Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 240-259)

26 JUNE 2003


  Q240  Dr Taylor: Changing the subject and going to Professor Lacey, it is probably a relatively small question, it is known that anti-depressant drugs contribute to weight gain, how significant is this?

  Professor Lacey: It is, particularly with the newer ones. I think the answer to your question is a significant issue in the treatment of depression, yes. Compared with the enormity of obesity in the whole population of course it is comparatively small. Whilst I recognise that prevention is clearly a very important role of this Committee we have to recognise that there is a clinical problem out there and there is a great need to develop treatment, programmes that can affect those that are currently sufferers.

  Q241  Dr Taylor: Right.

  Professor Lacey: The skills are there. The techniques have been used in our other populations. I think what is particularly exciting for those that are massively obese is the interplay between surgery and psychological and behavioural techniques. This is very exciting and showing perhaps the first glimmers of hope for this massive obese population.

  Q242  Dr Taylor: Are there guidelines for psychiatrists, particularly for coping with weight gain associated with the anti-depressant drugs?

  Professor Lacey: No. It is worth just noting that obesity is not a part of the curriculum for the memberships of the Royal College of Psychiatrists, and indeed it is worth noting that even the study of anorexia nervosa is not part of the curriculum of the membership of the Royal College of Psychiatrists.

  Q243  Dr Taylor: Obviously the latter two should be, should ordinary obesity be?

  Professor Lacey: Yes, I think so. I think increasingly psychological techniques, behavioural techniques and the sort of multi-disciplinary teams that psychiatrists have brought to perfection, perhaps more than our general medical colleagues, is probably the way forward for those people that are very overweight.

  Dr Taylor: I cannot help commenting on something that Professor Alberti said earlier, that he used to recommend 600 calorie diets, whenever I tried to do that I got into terrible trouble from my dieticians because dieticians seem to have a rule that anything less that 800 is positively dangerous for you. That was only a comment.

  Q244  Mr Burns: Professor Wardle, there has been a huge increase in obesity in England and paradoxically the best-seller lists are littered with books on dieting, what do you think is going wrong there?

  Professor Wardle: One of the great paradoxes, there are several in relation to obesity and it has proved quite hard to find evidence that people's own attempts at weight control, following the advice of diet books, make a substantial difference to their weight gain over time. I think one explanation for this may be that your typical diet book is promising something which it cannot deliver, namely there is something that you can do, just for six weeks or twelve weeks or ten weeks which is going to produce some marvellous outcome and either it does not or even if it does if you then revert to your usual life-style then all the same problems are going to reemerge. I think that the diet book and the diet industry has been based on something which is attractive to consumers, which is quick-fixes, and the obesity problem has not come from and is not going to be resolved by quick fixes.

  Professor Lacey: If I can add to that, a lot of the diet books are not aimed at people that are even overweight.

  Q245  Mr Burns: Absolutely. Young people are constantly been presented with stereotypes in magazines of models and celebrities who are super thin, glamorous and beautiful, can you comment on the impacts, such as it is, on the behaviour of young people?

  Professor Lacey: I think it is quite mild. All advertising has an effect, as my colleague on my right said. It seems that in fits particularly with the susceptibilities of young girls. The reasons for this are complex but, of course, women are fattier than men and it is there for sexual reasons and therefore they are particularly likely to be affected by such images. There seems to be a great deal of pressure on women particularly to be slim. Interestingly enough there is no evidence that men prefer women to be slim but every evidence that women prefer women to be slim. The evidence from men, if anything, is that a more Rubenesque figure is more attractive.

  Q246  Andy Burnham: Can we come on to health promotion and health education professionals and possibly a question for Professor Lacey and Dr Rayner, to what extent do we need to improve health promotion advice and eating advice we are giving at a primary care level? It seems to be a bit flat. People are becoming much more interventionist, do you have any thoughts on that?

  Dr Rayner: We have to make sure that we understand that it is a holistic model, it is about not changing people's ideas. If it was just about changing people's ideas the diet books would have been successful. The fact that there are so many diet books it proves they are all not very good. If we are competing in a terrain where there is so much advertising, so much discussion of food continually and yet we have this emerging problem it is clearly not going to be an approach that is merely going to be competing with all of the images out there round the same topic. You have to look at a perspective which, as I said, protects children, I think, which looks at the settings where people are, which understands why people are doing physical activity less and construct to help promotion strategy round creating normal activity. The mention of getting people to walk more, and so on. In towns it may be the construction of urban walks to make walking something which is natural rather than getting into your car.

