Memorandum by the UK Public Health Association
and Faculty of Public Health Medicine (OB 6)
The UKPHA is an independent, UK-wide voluntary
organisation which brings together individuals and organisations
from all sectors who share a common commitment to promoting the
The UKPHA has three priority objectives: Combating
health inequalities. Promoting Sustainable Development and Challenging
The Faculty of Public Health Medicine of the
Royal College of Physicians aims:
(1) To promote, for the public benefit,
the advancement of knowledge in the field of public health.
(2) To develop public health with a view
to maintaining the highest possible standards of professional
competence and practice, and to act as an authoritative body for
consultation in matters of education or public interest concerning
The form of this submission is to follow through
the questions posed by the Committee in the pursuit of its Inquiry.
The UKPHA and FPHM in their submission to the Inquiry will attempt
to address each of the points set out in the covering brief and
is prepared to make other forms of submission to the Inquiry and
supply supplementary evidence, as requested.
* The health implications of obesity
What are the health outcomes of obesity in society?
What are the economic and social costs? What efforts is the Government
making to evaluate these?
1. Obesity is an excess of body fat frequently
resulting in a significant impairment of health and longevity.
For adults levels of overweight and obesity are generally established
through the calculation of body mass index:
BMI = Body wt in Kg/(Ht in m)2
An overweight adult is usually defined as one
with a BMI between 25 and 29.9, while an obese adult has a BMI
of 30 or higher. It is useful to determine of a gradient body
weight, from low to high, together with associated health risks.
Classification of overweight and obesity
in adults according to BMI.
Obesity is classified as BMI > 30 kg/m2.
|BMI (kg/m2 )
|Risk of co-morbidities
|Low (but risk of other clinical problems increased)
2. The implications of obesity for mortality and morbidity
are now widely understood. The pattern of excess mortality variation
with relative weight is illustrated in men ages 15 to 39 in the
to Average Weight
3. The WHO projects that, by 2020, chronic diseases will
account for almost three-quarters of all deaths globally, and
that 71% of deaths due to ischaemic heart disease, 75% of deaths
due to stroke. There
is a strong association between the prevalence of obesity and
CVD risk factors. American evidence suggests that the prevalence
of reported diabetes is 2.9 times higher in overweight than non-overweight
persons. According to WHO 58% of diabetes mellitus, 21% of ischaemic
heart disease and between 8-42% of certain cancers were attributable
to BMI greater than 21kg/m2. WHO currently attributes one-third
of all global deaths (15.3 million) to CVD, with developing countries,
low-income and middle-income countries accounting for 86% of the
DALYs attributable to CVD lost worldwide in 1998. Nevertheless,
the full economic and social picture of nutrition-related and
physical activity linked disease is by no means complete, although
for the UK the National Audit Office's 2001 review (in England)
is a firm starting place. To develop a national picture of the
issues, including the means to tackle them, it is important that
further research is undertaken on a collaborative basis supported
by the Departments of Health, the Treasury (perhaps incorporating
in the current Treasury Review), specialist charities and researchers
in the public health community. A Public Health Research Collaboration
is one such model. This activity requires a major reorientation
of research and development activity by national research bodies
and the NHS to upstream factors and alternative policy pathways,
as for example, the Fully Engaged Strategy as set out in Securing
our Future Health (Wanless Report).
4. What must be stated firmly is that preventing obesity
and overweight requires a "whole society approach";
it is not simply, or even primarily, a medical matter, although
the NHS can be helpful in dealing with a range of dietary or lifestyle
problems and can assist with the diseases associated with obesity
Effective surveillance systems for diet, physical
activity and related health problems are essential to enable all
interested stakeholders to track progress towards health targets,
including health inequalities targets. A "Public Health Research
Collaboration" should be supported to address the variable
quality of information on the economic costs of dietary and physical
activity linked patterns of disease, to test epidemiological models
and to develop the "Fully Engaged" model of health,
as outlined in Securing our Future Health.
* Trends in obesity
What are the trends in obesity (including trends among particular
groups, by social class, age, gender, ethnicity and lifestyle?
What is the relationship between obesity and other health inequalities?
What are the international comparisons? (EU, OECD, USA)?
5. Warnings of the impact of obesity are not new. In
1974, an editorial in the Lancet identified obesity as "the
most important nutritional disease in the affluent countries of
the world." However
only recently have such warnings mobilised official concern. Even
so, the analytic and policy representations of this issue remain
fed through a generally narrow media narrative due to a variety
of factors: the immense lobbying power of the food industry, the
attention in discussions of weight to give attention to personal
appearance rather than health, the individualistic nature of the
discourse around diet (and dieting) and health, and the inability
of commentators to address the structural changes in society which,
more so than individualistic factors, explain the patterns of
diet and exercise, and consequential health effects, facing local
populations. These latter influences range from changes in transport
modes, entertainment, cultural and behavioural change, the reshaping
of childhood an the empowerment of childhood "choice",
the consequent underdevelopment of "health protection"
for children in the light of the commercialisation of culture,
and governmental involvement in private public partnerships which
fail to fully address health consequences.
