voluntary organisations. The work of NAPA will feed into SPAB.

  111.  DH is working with funding partners Sport England and the Countryside Agency on the Local Exercise Action Pilots (LEAP) programme to test different community approaches to increasing levels of and access to physical activity. The nine pilots will be led by PCTs and based in neighbourhood renewal areas, both urban and rural and will also involve Sport Action Zones. LSPs will contribute to the innovate multi agency approach to increasing activity in key target groups which will include young people, older people, black and minority ethnic groups, and those at high risk of illness such as diabetes and heart disease and people recovering from illness. The pilots will help to establish the evidence base on what works contributing to SPAB, and support the delivery of milestones in the NSFs. The ongoing results will inform and lead action on physical activity across the NHS and other relevant sectors.

  112.  DH meets regularly with OGDs to review progress and ensure joined up working and avoid duplication of effort. It contributes to on-going programmes such as the School Travel Advisory Group and the joint DfES/DCMS PE, School Sport and Club Links PESSCL strategy. At a local level programmes are at varying stages of development from comprehensive physical activity strategies to isolated initiatives. Progress is being made to enable greater linkages, for example through LSPs, the formation of regional sports boards and the requirement within the CHD NSF for PCTs to work in partnership with their Local Authorities.

  113.  Work is also underway by DH to develop a universally agreed physical activity communication message for adults and children for use by all those working to address inactivity. It is envisaged this will promote a simple and effective message on physical activity that will be relevant and accessible to the general population.

  114.  Regular walking can help in the maintenance of a healthy weight (Morris and Harman 1997) as well as helping to prevent and manage heart disease (Wannamethee et al 1998, Morris et al 1990). In its November 2001 response to the Environment and Transport Committee's report Walking in Towns and Cities, the Government agreed to publish a national walking strategy. The DfT aims to publish a consultation paper in Summer 2003, with publication of the final strategy to encourage more walking scheduled towards the end of this year.

  115.  DH is working in partnership with the Countryside Agency and the British Heart Foundation to part fund a targeted pilot project which will distribute pedometers to PCTs in areas of high deprivation as a motivational tool to encourage increased walking. This builds on the Countryside Agency's Walking the Way to Health initiative.

  116.  The HDA is currently building the evidence base of effective interventions to increase physical activity, as well as translating this evidence into practice.

  117.  Sport England is currently undertaking a modernisation and restructuring programme and as a result its new business strategy will have three new main objectives, one of which is "to increase participation in sport in order to improve the health of the nation". In addition, a placement from Sport England is working with DH to assist with policy development on physical activity as part of Sport England's placement programme.

Research and Development

  118.  DH carries out research and development activity related to diet, nutrition, physical activity and obesity, including the recently completed research initiative on nutrition funded through the Department's Policy Research Programme (PRP). Key areas includes:

—  Maintenance of a healthy weight: risk factors for childhood obesity, childhood predictors of adult obesity, interventions to prevent obesity;

—  Dietary change: interventions to increase fruit and vegetable consumption and reduce fat consumption, particularly in low income groups;

—  Physical activity: its role in obesity and bone health, and promoting physical activity among children and young people.

  Projects currently funded by DH include: systematic reviews of barriers and facilitators to the uptake of physical activity and of healthy eating amongst children and young people; a systematic review of the evidence on the prevention of adult disease through interventions in early life; trials assessing action to treat and prevent obesity in primary care; family based treatment for obese children; development of and obesity website for patients and health professionals. DH also provided funding for the development of advice for professionals in primary care on weight management in children and adolescents.

What is the role of the NHS, including that of primary care, hospitals and specialist clinics?

  119.  Action on obesity requires input from primary care staff, particularly GPs, health visitors, practice nurses, dietitians and psychologists. There is also the opportunity to provide support through the wider public health workforce, for example exercise specialists, school nurses, health promotion specialists and community workers, located in PCT areas. In order to address health inequalities, PCTs have been asked to work with partners through Local Strategic Partnerships on the wider determinants of health, and joint work on physical activity and obesity could be included as part of this approach.

