Examination of Witnesses (Questions 220-239)
26 JUNE 2003
PROFESSOR SIR
GEORGE ALBERTI,
DR GEOF
RAYNER, PROFESSOR
JULIAN PETO,
PROFESSOR HUBERT
LACEY, PROFESSOR
JANE WARDLE
AND DR
TIM BARRETT
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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