6. In low-income countries, obesity is more common in
urban areas and amongst people of higher social class. In more
the developed or more affluent countries, obesity has been common
in older age groups, particularly women, though is becoming increasingly
common in poorer populations. However, over several decades a
new pattern has formed based upon spectacular increases in weigh
across the population, allied to changes in food and drink consumption
and lifestyle changes. These trends are shown into sharp relief
in the US in particular and seem related to a pattern of social,
economic and cultural changes in that country. These bear examination,
in part because of the spread of US culture to the UK, but also
because of governmental and commercial responses which may provide
lessons for the UK and Europe. As a WHO expert group has noted:
"In many countries, perhaps most typified by the USA, changes
in family eating patterns and the consumption of fast foods, pre-prepared
meals and carbonated drinks, have taken place over the past 30
years. Likewise, the amount of physical activity has been greatly
reduced both at home and in school, as well as by increasing use
of mechanized transport."
7. Health care costs in the US. Health economics has
poorly addressed public health issues. The traditional preoccupation
of American health economists has not been with the determinants
of healthsuch as diet or level of exercise, or the social
and economic costs of avoidable illnessbut rather health
care costs, more accurately the costs of the medical care system,
which are now nevertheless linked overwhelmingly to lifestyle
based chronic diseases. One explanation for the dearth of such
studies that the causes of ill-health, and the economic calculation
of the field of effects, are often complex and require explanations
outside the realm of health economics, as traditionally conceived;
in contrast, data on medical costs is easily available and relatively
clear-cut, particularly in a country where cost accounting for
medicine is so well developed. What is known is that health care
spending in the United States will reach $2.8 trillion in 2011,
up from $1.3 trillion in 2000, and it is growing at an average
annual rate of 7.3%. Expressed as a percentage of Gross Domestic
Product (GDP), spending is expected to reach 17% in 2011, up from
13.2% in 2000. (Also
bear in mind that almost 40 million Americans in 2000approximately
14% of the population, remain outside health insurance.) This
projected level of spending will produce a heavy burden on the
US economy, since the majority of costs are born by employers
and the federal and state governments. Expenditures on prevention
in the US are a tiny fraction of the amount spent on medical care,
and, apart from the recent injection of funds due to fears of
bio-terrorism, have been falling over the last 20 years.
8. Within this picture the total economic burden of CVD
has officially been estimated at $498 billion for 2001, accounting
for 61% of all health care spending. In 1998 CVD claimed nearly
1 million lives and accounted for 40% of all deaths. Current estimates
are that more than 60 million Americans have one or more types
of CVD. According to the US Surgeon General, approximately 300,000
US deaths a year currently are associated with obesity and overweight
(compared to more than 400,000 deaths a year associated with cigarette
smoking). The total direct and indirect costs attributed to overweight
and obesity amounted to $117 billion in year 2000around
10% of total health care costs.
One recent study has suggested that obesity is associated with
a 36% increase in inpatient and outpatient spending and a 77%
increase in medications, compared with a 21% increase in inpatient
and outpatient spending and a 28% increase in medications for
current smokers and smaller effects for problem drinkers.
Other US research has indicated that there is a clear association
between body mass index and health care costs, largely due to
the link between BMI and coronary heart disease, hypertension,
and diabetes, on a range between 25% greater and 44% greater,
depending of level of BMI.
In 1998, there were some 400,000 liposuction procedures in the
United States. Over 100,000 Americans per year now receive gastric
bypass surgery, the "last ditch" technique for halting
further symptoms, such as those associated with diabetes.
The total cost of such surgery, ranging from $17,000 to $45,000
per operation, is very considerable, with US total expenditures
on obesity treatment exceeding the total health care expenditures
of many developing countries, where of course obesity is almost
totally absent. Nevertheless it does not seem that the growing
numbers of US citizens who are overweight and obese has appeared
within overall longevity trends.
9. Between 1991 and 2000, obesity levels in the US, according
to the accepted definition, rose 60%. About 61% Americans are
overweight and one in five is obese. Thirteen% of children ages
6-11 and 14% of those 12-19 were "seriously overweight"
in 1999. If attention has now focused on obesity, rather than
CVD generally, it is partly because of its sheer visibility as
an outward sign of the problems associated with diet and sedentary
lifestyle. In particular the rising consumption of energy-dense,
micronutrient poor foods, which are high in fat (such as fried
foods), sugar or starch has taken the place of energy-dilute foods
with a high water content (such as fruits and vegetables). According
to US Department of Agriculture data for 2000, the most recent
available, the national food supply provided 280 pounds of fruit
per person. Adjusted for losses and waste, that amounted to less
than half the per person per day minimum consumption of fruit
as recommended by the US Department of Health. Only 3% of the
population meet at least four of the five government dietary recommendations
for the intake of grains, fruits, vegetables, dairy products,
and meats. In contrast consumption of added sugars reached 31
teaspoons per person per day, far above the six- to 18-teaspoon
maximum recommended. Many of these sugars, for younger age groups,
came from the consumption of soft drinks. As regards the latter
there is a strong connection between rising consumption of these
drinks and obesity.
