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
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
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
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
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
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 sayand it is quite obvious I
am not going to agree with Andy herethat 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
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
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.