Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 200-219)

26 JUNE 2003

PROFESSOR SIR GEORGE ALBERTI, DR GEOF RAYNER, PROFESSOR JULIAN PETO, PROFESSOR HUBERT LACEY, PROFESSOR JANE WARDLE AND DR TIM BARRETT

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

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

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

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

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

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

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

  Professor Wardle: Absolutely.

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

  Professor Wardle: Yes.

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

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

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

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

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

  Professor Lacey: I think the answer to that is no. You are right, of course, that anorexia nervosa is a very serious condition. It is the psychiatric disorder with the very highest mortality—far more than alcoholism or schizophrenia or such like. It is a very high mortality. The latest Swedish study is showing 20% of girls dying between 15 and 40. That said, certainly bulimia nervosa is highly treatable—that is much more common: 5% of the relevant population—and, with anorexia nervosa, in treatment round about 50% can have a full and normal life. The answer is: yes, we should instill hope that treatment can help them. It is an interesting phenomena—and I do not want to be guilty of broadening the brief of your question—that in the papers that have been submitted there is a lot of evidence, for instance, on the use of the media in emphasising the dangers of obesity, and of course there is enormous evidence and enormous pressure in the media for women to lower their weight, and we do see the casualties of those. So it is an area, using media for the manipulation of food, which does have its dangers as well as its obvious desirabilities.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


 
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