Most of the evidence relates to soda drinks but many fruit drinks
and cordials are equally energy dense and may promote weight gain
if drunk in large quantities. In terms of physical activity less
than one-third of Americans meet the federal guidance to engage
in at least 30 minutes of moderate physical activity at least
five days a week, while 40% of adults engaged in no leisure-time
physical activity at all. Research has shown that there is a strong
age, sex, ethnic and social class dimension to these both dimensions
with "Latino" and Black communities seeing the most
severe representation. However given that almost two in three
Americans are overweight or obese the problem necessarily stretches
across all social groups.
10. The rise in obesity contrasts with changing patterns
of smoking prevalence, another determinant of CVD risk. US smoking
rates have been cut roughly in half since 1964. Based on comparative
treatment costs, the case is now being made to treat obesity with
equal seriousness as tobacco has been by the government and by
society generally. The significant fall in smoking rates is a
positive sign that the determinants of health can be changed.
It does not indicate, however, that the combination of approaches
applied to tackling the tobacco epidemic will necessarily work
for diet and sedentary lifestyle.
11. Europe, unlike the US, is divided by language and
national histories, and therefore does not evidence a similar
degree of cultural homogenisation as the US; nor is the conversion
to the fast food/television entertainment lifestyle as pronounced.
European data collection is also more diverse. Nevertheless, Europe
too is witnessing changes in diet and physical activity in ways,
which appear to follow the pattern set by the US. The result is
shown in the varying prevalence of obesity across a number of
Prevalence of obesity (BMI > 30) in a selection
of European countries
|% Men BMI
|% Women BMI < 30
|% Men BMI
|% Women BMI < 30
Table compiled by the IOTF, 1999.
12. The UK, like the US, shows growing, though comparatively
recent, trends towards obesity and overweight as well as a strong
age, sex, social class and ethnic dimension to the problem, as
shown in the table. The issue of adult obesity and overweight
has been much discussed but a major focus of any strategy should
be on children. It is believed that levels of obesity in Britain
are increasing at an appreciable rate in primary school children.
Surveys indicate little change was found in the prevalence of
overweight or obesity from 1974 to 1984. From 1984 to 1994 overweight
increased from 5.4% to 9.0% in English boys and from 6.4% to 10.0%
in Scottish boys; values for girls were 9.3% to 13.5% and from
10.4% to 15.8% respectively.
BMI is not considered by many researchers to be a reliable measure
for children and waist circumference has been used as an alternative
measure. Research using this measure suggests that waist circumference
in British youth has increased over the past 10-20 years at a
greater rate than body mass index, the increase being greatest
13. Prevention costs are money well spent. Each year
about 74 billion Euro are spent on treating cardiovascular disease
(CVD) in the European Union. But CVD also costs an additional
106 billion Euro a year in lost production of goods and services
because of premature death and disability. In total CVD costs
the European Union about 180 billion Euro a year. (These estimates
are based on four separate costs of disease analyses carried out
for the UK, the Netherlands, Sweden and Germany.) The WHO also
recommend that fat intake should be less than 30% of total energy
but the dietary survey data shows that 21 out of 26 countries
fail to meet this goal. There are paradoxes too, however. In Spain
overweight for children aged six to seven is above that of the
USA, while adolescent overweight levels are among the highest
in the world. Nevertheless, CVD mortality is low, as with Italy
and France, and the cancer mortality rate is lower than Italy
and France. Some
European states, such as Sweden have taken child health protection
seriously and have enforced an advertising ban on products sold
to children. On food the Swedish National Institute of Public
Health have reviewed the EU Common Agricultural policy and have
issued important recommendations for reform. Their proposed recommendations
include those with important implications for obesity and overweight,
including: phasing out all consumption aid to dairy products with
a high fat content, promotion of fruit and vegetables in schools,
redistribution of agricultural support to favour the fruit and
vegetable sector and increased consumption.
These policies bear closely consideration for adoption in the
UK and EU-wide.
Overweight and obesity are worldwide problems,
which require a global, European and UK-wide perspective. At the
global level the UK should be fully involved in the development
and implementation of the WHO strategy on Non-Communicable Diseases.
At the European level it must be involved in the reform of the
Common Agricultural Policy to stimulate reform based upon public
health principles and lobby to ensure that health protection is
given the highest prominence. At the UK level the Departments
of Health across all four nations must take the lead to stimulate
Investment must be made in prevention. The Chancellor
should give consideration to extra taxation of high fat, high
salt and high sugar processed foods and drinks. A hypothecated
tax may be able contribute towards the costs of the National Fruit
in Schools schemes and support further initiatives of this kind,
particularly focussed on poorer communities.
* What are the causes of the rise in obesity in recent
What has been the role of changes in diet? 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?
