Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 220-239)

26 JUNE 2003


  Q220  John Austin: I want to go back to the issue of children, Dr Barrett has told us of the impact on children's health if the trends continue, both on the physical and psycho-social side, what I would like to ask is how much the pediatric profession is alert to the issue of obesity?

  Dr Barrett: The Royal College of Pediatrics and Child Health have issued some issue guidance on the management of obesity, distributed to all health professionals, it offers general advice about separating out the medical cause from life-style and offering life-style advice to improve this. We have also had assistance from publications by Time Cole and others of body mass index charts for children, you can plot them properly and get some measure of fatness, or at least some very crude estimate anyway. Currently we are trying to put in a pediatric surveillance unit to get some accurate figures on the prevalence of obesity related illness, presenting each month over the next couple of years.

  Q221  John Austin: To what extent do you think GPs are able to deal with problems of overweight children?

  Dr Barrett: The problem is too great for one group, it is a life-style change rather than a medical problem until they get the obesity-related complications.

  Q222  John Austin: Doctor Rayner, in the submission that came from the Facility of Public Health Medicine there was a reference to a toolbox for local partnership action, clearly this needs to be tackled across the board, not only for the impact on children's health immediately but its long-term impact that we have heard about. If we are really going to tackle this surely the focus must be on children and changing life-style and habit?

  Dr Rayner: I think so. That is precisely the point that other people have made. Unless we address the issue of children's diets we will be looking at what is—I hate to use this expression—the tip of the iceberg. We project these things ahead and you have to change behaviour because children's diets solidify early on, our colleague will explain this in terms of dealing with children in the clinic. Unless you tackle a child's diet fairly early on then you are going to have a lifetime of dietary problems. If a child takes up smoking they can give it up again but once you acquire food problems early on they are going to be with you for a long time. I think the issue is also about understanding the needs of children. We are very protective of children. In terms of the surveys of parents looking at the impact of advertising, for example, there is a very high score all of the time from parents who see that it is there need to protect their children from food advertisers. I think the issue of children is not just for its own sake, it is also a way of having these arguments and having the education taken on within the adult population as well so that you can get to the parents through the children. I think it is one where the debate of the nanny state, and all that, whoever complains. I never hear complaints about the nanny state but our papers are full of it. People do accept that there is a role for the nanny state in protecting children, so child health protection is a legitimate area and I think it is the one that we should be pursuing.

  Q223  Chairman: Following this point about the nanny state, one of the things that struck me in last week's session was the way in which we appear to have lost the ability to monitor the health of children in a school environment. I recall being at school, certainly at primary school, and we used to have height checks, weight checks, eyesight tests, teeth, nits, you name it. Talking to head teachers in my own area we do not appear to be able to address this issue in a school environment, particularly obesity. One of the head teachers I spoke to recently his personal, anecdotal evidence was children are less fit than they used to be. In this inquiry should we be looking at mechanisms to reinstate a school Health Service? I think it was Professor Peto who made the point that stigmatising might be a positive thing rather than a negative thing. One of the objections that I picked up on the question of obesity and lack of fitness in a school environment was we should not stigmatise children through any process we introduce to monitor health. Dr Barrett, I do not know if you have any thoughts on that, what should we do?

  Dr Barrett: The issue I feel that needs tackling is the exercise that children undertake and the diet they have. The school Health Service has been cut back over a number of years, largely through Professor David Hall and the reports there because of a lack of evidence that different aspects of that service had in improving a child's health. At the moment the school nurse will weigh and measure children at school entry and screen them at that stage and if there are any problems they will be referred on for medical causes. Of course obesity is not a medical illness per se, it is more of a life-style issue. That goes back to the issue of children having opportunities for exercise and children's diets, both in school and in the home. Those are the areas, the exercise and the diet, that would be very helpful for you to address.

  Q224  John Austin: On the exercise issue we are talking about a lack of self-confidence and the low self-esteem of people who are grossly overweight. If we are talking about the children and the need for exercise often the exercise which is provided within the school framework is even more humiliating for the overweight child and adds a further humiliation. How do we introduce programmes of encouraging people to engage in activity?