—  The Priorities and Planning Framework for 2003-06 includes targets for reducing CHD. One of these targets requires practice-based registers and systematic treatment regimes, including appropriate advice on diet, physical activity and smoking. This also covers the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a BMI greater than 30. In order to tackle health inequalities, the Priorities and Planning Framework also sets a target to contribute to a national reduction in death rates from CHD focussing on the 20% of areas with the highest rates of CHD, and this should encourage action on obesity in disadvantaged areas. The Priorities and Planning Framework has also set a target to increase breastfeeding initiation rates by 2 percentage points each year, particularly among disadvantaged groups.

—  NICE and the HDA are to work collaboratively to develop guidance on the identification, prevention and management of obesity and maintenance of weight reduction. This follows the NAO (2001) recommendations that guidance be developed for the management of overweight and obese patients in primary care. NAO reported that 63% of general practitioners and 85% of practice nurses believe that such guidelines would be "useful" or "very useful".

—  NICE has provided guidance on drug treatments for obesity—Orlistat (March 2001) and Sibutramine (October 2001). The guidance emphasises that people who are prescribed the drugs should also be given appropriate advice and support on diet, activity and behavioural strategies. The Royal College of Physicians recently reiterated that while drugs can be useful, they should only be used as an addition to changes in diet and behaviour and an increase in regular physical activity (RCP 2003).

—  Standard One of the NSF for CHD relates to the reduction of coronary risk factors in the population and requires that all NHS bodies will have agreed and be contributing to the delivery of a local programme of effective policies on promoting healthy eating, increasing physical activity and reducing overweight and obesity and have quantified data on the programme by April 2002.

—  NOF funds 257 Healthy Living Centres in England. Communities define their own needs and solutions, and while some of the projects are PCT led, the majority are run with the PCT as a partner and are led by voluntary or community organisations. The centres enhance mainstream services, and diet and nutrition feature strongly—43% provide dietary advice, 40% run food coops, 32% have community cafes and 46% provide training in cookery skills and nutrition. The HLCs strong community basis gives them a headstart in engaging people successfully in improving their own health.

—  PCTs across England are currently piloting the Expert Patients Programme, a six-week training course for people in the self-management of long-term conditions, such as diabetes, CHD, overweight and obesity (which may also be present as a secondary problem alongside a range of chronic diseases). The course content and resource materials provide detailed advice on the importance of physical activity and a healthy diet as ways to reduce the risk of developing a range of health problems, including obesity.

—  People who are obese may experience a range of difficulties from low self-esteem to mild and moderate depression and more severe conditions such as binge eating. Conversely, people with a mental illness appear to be more at risk of physical ill health, including obesity. The NSF for mental health addresses eating disorders and DH has commissioned a NICE guideline on eating disorders.

—  There has been a three year programme to support health visitors and school nurses in targeting health priorities and inequalities, including CHD. Resource packs which are available to all practitioners include specific sections on promoting physical activity and healthier diets.

—  The Department has published a "National Quality Assurance Framework for Exercise Referral Systems" (April 2001), aimed at GPs. Recent reviews have shown extremely good uptake of this initiative.

—  Funding through Section 64 grants—for example, the Department contributed to the funding of the charity Weight Concern to develop a "toolkit" on obesity, for health professionals to use with patients in a group setting. DH has also funded the British Dietetic Association to develop an obesity website for consumers.

—  NICE has provided guidance on obesity surgery which is the recommended treatment for individuals with BMI > 40 kg/m2. At present around 200 operations are performed annually, many of which are privately funded (NICE 2002). Currently there are 10 specialist obesity clinics in England (ASO), NICE guidance emphasises that services and skills to support surgery for people with morbid obesity be developed in a planned and co-ordinated way.

—  NHS Direct provides general advice on nutrition, physical activity and the maintenance of a healthy weight, as well as information on available treatments for obesity. It was recently announced that the capacity of this service is to double over the next three years. NHS Direct online is the largest and most successful e-healthcare provider in the world.

What is the role of families?