14. The dietary evidence for good health is clear. The
World Health Organisation (WHO) and the UK's Committee on Medical
Aspects of Food and Nutrition (COMA) recommend eating at least
five portions 400g) of fruit and vegetables a day.
The World Health Organisation have summarised a range of factors
that might promote or protect against weight gain and obesity
(see chart below).
It has been shown that consumption of antioxidant vitamins through
dietary sources such as fruits and vegetables, oily fish and fibre
from fruits and vegetables (in particular from cereals and grains)
can protect against the development of CVD.
The key issues in maintaining weight control and improving health
are not mysterious: a balanced and varied diet and an active lifestyle.
Dieting should be avoided because it leads to behaviour swings
rather than balance. Most people in Britain know this. Why therefore
is the situation worsening?
Summary of strength of evidence on factors that might
promote or protect against weight gain and obesitya
|Regular physical activity
|High dietary intake of NSP (dietary fibre) b
|High intake of engery-dense micronutrient-poor foodsc
|Home and school environments that support healthy food choices for childrend
|Heavy marketing of energy-dense foodsd and fast-food outletsd Sugar-sweetened soft drinks and fruit jucies
|Adverse social and economic conditionsd (in developed countries, especially for women)
|Low glyacemic index foods
|Protein content of the diet
|Large portion sizes High proportion of food prepared outside the home (developed countries) "Rigid restraint/periodic distribution"" eating patterns
|Increased eating frequency
a Strength of evidence: the totality of the evidence was
taken into account. The World Cancer Research Fund schema was
taken as the starting point but was modified in the following
manner: randomised controlled trials were given prominence as
the highest ranking study design (randomised controlled trials
were not a major source of cancer evidence); associated evidence
and expert opinion was also taken into account in relation to
environmental determinants (direct trials were usually not available).
b Specific amounts will depend on the analytical methodologies
used to measure fibre.
c Energy-dense and micronutrient-poor foods tend to be processed
foods that are high in fat and/or sugar. Low energy-dense (or
energy-dilute) foods, such as fruit, legumes, vegetables and whole
grain cereals, are high in dietary fibre and water.
d Associated evidence and expert opinion included.
15. The answer can be found in starkest form in the US.
One leading culprit is the "fast foodhigh fatsoft
drink" diet and the constant pressure on individuals to consumewhich
makes the attempt to secure a balanced diet socially deviant.
According to Eric Schlosser in "Fast Food Nation", Happy
Meals were introduced by McDonald's Corporation in 1979just
one year before childhood obesity rates began to climb. About
90% of America's children between three and nine years visit a
McDonald's every month. In the US over the last 30 years average
portion sizes in hamburger chains have doubled as well as has
the consumption of fizzy, sugary drinks. In the case of the US
schools are no longer protected areas and children are marketed
to extensivelywith McDonald's advertising budget alone
exceeding one billion dollars. According to Fortune magazine $4.5
billion a year is spent by the food industry on advertising and
$50 million a year is spent on lobbying in Washington, DC
The US Surgeon General reported that that school foods had the
highest saturated fat density of all food outlets. The key economic
importance of screen based entertainment (television, videogames)
and private motor transportation means that rates of exercise
16. British culture has been following the US in many
respects. Young adults (aged 19 to 24 years) are the group most
likely to have adapted to the new commercial cultural influences
and to consume energy-dense fast foods, typically fried chicken,
burgers, kebabs, savoury snacks, together high sugar carbonated
soft drinks. One large government survey indicated that nearly
two-thirds of men, and one-third of women, aged 19 to 24 years
had eaten burgers and kebabs during the recording period, compared
with one in ten of the oldest group of men and women. Over half
of all respondents, 54% of men and 57% of women, had eaten chocolate
confectionery during the seven-day dietary recording period, and
about a fifth, 20% of men and 25% of women, had eaten sugar confectionery.
On the healthier food ranges 30% of men and 43% of women aged
19 to 24 years had consumed leafy green vegetables compared with
64% of men and 70% of women aged 50 to 64 years.
Data would appear to indicate that younger people are adopting
less healthy diets than the older generation, and comment has
already been made in the US that older people are getting on average
healthier while younger people are experiencing substantial growth
in asthma and diabetes.
The diet of the poorer people in the UK provides cheap energy
from foods such as meat products, full cream milk, fats, sugars,
preserves, potatoes, and cereals but has little intake of vegetables,
fruit, and whole wheat bread. According to one assessment: "Households
in the bottom tenth of the income distribution spend on average
29% of their disposable income on food (after allowance for housing
costs); those in the top tenth spend 18%. In families with children,
expenditure on food per person in the bottom fifth of income is
extraordinarily low (£1.64/person/day in lone parent families).
Low socioeconomic groups, however, buy more efficiently than high-income
households : the bottom tenth spends far less on alcohol (£1.85/person/week
v £7.73 in the top tenth) and sweets (£0.46 v £0.68).
