Examination of Witnesses (Questions 260-275)
26 JUNE 2003
PROFESSOR SIR
GEORGE ALBERTI,
DR GEOF
RAYNER, PROFESSOR
JULIAN PETO,
PROFESSOR HUBERT
LACEY, PROFESSOR
JANE WARDLE
AND DR
TIM BARRETT
Q260 Dr Taylor: I have been looking
at food labelling for a salt debate yesterday and on some packets
of crisps and things it is in seven different languages, but the
bit you need to know is almost illegible because it is so small,
so it really is something to tackle.
Professor Peto: It needs to say
"obesity kills" in letters three foot long.
Q261 Jim Dowd: It is also a question
of the usefulness of that information. On sweet packets they have
how many kilojoules there are in it and various numbers referring
to magnesium, but these things just do not mean anything to anybody.
Is 2,000 a big number, is it a small number, should it be more,
should it be less, it is information but it carries no meaning.
Professor Peto: If it said what
the death rate was above certain levels of body mass index I think
that would concentrate the mind. If people could talk about that
in the pub I think it would help.
Chairman: It was 38 inches and it has
come down to 36 this week. Some of us are getting a bit worried!
Q262 Dr Taylor: That sort of measurement
is what we like because it is so easy to comprehend.
Professor Sir George Alberti:
Can we take any of this on until you take the food industry on?
I am just thinking about what they have done in the States recently.
After a very sensible WHO statement the food industry then attempted
to get Bush to withdraw the United States' support for the World
Health Organisation. That was just overt behaviour of the sort
we have had in a covert way in this country for a very long time.
Q263 Dr Taylor: This was very much
the message from last week, that we have got to change the behaviour
of people so the demands on the food industry change and that
is the crucial thing.
Professor Lacey: You might consider
trying to change the behaviour of the food industry where it is
likely to do so, which is a means that increases their profits.
You have already said, perhaps with some disparagement, about
the idea that there is a greater margin on fruits and vegetables
than there is on other products, but maybe that is something we
should be encouraging.
Q264 Andy Burnham: We have focused
in this debate on food. What role is alcohol playing in this drive?
People do not really think about the calories as much when they
are drinking, but there is a huge calorie intake when you go out
for a few beers. Are we thinking enough about this?
Professor Wardle: I think it is
an important issue. It seems to be poorly regulated. Whereas to
some extent calories from food will suppress your urge to eat
more calories within the next little while, calories from alcohol
do not seem to have such a suppressant effect. It is certainly
being argued that children often put on a substantial amount of
weight while they are at university which, as everyone has said,
is extraordinarily difficult to get off again. They are not becoming
obese at that age, they are just accelerating their trajectory
and there is quite a lot of suggestion now that the high levels
of alcohol in student life is contributing to this.
Professor Peto: I think the quantity
of drink is important. The fact is that drinking small amounts
of alcohol reduces overall mortality and it reduces mortality
from heart disease. The real danger in all these things is that
you are being seen as the killjoy nanny state. Excessive drinking
is very dangerous. Moderate drinking is actually beneficial to
health. If that message goes across at the same time it would
make the package more attractive. To target alcohol in this context
is a mistake, I do not think it is the point. Heavy drinkers may
get fat but that is not the fundamental reason for obesity in
the population.
Q265 Andy Burnham: Surely there are
people who eat a fairly moderate and balanced diet but drink a
lot of beer and they are overweight because of their drinking.
Professor Peto: Excessive drinking
is dangerous just as excessive eating is dangerous. There is a
danger with alcohol because it is such a part of the social fabric
and because in small quantities it is beneficial. Most people
are moderate drinkers. The proportion of the population who drink
dangerously is really quite small.
Q266 Dr Naysmith: That view is not
accepted by everyone, the fact that moderate drinking is not harmful
and it may even be helpful.
Professor Sir George Alberti:
Three units a day added up over a year is an awful lot of calories.
People have at least to knowand many people do notthat
there are actually calories in beer, wine, etcetera, that is an
educational thing, it is part of your daily calories.
Professor Wardle: From a population
point of view, if you calculate how many excess calories per person
per day have to be consumed to shift the weight up like that,
we are talking about very small amounts of calories. So people
have got to learn. It is thought that probably the average over-consumption
is 100 calories a day. Most people cannot tell subjectively the
difference between a meal which has 500 and 600 calories.
Q267 Andy Burnham: I am sorry to
labour this point, but it seems to happen in the States that "lite"
beers are very common and we do not have that at all here. Have
we not picked up on this issue at all or has it been in a much
less developed way?
Professor Wardle: I think not.