  120.  It is likely that the forthcoming NSF for Children will highlight the family environment as a key determinant of children's health and a key setting for the development of healthy habits. A range of government initiatives are likely to have an impact on family eating and physical activity habits, including Sure Start, the WFS, the NSFS, the 5 A DAY programme and Local Exercise Action Pilots.

  121.  Sure Start programmes work with parents-to-be, parents and children to promote the physical, intellectual and social development of young children—particularly those who are disadvantaged—so that they can flourish at home, when they get to school and during later life. The Sure Start Unit has a PSA target of "a 6 percentage point reduction in the proportion of mothers who continue to smoke during pregnancy". Babies whose mothers did not smoke during pregnancy are more likely to have normal birth weight, experience less respiratory illness, more likely to be breastfed and to be generally healthier. There is also an SDA target—"Information and guidance on breastfeeding, nutrition, hygiene and safety available to all families with young children in Sure Start local programme and Children's Centre areas".

  122.  The Sure Start local programmes enable better access to health services, including ante-natal and baby clinics, with provision of advice on infant feeding. Local programmes include:

—  encouragement and guidance on breastfeeding and weaning;

—  advice and information on healthy eating and nutrition for families on low incomes;

—  nutrition and cookery, including as part of their parenting skills programme, and "Get Cooking" groups for healthy eating on a budget;

—  local food co-ops where parents can buy fresh fruit and vegetables at affordable prices and community garden/allotment schemes; and

—  encouragement of active play, for example by providing access to outdoor play facilities to encourage exercise and physical activity, playgrounds for under-4s and exercise programmes for young children.

  123.  As part of the HDA's evidence into practice work, family based approaches will be further investigated by working with families and practitioners, drawing on their experience of promising practice.

What is the role of transport?

  124.  The White Paper Saving Lives: Our Healthier Nation (1999) describes how local communities can increase active transport by:

—  implementing the Integrated Transport Policy—A new deal for transport: Better for everyone;

—  providing safe cycling and walking routes;

—  providing facilities for physical activity and reliable transport for people to gain access to them;

—  developing traffic calming and other safer measures as part of transport plans; and

—  adopting school travel and green transport plans.

  125.  To improve access to services that can help prevent obesity—including leisure facilities and healthier food options (eg fruit and vegetables)—the Government is implementing the recommendations of the Social Exclusion Unit's report Making the Connections: Final Report on Transport and Social Exclusion (2003).

  126.  The DfT is leading on a number of initiatives including:

—  bursaries to 84 local authorities to fund travel plan co-ordinators to spend time working with schools and businesses on the development of local measures to reduce reliance on the car;

—  site specific advice to help schools, businesses and other organisations to develop travel plans;

—  seminars for staff in local authorities working on school travel plans;

—  £3 million investment to create a team of regional cycling co-ordinators to help reverse the decline in cycling and deliver the target of fourfold growth on 1996 levels by 2012;

—  Cycling Projects Fund, supporting 138 projects, including safer access and secure cycle parking facilities as part of school travel or safe route to school projects; improved cycle parking at bus interchanges and train stations; cycle park and ride schemes; cycle parking at various NHS Hospital sites; workplace cycling initiatives and cycle routes;

—  within the next few months a consultation on a strategy to encourage and promote walking will be launched.

  127.  The HDA is producing a review of evidence of effective transport interventions that improve health or reduce health inequalities. This will include a section on evidence of effective transport plans, schemes or initiatives that promote cycling and walking. A report describing local approaches to improving health through transport between PCTs and local authorities will also be published in 2003.

How effective are the structures for health promotion?

  128.  For health promotion to be effective, a wide range of barriers and facilitators need to be addressed—including income, access, knowledge and skills. This requires input from a range of health professionals, including GPs, dietitians, nutritionists, health promotion specialists, health visitors, midwives and practice nurses. It also requires the PCT, through the Professional Executive Committee to increase health promotion resources.

  129.   Shifting the Balance of Power has provided opportunities for the provision of health promotion on issues relating to obesity prevention and management. Greater integration of community based services such as dietetics, health promotion and health visiting into PCTs should enable the development of improved multidisciplinary working, more seamless care and improved allocation of resources.