But these efficiencies lead to the purchase of foods richer in
energy (high in fat and sugar) to satisfy hunger, which are much
cheaper per unit of energy than foods rich in protective nutrients
(like fruits and vegetables). The purchase of healthy options
within mainstream eating patterns is likely to increase the food
bill by 6-13%."
Food poverty must be part of the understanding of population weight
gain, but it is only one. If health inequalities are to be tackled
food poverty must be an essential component of the national strategy.
17. The other side of the coin to dietary problems is
declining physical activity. There is a dispute, particularly
present in the US, that the decline in physical activity is more
significant for health than changes in diet, although this suggestion
is most loudly voiced by organisations and researchers financially
supported by the food industry. We suggest that both factors are
important and that they are linked. In the UK there is ample evidence
that rates of "passive exercise"physical activity
undertaken as part of everyday lifehas declined. Government
studies show that the number of trips per person on foot fell
by 20% between 1985-86 and 1997-99.
The principal cause for the decline in walking was, as argued
by the House of Commons Select Committee on Environment, Transport
and Regional Affairs, that "the convenience and comfort of
car travel; land use planning policies; the truly awful conditions
for pedestrians; and increasingly the fear of being attacked or
robbed. These factors are heavily influenced by the extraordinarily
low status accorded to pedestrians. As a result walking is seen
by many as the mode of transport for those who have no alternative"
It is probable that London's traffic congestion charge, which
has reduced traffic levels in central London by 18%, will have
also boosted levels of exercise by shifting people to public transportation
and to walking. An implication that may be drawn is that policies,
which make good sense on environmental grounds, also make good
sense on health grounds. According to a briefing Parliamentary
Office of Science and Technology, the facts behind the decline
in physical activity are the following:
Reduction in occupational physical activity
Decline of walkingpersonal safety especially
of children women and older people
Increase in energy saving devices in public placesescalators,
lifts, automatic doors
Reduction in physical education and sport in some
Adults fears of childrens' safety in unsupervised
Substitution of physical activity leisure with
sedentary pastimes like television, computer games and the internet
18. The result is that in the general population in England,
only one-third of men meet the current guideline for recommended
participation in physical activity. Within this general picture
there is considerable variation by ethnicity and sex. Surveys
using age-standardised ratios indicate that Black Caribbean men
are more active than average and most other minority ethnic groups
less than average, in particular Chinese and Bangladeshi men.
For women however, only just over one in five of the general population
met the guideline. Again, Black Caribbean women were more active,
but other groups, Chinese, Indian, Pakistani, and Bangladeshi
were far less active. The statistics on the Bangladeshi community
are notable, Bangladeshi men are almost twice as likely than the
general population to be classified as sedentary and Bangladeshi
women almost three times. A
study commissioned by Sport England, showed that young people
spend less time doing PE in school than they used to (in 1994,
46% did two or more hours per week compared to 33% in 1999).
19. One major feature of physical inactivity is the pervasiveness
of screen-based entertainment in a variety of forms, ranging from
television to computer games. There are two sides to the issue.
People watching television are physically inactive: children who
watch television five or more hours a day are five times as likely
to be overweight as those who watch less than two hours a day.
Time spent playing computer games and surfing the Internet is
time lost playing outside and being physically active. Secondly,
children watching television are influenced by food advertising,
which is invariably linked to the unhealthier range of food products.
Young children are unable to distinguish programme content from
the persuasive intent of advertisements. It might be noted that
parents are very concerned about the influences of television
on their children. ITC research has noted: "There was a widespread
belief that children are affected by advertising on television.
This manifested itself through pester power, direct copying of
behaviour, and a more subtle and gradual effect on attitudes.
The concern was felt most strongly for children without much family
advertising to children makes food into "fun" and presents
to them that food choices are "their choices" (in fact
the advertiser's) rather than those of their parents.
A national strategy for obesity and overweight
requires interventions right across society, engaging industry
and the food sector, television and the media, schools, and communities.
* What can be done about it?
What is the range of "levers" and drivers (food
industry, marketing, education, family life, genetics, drugs,
surgery)? Within that range, what role can the food industry,
marketing and advertising, transport, schooling play? What are
the responsibilities of the food industry in respect of marketing?
How influential is the media? How can the amount of physical activity
being undertaken be increased? To what extent can and should Government,
at central and local level, influence lifestyle choices? How coherent
is national and local strategy? What is international best practice?
20. The food industry is not monolithic. Farmers and
grower produce fruit and vegetables which should be consumed more,
but which are in decline; but farmers and food processors, soft
drink makers and others produce products which should be consumed
less, but which are profitable. In the case of the former advertising
in minimal; in the case of the latter they are subject to high
advertising budgets. It is particularly relevant and meaningful
that numerous sports stars at the peak of activity are connected
to products, which are unhealthy. The link between David Beckham
and Pepsi Cola and Gary Lineker, former footballer and trusted
commentator, and Walkers Crisps (also a Pepsi product) is symptomatic
of the issue.