  Q247  Andy Burnham: Those messages are well understood by the public. If you tested those ideas about tackling obesity you would get high recognition about and exercise diet, people understand them. Changing behaviour is the key, the question I really want to get out of you is, is there enough sophistication about understanding the needs of patients and what will trigger a change in behaviour? It is all very well having the messages do we have to educate health professionals more so they can trigger those changes?

  Professor Lacey: I now understand your question, there is a dearth of knowledge amongst many different professional groups. I have indicated in my own profession on the sort of advice that should be given to patients, so I think it is an issue. I think that often the advice is to go on some sort of diet, sometimes a crash diet, as Dr Taylor was commenting on a moment ago, and of course the dangers of this are often not fully recognised. It is probably the best way of a young adolescent to develop a binge eating pattern, and then you go off not into obesity immediately but via bulimia nervosa you go into obesity later. I do not think advice is well formulated, not only is it not well known I do not think that the professionals in the area that do know have properly formulated it for their general and professional colleagues.

  Professor Sir George Alberti: We really do not know how to achieve behavioural change. We do not actually know what advice to give. When I chaired a national nutrition research programme in the United Kingdom the top three priorities people chose for further work were all to do with behavioural change, because we did not have the tools and the knowledge to do this. We are scratching round but we are not good at it.

  Andy Burnham: With smoking and drink there is a clear, if you carry on you will die, that clearly does change people's behaviour. With food it is not quite the same.

  Q248  Jim Dowd: Why are food manufacturers so good at promoting behavioural change?

  Professor Sir George Alberti: We have tried to ask them to help us do research into this but they were not keen.

  Professor Wardle: There has been limited research on the extent to which the public really understand the association between life-style and weight gain. One of the things that comes up time and time again when you work with people who are overweight is their misunderstanding of portion sizes and the amount. The message about trying to eat lower fat foods has got through fairly well. You can see the saturated fat intake has gone down and overall fat intake is not going up. Portion size knowledge, certainly when we see families with overweight children and we show them what the recommended portion sizes are for children of that age group they are totally stunned. You know when you buy a little small packet of cereal time and time again people say to me how does somebody have that amount, I always have to have two. This relates to the super-sizing issue in fast food places that is giving people the message that these are normal portion sizes. I think that is one thing that is very important.

  Q249  Andy Burnham: Do you think we are losing that kind of shock, for example when you go to America and get a coke in the cinema it is absolutely massive?

  Professor Wardle: You can see it all happening here.

  Q250  Andy Burnham: It is going that way.

  Professor Wardle: Some of the new cinemas are selling their popcorn in what look more like buckets than anything else. I think the comment earlier, which has come up several times, nanny state and multi-sectorial influence in trying to get changes in health education, one of the reasons that I think it would be really important that school food should be healthy is not just the impact that will have on children's diets but the impact that has on the message that we are giving out about the critical importance of this. It is the message that it is okay in schools to have soft drink machines and sweet machines. Likewise in hospitals, St George's have opened a Burger King in their foyer. What message does that give about what health professionals think?

  Q251  Andy Burnham: It is much easier to give people a positive message, say to children, "do more exercise", intervene in that way and give more positive opportunities rather than come in with messages about banning drink machines in school. The side of the equation where we can change behaviour is increasing physical activity and doing that through providing better sports facilities, prescribing exercise at a primary care level, giving people walking counters to wear, that kind of thing. Going heavy on the other side, banning advertising, maybe that—

  Professor Wardle: You are comparing going heavy there with not going so heavy on the activities side. I think it would be completely wrong if you reached the conclusion that we should intervene on the energy expenditure side and not be thinking of intervening on the energy credit side. All the evidence suggests that the two things work together. The energy density of the diet is a crucial influence on obesity change, epidemiological studies show that. It would be a mistake to say that. As a matter of fact, we have not yet had a single intervention study in schools which has produced good outcomes in terms of weight change in children. Yes, I think we should be trying to do these things for lots of reasons, but it is not an obvious and simple answer and you can forget about the input side. I would say there was zero chance of significantly impacting on the obesity epidemic if you take one side of the equation and ignore the other.

  Q252  Andy Burnham: My local PCT has just had a small amount of funding to promote physical exercise. Would you favour that being used to promote exercise?