  130.  The HDA's future "evidence into practice" work will draw together practitioners from a broad spectrum of sectors to enable delivery and implementation of the weight management evidence-based guidance. The HDA will also have a role in facilitating and supporting changes in practice for those practitioners/organisations implementing the guidelines.

  131.  A voluntary register for specialists in public health has recently been launched and will provide a way of accrediting multi-disciplinary public health specialists so that potential employers and others can be assured of their competence.

  132.  The joint DfES/DoH project "Skilled for Health" is designing new health based curriculum materials for the Learning and Skills Council (LSC) programmes which are aimed at improving the basic skills of adults. Participants will be able to take better care of themselves through having a better understanding of their own health and how the make the best use of the NHS, as well as improving their basic skills. The project will also design and generate health related curricular programmes in demonstration sites focussed on particular aspects of health. These can then be replicated throughout the LSC programme to suit the particular needs of adults in different parts of the country.

Can health promotion compete with huge food sector advertising budgets? To what extent can the food industry be part of a solution?

  133.  The relative funds for health promotion compared to advertising spend emphasises the importance of working with industry and ensuring consistency in the message through all programmes of work. Industry has a major role in enabling access to a healthy balanced diet. Manufacturers and caterers can assist consumers through reviewing recipes in relation to fat, added sugars and salt content, portion size and labelling in line with Government advice on healthy eating.

  134.  The food and farming industries have a vital role in the Food and Health Action Plan (as discussed in paragraphs 102 to 105).

  135.  The NHS Plan made commitments to initiatives with the food industry (including manufacturers and caterers) to improve the overall balance of diet including salt, fat and sugar in food, working with the FSA. Discussions with the food industry and retailers are underway on reducing the level of salt in processed foods. These discussions have demonstrated that industry have made some steps towards reducing salt in processed foods but there is scope for further action. The situation is likely to be similar for fat and added sugars. Options for working with industry on these areas will be considered through 2003-04.

  136.  There is also on-going work with industry (including producers and retailers) to increase provision and access to fruit and vegetables as part of the 5 A DAY programme. Indeed the success of the programme will depend on partnership working with the food industry, and with health, consumer and education organisations—all giving the same consistent messages facilitated by the 5 A DAY logo/brand.

  137.  A communications programme has been developed to ensure that consumers receive consistent messages and advice about eating 5 A DAY, supported by the production of information materials for consumers and guidance on establishing local 5 A DAY programmes based on evidence. This work will continue through 2003-06.

  138.  The development of the 5 A DAY logo has been carried out in close consultation with industry and health, education and consumer bodies. At present, the logo can only be used on products without any added sugar, fat or salt. While the message to eat more fruit and vegetables is an important one, the advice needs to be considered in the context of general dietary advice to reduce the consumption of fat, salt and added sugars. Therefore nutrition criteria for the use of the logo on fruit and vegetable products with added ingredients are currently being considered by a small expert group. The logo and associated nutritional criteria provide an incentive for industry to increase the fruit and vegetable content of products and consider the levels of added sugar, fat and salt.

To what extent is the Food Standards Agency influential?

  139.  The FSA is an independent non-ministerial government department set up by an Act of Parliament in 2000 to protect the public's health and consumer interests in relation to food. Between 2001 and 2006, the FSA's key aims include helping people to eat more healthily, promoting honest and informative labelling and promoting best practice with the food industry. DH and the FSA share responsibility for providing the joint secretariat of SACN, surveillance of the nutrition status of people, defining the health education message on nutrition issues, taking account of both food and wider health issues and policy formulation and advice to Ministers on these issues.

  140.  The FSA's role includes obtaining sound evidence on which to base dietary recommendations. This is achieved by commissioning research and dietary surveys and by seeking advice from expert advisory committees. The FSA has a major role to play in enabling, motivating and informing people about diet and in identifying what steps people can take to change their eating habits for the better. The FSA's aim is to find out what information the general public and specific groups require about healthy eating and the best means of communicating these key messages.