21. In the UK, the market for biscuits, chocolates and
sugar confectionary alone in 2001 was £1.79 billion for biscuits,
£3.89 billion for chocolate confectionery and £1.75
billion for sugar confectionery.
These are significant industries with significant advertising
budgets. The advertising industry, for whom children's advertising
is part of their staple income, naturally opposes advertising
controls: "To advocate arbitrary restrictions on food advertising
to children is to misunderstand fundamentally the role of advertising
in the context of the media as a whole, family life, individual
choice, programme funding and market competition."
Other organisations, such as the Social Issues Resource Centre,
oppose more thorough restrictions on the food sector, such as
taxation related to fat content. Coincidentally, this charitable
organisation has received funding from Kelloggs, Mars, the Biscuit,
Cake, Chocolate and Confectionery Alliance, HP Danone, the Sugar
Bureau, among others. These companies "share SIRC's basic
interest in promoting better understanding of health and social
issues" We merely
observe that not all organisations which purport to offer advice
to government or to the public do so in the interest of public
health. There are many things that can be done working with industry.
But the involvement of industry should operate within clear guidance
and clearly set out principles, recognising that if industry is
willing to finance public campaigns this partnership may undermine
the independence of governmental advice and furthermore that its
primary agenda is financial returns to investors.
22. On the other hand, some parts of the food industry
take the issue of obesity extremely seriously in the light of
the threat of US-originated legal actions. Following massive legal
actions brought by US States and consumers against the tobacco
industry litigation has begun to focus on the link between fast
foods and obesity, particularly around children. As Fortune magazine
notes: "Fast food, snack food, and soft drink companies focus
their marketing on children and adolescents through Saturday morning
TV commercials; through cuddly characters like Ronald McDonald
(the second most recognized figure among children after Santa
Claus); through contracts to advertise and serve soft drinks and
fast food in schools; and through ever-changing toys included
in Happy Meals."
23. This trend is a warning to the food industry and
government. The assumption by much of industry is that it can
it protect its interests by financially supporting physical activity
initiatives, as in the case of Cadbury/Youth Sports Trust voucher
scheme. Such schemes may ultimately be self-defeating in both
publicity terms and in health terms, since critics point out that
any benefits are reduced by the requirement of extra sales of
high fat products.
The question for government support for such schemes is whether
it is willing to split physical activity benefits from health
losses due to the consumption of fatty foods. We must be emphatic:
the state has a duty to protect the health of young people and
should not place itself in the trading off benefit for losses;
in any case, as noted, by nutrition and physical activity are
24. The rise of diet related disease in this new century
may be as serious as recent (and continuing) epidemics, where
the state was also slow to acteg tobaccoand prevaricated
over critical public health measures, such as advertising bans.
In the case of food choices/dietary problems among young people,
however, these tend to persist throughout life unless something
is done in the earliest stages. Chronic disease risks frequently
begin early in life (in fact in the womb). Adult chronic disease
reflects cumulative differential lifetime exposures to damaging
physical and social environments. A life course analysis indicates
that actions can be taken from the earliest phase of life to its
last phases: from the encouragement of breast feeding, for which
there is increasingly strong evidence suggesting that a lower
risk of developing obesity,
to old age, where exercise can appreciably influence a range of
factors, from quality of life to risk of osteoporosis and reduced
less risk of CVD.#
There is a role for individuals and communities, for the commercial
sector and for the state, but the respective interaction between
each should be part of a national strategy and should not be decided
on an ad hoc basis by one department of government (for example
education or sports) without being part of an overall framework
monitored either by the Department of Health or else through a
cross-departmental body such as the Cabinet Office.
25. Individuals and communities have an important role
to play in maintaining their health. Highly motivated individuals
can significantly reduce the risk of becoming obese or their risks
of developing type 2 diabetes through a daily brisk walk, by reducing
the hours they watch television, or making minor adjustments to
their diet. On
the other hand for the population as a whole rejuvenating the
household "food culture" or restoring exercise in their
daily lives will not be easyfor reasons addressed by the
earlier mentioned report of Commons Select Committee on Environment,
Transport and Regional Affairs. British towns and cities have
been increasingly redesigned for cars, leading to a life-threatening
level of exercise deprivation. Our future health depends on creating
neighbourhoods that are conducive to walking, strolling, running
and bicycling. The challenge is to redesign our communities and
to build in "health regeneration" into all schemes for
town planning, making public transportation the centrepiece of
urban transport, and augmenting it with bikeways or footpaths.
This also means replacing parking areas with parks, playgrounds,
and playing fields. Unless Britain can design society to systematically
restore exercise to our daily routines, the obesity epidemicand
the health deterioration associated with itwill continue
to spread. The House of Commons Health Committee will doubtless
be presented with many examples of societies, not so dissimilar
to our own, which give a far higher commitment to the dietary
health of children, the "health protection" of children
from advertising and the pervasive marketing of unhealthy foods,
which build daily life around exercise, such as walking or cycling.