  Professor Wardle: As part of the interventions for overweight and obese people, absolutely. I think at the public health level you have to think about how we shift the average level of physical activity back up again. Where it has slumped over the past 50 years we will have to think about how to push it back up. The answers there do not just lie in what you do in schools or in health education, they also lie in the design of environments, in the design of buildings and in the design of workplaces, it all has to work together.

  Q253  Dr Naysmith: I have heard a professional in this area say—and it is quite obvious I am not going to agree with Andy here—that it is just a waste of time going for the exercise bit unless you also do the other half of the equation we are talking about. Is that an extreme view?

  Professor Sir George Alberti: I think anything helps.

  Professor Wardle: I was taking the view that the Committee should not say one thing or other.

  Professor Sir George Alberti: The Department of Health's view was to go for the exercise and the dos rather than the don'ts and that is very much what you were getting at too.

  Q254  Dr Naysmith: And if you just do that then you are fooling yourself, are you not?

  Professor Sir George Alberti: I think so, yes. A lot of people will get a modest impact from exercise but I think you need the other message as well. It is about the quality of food, which Jane was mentioning, as well as the actual quantity.

  Professor Lacey: Can I just say, to coin a phrase, obesity is a big subject. With massive obesity exercise as a form of treatment has comparatively little to give, frankly, because of breathlessness and joint problems, it does not have a big role at all.

  Q255  Andy Burnham: Are there not a whole range of practical steps we could be taking on either side of the equation that we are not taking at the moment?

  Professor Lacey: Yes.

  Q256  Andy Burnham: That could have an impact within five or 10 years.

  Professor Wardle: It has been multiple small changes in society which have contributed to the changing population weights and we are going to have to intervene in multiple ways to push it back down again, there is not one simple answer.

  Q257  Dr Taylor: We had an excellent presentation last week from our advisers which really brought home the enormity of the problem and that is the fact that it is behavioural change that we are aiming for. I have to remind the Committee of a quote I have already used once before. A member of the station staff at home who was picking up fag ends said, "We might be able to change policies, it's a job to change people." I thought that was very apt. It says in Dr Rayner's evidence that the market for biscuits, chocolates and sugared confectionary alone added up to £7.43 billion in 2001. Somehow we have got to change the behaviour of people so they do not want to buy that sort of food and the producers produce the food that they ought to be eating. How do we do that?

  Dr Rayner: I think we are actually having to consider these issues for the first time and going back to the dearth of research in this area, starting with smoking, where you have a similar situation, where you want to change behaviour. What tools do you have for doing that? One of them is the taxation system. Another one is telling them they should not do it or giving incentives for not doing it. There is a whole set of things and I think these still have to be properly explored in terms of the impacts. We have differential taxation on tins of beer according to the alcohol content. I think we should apply similar reasoning in terms of certain types of foods. You could look at some ways of controlling the marketing of foods. It may be that we want to introduce taxation. At least we should be exploring these things. We do not have enough information to say what the impacts will be on these things. I think there are big public policy issues in modelling the impacts both on the industry and on individuals from doing this sort of work. It is early days, but I do think it needs to be done, I think that work needs to be commissioned. Whether it is the Department of Health or the Treasury or someone else, the sort of work that is being done in the tobacco field needs to be applied in this area.

  Q258  Dr Taylor: Any other thoughts from any of the other members of the panel on how we change behaviour?

  Professor Peto: Following the analogy with tobacco, some of the information that you have heard today could be condensed on little labels and go on packets of biscuits. It is not clear what effect the health messages on packets of cigarettes have but they have had some effect. The other thing is people ought to know what their BMI is. I do not know what my body mass index is. I have always assumed it is not too big. People talk about obesity, but most people do not even know whether they are technically obese. Maybe we should be finding out about what proportion of people die of heart disease and cancer and diabetes above levels of 25, 30 and 35 and so on and putting on the packet, "Do you know your BMI?" If you put that on a packet of biscuits and stick 10% in tax on it, it would have some impact. It has the merit of saving money as well. Teachers weighing children and recording it and sticking messages on packets of biscuits while you increase the taxation, Gordon Brown would love all that because you would get huge benefits from the expenditure.

  Q259  Dr Taylor: So food labelling is something we should address?

  Professor Peto: Yes, because the information is just lacking. Even educated people do not know this. I am sure a lot of people in this room did not know all these facts until a week ago. It is not common knowledge.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2004
Prepared 27 May 2004