Examination of Witnesses (Questions 200-219)
26 JUNE 2003
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
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 controlyou know, limiting
things and saying no about things and denying their children thingsis
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 realisedyou 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
wrongthat 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 obeseif you measure
the kids and ask the parents to make a judgmentparents
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
Professor Wardle: Absolutely.
Q203 Andy Burnham: Their worst fear
is that you might be under-eating. That is their great fear, is
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 mortalityfar 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 treatablethat is much
more common: 5% of the relevant populationand, 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 phenomenaand I do not
want to be guilty of broadening the brief of your questionthat
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 upso 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 elseparticularly
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
BurnsBurns 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-smokersat
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
diseasefour out of five smoking-related deaths are after
retirementthey 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
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 sizewrong wordof 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
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 condensedI 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
Researchthen 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.