Unfortunately there is no national debate over the potential for
introducing these desirable features into British life. On the
contrary, even public sector broadcasters like the BBC are more
eager to make programmes on the virtues of driving fast cars,
as ironically indicated by the expanding girth of their presenters.
To the question of whether there is a coherent, government-wide,
and economically and media grounded strategy, the answer must
be that for diet (or for exercise) there is none.
This matter must be urgently redressed.
33. This response has suggested the usefulness of on
international perspective on obesity and overweight, In the US
official recognition of the severity of the economic, social and
health costs of obesity has led the US Surgeon General to issue
a Call to Action. The US Surgeon General's strategies include
Ensure daily, quality physical education for all
school grades. Currently, only one state in the countryIllinoisrequires
physical education (for school children) while only about one
in four teenagers nationwide take part in some form of physical
Ensure that more food options that are low in
fat and calories, as well as fruits, vegetables, whole grains,
and low fat or non-fat dairy products, are available on school
campuses and at school events. A modest step toward achieving
this would be to enforce existing U.S. Department of Agriculture
regulations that prohibit serving foods of minimal nutritional
value during mealtimes in school food service areas, including
in vending machines.
Make community facilities available for physical
activity for all people, including on the weekends.
Create more opportunities for physical activity
at work sites.
Reduce time spent watching television and in other
sedentary behaviours. In 1999, 43% of high-school students reported
watching two hours of TV or more a day.
Educate all expectant parents about the benefits
of breast-feeding. Studies indicate breast-fed infants may be
less likely to become overweight as they grow older.
Change the perception of obesity so that health
becomes the chief concern, not personal appearance.
Increase research on the behavioural and biological
causes of overweight and obesity. Direct research toward prevention
and treatment, and toward ethnic/racial health disparities.
Educate health care providers and health profession
students on the prevention and treatment of overweight and obesity
across the lifespan.
34. For the most part, these are sensible suggestions some
of which have UK relevance. Unfortunately, these strategies are
mostly at the level of exhortation and, without powers of implementation,
resemble a wish list. In devising a UK strategy in the light of
the challenge this implies that more than "modest steps"
Advertising to children. There is a case to be
made for proper analysis and action around the Health Protection
needs of children. One part of this must be the review of restrictions
on food advertisements. We propose that all advertising for foods
during television programmes watched by children under the end
of 10 years should be halted. For older age groups the Department
of Health and Food Standards Agency should formulate guidance
The NAO 2002 report on obesity recommended that
the Department of Health should lead the development of a new
cross-Government strategy to promote the health benefits of physical
activity. This is now promised. This must be focussed on matters
far wider than encouragement of exercise and should be accompanied
by guidance to planners across government and local authorities
to stimulate a physical activity culture. Recognition should be
given to the value of alternative forms of physical activity such
as the Green Gyms programme.
Transport and recreation policies promote, support
and protect physical activity. For example, urban planning, transportation
and building design should give priority to the safety and transit
of pedestrians and safe bicycle use. Policy innovations range
from congestion charging to reduced speed limits in urban areas.
Safe routes to School programme rolled out to include all schools.
Food in schools. Nutritional guidance on school
meals neglects the general question of what children are actually
eating in schools, the evidence being that they are eating unhealthy
foodwhile under the supervision of the State. Greater regulation
of free school meals to ensure that they provide a healthy meal
for all recipients. Provision of free healthy breakfasts for all
primary school children. All schools-based commercial promotions
of foods should be ended and schools encouraged to adopt model
school foods policies, which for, example, end the link between
income generation and the operation of school tuck-shops. Price
differentials should be introduced in schools to encourage the
consumption of the healthier range of foods. Free drinking water
should be provided in all schools to provide an alternative to
carbonated sugary drinks.
* Are the institutional structures in place to deliver
What is the role of the Department of Health (DoH) and of
the NHS, including that of primary care, hospitals and specialist
clinics? How effective are the structures for health promotion?
Can health promotion compete with huge food sector advertising
budgets? To what extent can the food industry be part of a solution?
To what extent is the Food Standards Agency influential? How well
is the DH liaising with, and what is the role of, other central
and local government departments and bodies? What is the role
of schools, including sport in schools? Who should "own"
and, drive delivery? Have we the appropriate institutional structures,
budgets and priorities?
26. All public authorities, including the NHS, Transport,
Education, Defra, etc, as well as private bodies, ranging from
public health to voluntary organisations, should fully address
the seriousness of this new situation. What must be considered
however, is the appropriate strategy they should adopt towards
those companies and practices, which are "fattening the nation".