  141.  The FSA's Nutrition Action Plan identifies a range of work relating to delivering the Agency's Nutrition Strategic Framework (March 2001). This includes activity related to securing the evidence base, identifying and addressing barriers to achieving a balanced diet, informing the public and monitoring activity. In carrying this out, the FSA will look at every stage of the food chain, working with industry and consumers to see how all stakeholders can contribute to better health, and be involved in finding solutions.

  142.  The FSA also has a Food Labelling Action Plan to improve consumer choice through provision of accurate, meaningful and honest information. The Action Plan seeks to regulate to protect consumer interests where most appropriate and provide advice and guidance where this is likely to be more effective. Nutrition labelling legislation is supplemented by guidelines to ensure consumers have the right level of information. The FSA is also pursuing legislation on health and nutrition claims in Europe which will seek to limit inappropriate claims for, among other reasons, particular classes of food.

  143.  Rules on the provision of the energy and nutrient content in food labelling are harmonised at European level. These require that such information be provided on pre-packaged foods bearing nutrition claims. The FSA, in its guidance to manufacturers on the nutrition labelling regulations, recommends that this information be provided on all pre-packaged foods to enable consumers to make a judgement about its suitability in line with healthy eating advice.

How well is DoH liaising with, and what is the role of, other central and local government departments and bodies?

  144.  Examples are provided throughout this document, particularly in see paragraphs 91, 92 and 98 to 119.

What is the role of schools, including sport in schools?

  145.  The school is a key setting in which to improve both health and education.

—  Our Healthier Nation (1999) and the Independent Inquiry into Inequalities of Health (1998) recognised the importance of a sound education in promoting better health and emotional well-being for children and young people, in particular those who are disadvantaged.

—  It is likely that the forthcoming children's NSF will also identify schools as a key setting for promoting a healthy diet and physical activity among children, as part of action to promote the health of children in general.

—  Personal, Social and Health Education (PSHE) has an assured place in the curriculum.

  146.  The National Healthy School Standard is the mainstay of the Healthy Schools Programme. Introduced in October 1999, it supports delivery of PSHE and citizenship in schools. All 150 LEAs along with their health partners have now achieved accreditation under the NHSS. The Standard promotes a whole school approach to health and healthy eating and physical activity are key areas for action. Work in this area is taken forward through joint initiatives involving DfES with DH and FSA. For example, the FSA-led work to identify the minimum food/nutrition knowledge and skills of young people in preparation for independent living (anticipated in late Spring 2003) and for the first time monitoring of the nutritional guidelines on school lunches.

  147.  The NSFS will be fully operational by 2004 and will entitle every child aged four to six in infant schools to a free piece of fruit each school day, as part of a national campaign to improve the diet of children. The Scheme is currently being rolled out through a £42 million NOF grant scheme. Children in the West Midlands, London and North West regions are currently in receipt of fruit. From the Summer term 2003, one million four to six year olds, in 8,000 schools will receive fruit. Further regions will be brought on stream during subsequent terms.

  148.  The local 5 A DAY community initiatives will also deliver effective interventions to increase fruit and vegetables consumption in schools (see paragraph 105).

  149.  Providing a consistent message to children on healthy lifestyles is vital if we are to meet our objectives. The DH / DfES Food in Schools Programme aims to improve children's health by encouraging a healthy diet at school and promoting clear and consistent messages about diet and nutrition within the school environment. The scope of the Programme is broad—initiatives include the assessment of the overall impact, feasibility and sustainability of water provision and the inclusion of healthier products in vending machines. This programme will support other on-going action in schools—such as nutritional standards for school lunches, NSFS and the National Healthy Schools Programme.

  150.  Building on the Government's Plan for Sport (2001), there is a joint DfES/DCMS 2002 PSA target to enhance the take-up of sporting opportunities by 5-16 year olds: by increasing the percentage of school children who spend a minimum of two hours each week on high quality PE and school sport (within and beyond the curriculum) from 25% in 2002 to 75% by 2006. The two Departments are investing £459 million over the three years from April 2003 to deliver this target through a national strategy for PE, school sport and club links, with the aim of improving the quality of teaching, coaching and learning in PE and school sport.