  Dr Barrett: The school development plans try and build exercise into that. There are school health buses that can go and visit schools and educate children on these things. The problem is the school timetable is quite taken up with national curriculum targets, as they should be, for numeracy and literacy and exercise opportunities are being squeezed out of that timetable, so children are doing less. Fewer children are walking to school and almost no child cycles to school nowadays because of traffic concerns and child protection issues, so there are lost opportunities there. When children get home there are lots of opportunities to watch television or play on Game Boy rather than riding out on their bicycles. These are major issues to do with child obesity.

  John Austin: In my generation we did not have television and there was a bomb site on every street corner. We now have Game Boys and computers and televisions.

  Jim Dowd: We were happy.

  Q225  John Austin: I know that Dr Rayner's organisation produced Getting Active, a local guide for partnership action. I am wondering whether there are any examples of success that you can point to that we as a Committee might go and look at?

  Dr Rayner: I can submit you with a list, I am very happy to do that. There are examples of things. My colleague is right, we are talking about small remedies, I mentioned the cultural changes, these are the changes which are the full extent of the explanations from a society which feels insecure about their children walking to school, about cycling, we also have the school tuck shop, a central income generator for the school. Going back to the point about the school nurse service, there is a sea of trouble, if you like, which is pointing towards a more inactive, more snacking culture and I do not think one service is going to address that. We need to have a complete, whole school perspective and we need more local action. Some of the things we suggest in our documents, and I am very happy to send you a list and to take you round places, I think are good examples. The issue is that the schools are doing them on an independent basis. There are troubles in having these things sponsored by confectionary companies—you may wish to go into this issue—and it is about the school creating an environment where good, healthy food is accepted as the norm rather than this aspirational food which comes out of a world which is peddled by footballers, or whoever, and actually emphasising the basics. We are not talking rocket science here, it is about the world in which young people live and understanding the things that confront them now which our generations did not have to confront, when things were looked at as treats rather than the mainstream. The world has changed. We have to look at it from the young people's perspective.

  Q226  John Austin: We did raise the issue when the Minister was here of Coca-Cola machines in schools or the association of Pepsi Cola in sponsoring activities of an educational type. The Minister's view was that this was a matter for local school governors and parents to determine and not one for the nanny state to intervene. Your view would be?

  Dr Rayner: In which case we have a very bad nanny, do we not? I think it is the responsibility of the state to protect children with parents and with schools. The children are in a state institution and the state has the responsibility to protect them while they are there. It is funny that we can give guidance on many matters but we cannot give guidance on this. The question is, why? We need a response by the state which is proportional to the problem. It is lacking in proportionality towards the growing problem.

  Professor Sir George Alberti: I can comment on that, I have a very good example from one of my pediatric diabetes colleagues in Los Angeles who led a public campaign to have sugar containing drinks banned from schools in the public sector and succeeded, and that was done on a popular public vote, they always add things on to their votes, and they have gone. That was done by one determined individual. I think the state ought to pick up on this and take responsibility and not get the brush off I have had from the Public Health Department saying, we cannot interfere with people's liberty.

  Q227  John Austin: Can I ask one final question on trends, if the current trends continue are we going to see a substantial increase in the number of children who will pre-decease their parents?

  Dr Barrett: We cannot predict the future but we can look at the pattern that has happened in North America over the last 20 years, the evidence is that obesity-related diabetes in North American illness was about 5% in about 1982, and some centres are reporting up to 45% in parts of Texas in the year 2000. The problem has ballooned. These people are getting cardiovascular complications in their late 20s.

  Professor Peto: The idea of measuring just height and weight and perhaps hip and waist measurements in children perhaps once every year in school would be enormously helpful for several reasons. It would have a considerable publicity value, it would draw attention to the fact that it is seen as a problem. It would also have the immediate benefit that children and their parents would know where they were on the scale and they would also know which way they were moving over a couple of years. It would be enormously helpful because this is a problem that creeps up and children are very fat by the time their parents notice. It would be a huge help to research in the short-term because to have that data at a national level as a basic framework within which you can do more detailed studies, given that this is a major public health problem you have to support the research of it, and this is a huge contribution that costs nothing at all. You do not need a school nurse to measure height, the teachers can do it. This does not have to all be done on one day, you can measure every child during the course of a school year, that would be quite sufficient.

  Q228  Chairman: Why have we not done it already?

  Professor Peto: The long-term effects are probably more serious than the short-term effects and although you will wait 35 years to do it, in 35 years' time it will be an enormous bonus to an epidemiologist to have that data. If you do recommend that you should also recommend that the data be available to medical researchers. Lord Falconer said that such records are confidential because of the common law of confidentiality, I think he is technically wrong. This has to be addressed because otherwise the data is not worth having. We have to be able to look at them to be able to use them.