The role of individual departments of government has to be set
within an overall cross-governmental strategy led from the highest
reaches of government, based on the advice of the Chief Medical
Officer, in concert with the Department of Health and the Food
Standards Agency. Many voluntary organisations and professional
organisations can play a role, particularly in developing innovative
programmes focused on young people (such as the NHF Young at Heart
Campaign). It is essential that government is open to innovation
27. From the centre the Department of Health has devised
a variety of schemes to improve nutrition in schools (principally
the National Fruit in Schools Scheme) and is the Departmental
Sponsor, with the Education Department, of Healthy Schools. The
Five a Day initiative and other schemes, hold considerable promisealthough
we have witnessed two supermarket groups failing to offer their
support. The bigger picture is that the Department's work faces
almost insuperable odds: industry marketing of fatty, surgery
or salty foods is far better funded and its marketing is far more
influential, particularly at a time when centrally the Department
of Health is being reorganised and personnel downsized by one-third.
The critical issue for the Department is its capacity to provide
leadership across government, in concert with the Food Standards
28. The NHS, within the general framework of the DH,
has an extremely important role to play and National Service Frameworks
should offer a strong guide to effective clinical practice. Primary
care trusts in England, and their devolved counterparts, also
have a role to play and leadership in nutrition and physical activity
should be vested through Directors of Public Health, working closely
with local authorities. Far more can also be achieved by Environmental
Health Departments, and more should be asked of them. The aim
must be engage all local bodies in locally-owned activities to
promote not just individual behaviour change but the everyday
frameworks through which people operate their lives. Healthy choices
in diet and physical activity must be made the automatic choice,
not somethinglike dietingthat people have to consciously
think about and where they usually fail. There is a further, and
more difficult question for the NHS. How many of its large staff
are given opportunities to improve their diet and increase their
physical activity? In other words, how far in the NHS a health
service for its staff?
29. The support and protection of children through healthy
pathways to adult life is particularly important. Unfortunately
the Education Department (DFES) has been "symbolically compromised"
through its involvement in cause related marketing initiatives
such as with Walkers Crisps (a division of Pepsi-Cola) in their
"Free books for School" campaign. This scheme was criticised
by the Consumer's Association as poor value and by the National
Audit Office as compromising the government's general health message
to young people. To its credit, the Education Department has introduced
nutritional standards for school meals in 2001 to improve children's
diets. Unfortunately, this approach has been shown to be far too
narrow. Which? found that the schools visited indicated that the
caterers are meeting the standards, which specify how frequently
certain foods must be offered. A wide variety of foods, including
vegetables, salad and fruit were on offer every day. However,
the children usually opted for the less healthy dishes. In 2003
Which? asked 246 children to keep a food diary. The diaries were
filled with details of crisps, chips and chocolate bars, but rarely
mentioned fruit or vegetables. Diets were typically lacking many
vital nutrients, and often high in saturated fat, sugar and salt.
The Education Department must do better. Children and their families
should not be used a fodder for marketing schemes of the junk
food manufacturers. This said the protection of children must
extend beyond the school gates, particularly since some evidence
suggests that The question is: who will protect society from large
companies whose are adapt at marketing and whose very business
engages the sales of fatty surgery or salty foods? The answer,
as yet, does not seem with the Education Department, the Department
of Health or the Food Standards Agency. They must be given the
powers and political support to do so.
30. The Department of Work and Pensions should work with
the Department of Health and Food Standards Agency to examine
the link between benefits and diet. Clearly, if poverty related
problems in food and access to physical activity are to be addressed
DWP can be a substantial source of help. Pathways to Work notes
the rise in people receiving incapacity benefit, and that a rising
part of incapacity is associated with mental health problems.
It is critical to find ways to help people out of work or in receipt
of incapacity benefit to establish the means of leading healthier
lives. What mechanisms can be built within the framework of DWP
activities to encourage healthier lifestyles, which can play an
important part in improving well-being and hence stimulate a return
Actions are required right across government.
We propose the formation of Task Force, involving bodies outside
government, to assemble a national strategy, having the power
to make recommendations to government. This Task Force should
report back to the Prime Minister within six months.
The proposed local Food Action Plans (in England),
operated through Local Strategic Partnerships, should be adequately
funded and closely linked with Physical Activity Strategies. There
is a strong leadership role here for Directors of Public Health,
but their work must be integrated through Local Strategic Partnerships
and must engage Environmental Health Departments and other departments
in the Local Authority (leisure, planning, housing, education).
* Recommendations for national and local strategy
How can the Government's strategy be improved? What are the
policy options? Can they be better integrated? What are the priorities
32. The key issue is that human diet and fitness, particularly
for children, must be made a matter of national urgency. It is
not simply a matter for the Government, indeed early leadership
in this area has come from professional bodies, non-governmental
organisations, and others. Nutrition forms part of the NHS Plan,
but note, this was a plan for the NHSnot for society or
for governmentas along the lines of the previous Our Healthier
Nation: Saving Lives initiatives (for England, with differences
in name and emphasis for the devolved administrations). The UKPHA
and the Faculty of Public Health Medicine emphasises that action
should be taking place across government and that there should
be regular evaluation reports on progress issued by the Health
Development Agency. At present it appears that the HDA can evaluate
activities in the field but that it cannot evaluate the activities
of the Department of Health. To the question of who evaluates
the work of the Department of Health or the success of coordination
across government the answer must be "no one".
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