  151.  The Government is committed to the preservation of playing fields for the benefit of sport and local communities:

—  Active protection (through legislation introduced in 1998) and strict planning regulations has resulted in an average of only three applications a month being approved, and almost half of these are at schools which are closed or closing. In all cases, any proceeds are being ploughed back into improving sports or educational facilities—the proceeds are not being spent on school books or paying teachers' salaries.

—  The DfES Sporting Playgrounds programme will enhance physical/sporting activities and improve behaviour.

—  Sport England has invested over £220 million on pitch sports since 1995.

  152.  £581 million is being invested in England by NOF with the aim of improving and increasing sports facilities at schools. This funding will be used to support projects designed to bring about a step-change in the provision of sporting facilities for young people and for the wider community, through the modernisation and development of existing and new facilities for school and community use including outdoor adventure facilities, and providing initial revenue funding in support of the developments.

  153.  An investment of £130 million which is being allocated to 65 LEAs through the Space for Sport and the Arts programme to develop new sports and arts facilities on primary school sites. As well as benefiting schools themselves, these will also be available for community use, with the emphasis on inclusion of currently under-represented groups.

  154.  As part of the HDA's "evidence into practice" work on obesity, school based work will be further investigated by working with practitioners and drawing on their experience.

Who should own and drive delivery?

  155.  DH is working with OGDs to establish co-ordinated action and is driving local action through the NHS. In addition:

—  DH is leading on the development of a Food and Health Action Plan.

—  DCMS and DH are leading on SPAB.

—  RGOs, PHNs and LSPs provide the mechanisms for effective co-ordination of local policies.

—  The DfES/DCMS delivery board oversee the implementation of the Government's Physical Education, School Sport and Club Links strategy. The board brings together different Government departments including the DH and other partners to combine effort to maximise the impact of the funding and strategy.

Have we the appropriate institutional structures, budgets and priorities?

  156.  As already highlighted, addressing the prevention and management of obesity is key if Government priorities in England are to be met, as highlighted in the NHS Plan, Cancer Plan and NSFs, particularly those outlining action on CHD and diabetes.

—  The Priorities and Planning Framework for 2003-06 (see paragraph 119).

—  To meet the increase in demand, the NHS workforce is expanding. For example the number of dietitians employed in the NHS has increased by 20% since 1997 and further expansion is expected. Delivering the NHS Plan includes projections for 35,000 more nurses, midwives and health visitors, 30,000 more therapists and scientists and 15,000 more GPs and consultants to be employed in the NHS by 2008 over a 2001 baseline. There is also the opportunity for additional staff support through initiatives such as the development of dietetic assistant posts and "skills escalator" schemes.

—  The Lifelong Learning budget has allocated £24 million to professional skills development for the spending review period 2003-04—2005-06. £3.6 million of this budget has been allocated over the three years to provide training on obesity for primary care staff—enabling 5,900 existing staff to develop their skills and boosting the capacity of the NHS in this area.

RECOMMENDATIONS FOR NATIONAL AND LOCAL STRATEGY

How can the Government's strategy by improved? What are the policy options? Can they be better integrated? What are the priorities for action?

  157.  In conclusion, obesity is an international problem, which no country has successfully tackled. Prevention is likely to be the best long term approach, addressing the risk factors of diet and physical inactivity, however effective management of overweight and obesity is also being addressed.

  158.  The prevention and management of obesity are at the heart of many of the Government's priority areas, as highlighted in the NHS Plan, Cancer Plan, and NSFs, particularly those outlining action on coronary heart disease, diabetes and older people.

  159.  One Government department cannot tackle obesity on its own. An integrated, evidence based cross-government approach is underway to tackle obesity, improve diet and increase physical activity levels, and to tackle inequalities. Key to this is the development of the Food and Health Action Plan and the Sport and Physical Activity Board which will help shape policy in this area, ensure a consistent, effective approach, and is likely to have a major impact on trends in England.

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Prepared 27 May 2004