  Q229  John Austin: I know it is important for babies to gain weight but has there been too much emphasis on weight gain and too much emphasis on bonny bouncy babies? Does that have an impact?

  Dr Barrett: It is hard to know. There is good research being done in Cambridge looking at the rapidity of weight gain in relation to the later development of obesity, it seems the thinner babies that gain weight the fastest are the ones that end up in trouble. Continuing the Government programme to promote breast feeding is a very positive thing that would help against that.

  Q230  Mr Burstow: I just want to pick it up on the point about data collection and ask whether there are other examples where there are gaps in data collection that would be relevant to ensuring that we have a good understanding and information on which we can base policy in the future and whether there are any other research gaps? It would be useful to know where there are problems with not have systematic collections of data that would be useful to informing future policy and indeed research.

  Professor Peto: We do not have a huge cohort like the American cohort. The American Cancer Society has done these studies seriously since the 1960s and they have been incredibly helpful and we do not have a huge national cohort of that sort. The Bio-Bank project may or may not get going, it is just in the process of being launched, but that does not include anybody under the age of 45. To establish a huge, national cohort where you have measurements of this sort on all children and then on a volunteer basis you get them and their parents to fill out questionnaires on things like smoking, drinking, dieting and exercise would be an amazing resource for national health monitoring. The other thing about that is you get a chance to address questions, you ask questions about weight gain versus weight and you do not know the answer, the data is not there. That data would simply be there for nothing if you set up this national cohort and within a very short time you would have a goldmine for addressing these questions.

  Professor Sir George Alberti: For getting blood pressure, glucose, the waist circumference, we have to keep remembering that it is central obesity that is the really damaging one in terms of diabetes and heart disease compared with total obesity. There are one or two smaller cohort studies but nothing like big enough to give us this continuing trend so that we can say, okay if we take action now, we are always running behind ourselves.

  Dr Barrett: Can I say there is a very big gap in the research area in terms of interventions to prevent obesity at an early stage. There are one or two studies in the United Kingdom but the vast majority of it is coming from North America. There is a big area of getting funding for studies to prevent obesity in the early years when you could do something about it, and that needs to be addressed.

  Q231  Mr Burstow: What is the reason? If this is so blindingly obvious what are the main pressures and reasons that this has not been something that has been done to date?

  Professor Wardle: Can I add to that point, maybe this relates to problems, I think what we have to say on prevention studies for childhood obesity, which I agree are really critical, is we are talking about studies which will very likely have very small effects which are only going to be measurable over quite long periods of time and therefore they are expensive, so they have to be large studies. There is also no funding organisation, we do not have the equivalent of the National Heart, Lung and Blood Institute which takes responsibility for the obesity issues. Given that almost everyone would agree this is the single largest new health problem that we now have it seems to me there ought be recognition of that in terms of funding organisations.

  Professor Sir George Alberti: It does not feature on the MRC's list of priorities much to the annoyance of us who are in this sort of more practical physiological type of research.

  Q232  Andy Burnham: This issue about data collection, do think generally that civil liberty concerns in this country play far too much of a role in balancing public health. Do you think we do not have this balance right, we are too obsessed on privacy and not taking enough sensible action?

  Professor Sir George Alberti: Yes.

  Professor Peto: It is asserted, as I said Lord Falconer famously asserted it, he said the common law of confidentiality says that medical records are confidential and you have to get them cleared under section 60 of the Health and Social Care Act to approve the study before you can look at medical records. It was routine for people doing medical research to look at medical records without informing patients until two or three years ago, when the MRC guidelines were officially changed, it was written in the MRC the guidelines, once an ethics committee had reviewed it. Confidentiality is absolute, if we breached it we would lose our jobs. We never, ever did. In 35 years I have never known a case to breach confidentiality from that sort of work. If you stop people in the street and say: "Should medical researchers be able to see your GP records without telling you?" 90% say "no", but if you explain the question 95% say "yes". There was a meeting last November organised by the All-party Parliamentary Group on Cancer, where I gave a little 15 minute talk on epidemiology and how wonderful it all was. At the end of it I explained what a disaster this was for our work. I put up a proposed law which simply said that consent is not required for medical researchers to look at medical records and 93% of the audience voted for it—the audience had little buttons to vote yes or no. Because I gave a 15 minute talk explaining what the question meant 93 voted yes. I think we have been hijacked by a ludicrous campaigning minority. All medical researchers agree with what I am saying and more than 90% of the general population do as well when they have had the question explained to them. The damage to research is unbelievable, it is not the subject of this meeting, but it is an absolute catastrophe for English medical research and for some reason we are doing it more enthusiastically than any other country in the world. It has no basis in law. It is an absolute disaster for medical research.

  Q233  Andy Burnham: Can I ask a question to anybody who would like to comment, to what extent is the epidemic a class issue? To what extent is it an issue that effects the lower social groups we were talking about?

  Dr Rayner: Yes, it is a social class issue and it is also an issue of ethnicity, as we have pointed out. Certain groups are effected more than others. Again my explanation is culture, you have to look at the background of where people have come from, obviously there is a genetic importable invariable there too. It is a class issue and it is about where people live, how they shop, what is available in the local store, if you walk to the shops, it is about the changes we have had of some people taking cars. It is about what is in your pocket to be able to buy the healthier foods as well.

  Q234  Andy Burnham: Is it rising affluence of the lowest social groups? Is it the cost of food in supermarkets? Going back 30 years in this county it would not have been the same, it is rising fastest for the lowest social group, what is it that has changed?

  Dr Rayner: I would like to look at the marketing materials of some of the food companies to see who they are targeting. It is clear that children are being targeted for some sort of products, that lower income families are targeted for some products.

  Q235  Andy Burnham: That is possibly slightly patronising because it is suggesting that people on lower incomes are more susceptible to advertising messages?

  Dr Rayner: There is no denying advertising has an effect, it has an effect on me, you and everybody, they would not it do otherwise. Your green-grocer shops have closed down locally, look at the social exclusion units studies of retailing in poorer districts. Simply the access issues are quite pertinent here. Also if you go to the shops which are there it is the long-life products which are on the shelves, the snacking and so on and so forth. People are vulnerable. One of the consequences of being poor and socially excluded is that you can become more vulnerable to advertising, it is not patronising to point it out I do not think.

  Q236  Andy Burnham: Most people have access to a large supermarket within reasonable distance these days and the margins on some food sales is very, very low and the price is in proportion.

  Dr Rayner: The margins on fruit and vegetable in supermarkets are the highest margins in the supermarket.

  Professor Lacey: It is a class issue, it is a sexual issue, it is a racial issue, but it also is an epidemic, it effects all social groups, both sexes and all ethnic groups too. I think that we should not lose sight of concentrating down in certain particular areas unless we are looking at sub groups deliberately. It is far better to see this as an issue that effects the whole population.

  Professor Sir George Alberti: I would agree with that. One of the interesting things is that in the developing world it is the reverse, obesity is hitting the well-off people and that is because the poor people really have such bear subsistence foods available to them, it is what they grow and till on the whole and they are still exercising vigorously to get the food. We have reversed all that. In our society it has gone the other way round, the chattering classes tend to be the ones that go jogging and perhaps trying to do something about it but it is effecting all tiers of society, yes, there may be more in certain tiers but it is there all of the way through.

  Q237  Jim Dowd: Where is the crossover?

  Professor Sir George Alberti: We are beginning, just beginning, to see it in Africa, when the balance of food availability and cash in hand, just catching up, we are seeing it in the urban areas, improved bus services, people walking less, it is all just beginning to turnover in the urban areas.

  Q238  Andy Burnham: Quite simply, as society has developed we get fatter. We have to understand that and start to—

  Professor Sir George Alberti: We have to work at it as a society. This is not a medical problem, this is a societal problem, as several of my colleagues have said. Yes, there are the medical bits of it that we all play with.

  Q239  Andy Burnham: You are picking up the pieces of changes in society really. There the key is the schools, it is transport, it is—

  Professor Sir George Alberti: We have done a societal experiment with a group of South Asian immigrants in East Africa, we took the whole community, who had 25% diabetes in the adults, and the only messages we gave, because I do not believe in all of this complicated dietetic stuff, because it boring, was walk more eat, less, eat less, walk more. They set up their own walking clubs. It is that sort of thing. Okay they were overweight but they could walk and they walked and that became a social phenomenon. After six years everything had got a bit better, the weight had gone down a bit, nothing dramatic, but diabetes had gone down by 70%.

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