Q268 Mr Burstow: I wanted to move
on from the issues around influencing behaviour which we have
been talking about to broader strategies for change and try to
get from all of you some steer as to those small incremental changes
that Professor Wardle was talking about. We have had small changes
that have led to where we are now, we need to step back through
a series of small changes. The NAO published a report in 2001
on these issues and it outlined initiatives that were being taken.
Dr Rayner, can you say whether or not you feel the package of
measures that is already in place both locally or nationally of
itself will be sufficient to make a difference over the next few
years, or do we need to do other things as well?
Dr Rayner: There are some initiatives
which are highly commendable. One is putting fruit into the hands
of school children. That is a particularly important strategy,
developed by the Department of Health and paid for by the New
Opportunities Fund. I think that is critical. The trouble is that
these are often isolated things. I think I have said a couple
of times they need to look at whole systems and not just elements
within things. It is getting a reconnection and a cultural change
towards an acceptance of fruit and vegetables, which is an absolutely
critical issue. Going back to other things, they need to be supplemented
by the protection side. We cannot always have positives without
dealing with the negatives. That is the area which governments
do not like dealing with and they do not like dealing with it
because they are subject to the "nanny state" criticism.
We were just talking about issues of alcohol a moment ago but
the issue of carbonated drinks in schools is particularly important.
I do not know that it is about banning it, it is protecting children
from a drink that is 50% sugar. I prefer to see it in those terms.
To give an example, there are certain cereals on the market which
are aimed at children when actually you should not be calling
them cereals, you should call them sugar products with added cereal
Q269 Mr Burstow: And salt.
Dr Rayner: And salt. So it is
not just the fruit in school issue, which is one initiative which
is commendable, it is the total package of joining up that is
essential.
Q270 Mr Burstow: Could you signpost
any other countries where they have gone down a much more aggressive
route in terms of labelling to raise awareness of those sorts
of points?
Dr Rayner: If you look around
Europe certainly the Swedes would be a good example of people
who are thinking about those things and they are thinking about
it both from one side of it, which is protecting children from
food advertisements, right the way through to the investigation
of the impact of the Common Agricultural Policy. So here is a
society that is concerned about those things and it is showing
in terms of their general health indicators, which are superb
where health inequalities are much smaller (almost tiny in comparison
with the UK) although obviously they have made their expenditures
on health services too. So there are good examples. Mention has
been made of California. California is interesting because the
problem there is so large that the states and communities and
individuals are driven to take action. So, if you like, there
is one set of examples where societies want to be ahead of things
merely because they have a very mature response to things, and
there are other examples of societies merely by the size of the
problem saying, "We have to do something." In California
in schools there are charters to protect children, they have nutrition,
they are stopping the "sweetheart" deals between the
vendors of carbonated drinks, and so on. I think there are lots
of other examples around Europe as well. What we do know in terms
of Europe is there is not enough serious, good quality research
pulling these things together. One of the bits of added value
that the European Union should be doing is pulling together good
examples of health promotion around Europe. In England at the
moment the Health Development Agency is putting an evidence base
around obesity and that will be available soon, I have not seen
it in draft yet. Clearly it would be useful for the Committee
to visit places around Europe and the US and to see the two dimensions,
both the prospective where they are looking ahead and also these
emergency actions where the communities are taking efforts into
their own hands.
Q271 Mr Burstow: Thank you for that.
I want to ask a question which might be useful for all witnesses
to answer. What do you all feel should be the key priorities for
government that we ought to be considering in terms of the report,
in terms of what should be done first or next, in terms of where
we are now? What should be done next as a key priority? What would
be the things you are recommending?
Dr Barrett: From a child health
point of view increasing opportunities for children to undertake
organised exercise in schools and raising the priority of exercise
on the curriculum in primary schools would be very helpful. And,
secondly, warning on dietary products aimed at children of the
health dangers of obesity from them would also be very helpful.
Dr Rayner: I would reiterate some
of the points I have already made. First of all, this Committee's
work is very, very important because we are now taking the issue
very, very seriously. That means we cannot just have bits of intervention,
we need a total whole society perspective. Therefore, we need
information and we need a change of attitudes in the general public.
We need to be more assertive in the way we deal with manufacturers.
That needs to be a joined-up across government. We cannot have
one department of government undermining another department, the
Department of Health for example, by relationships with food manufacturers.
In the Department of Education, for example, people have mentioned
things like "free books for schools", you need consistency
across government.
Q272 Mr Burstow: There has been a
change for lead responsibility now in terms of children's policy
and it is now within the DfES under Margaret Hodge. Is that a
good thing, bad thing or completely neutral in terms of what you
are talking about?
Dr Rayner: It should be very positive,
if she takes up the issues seriously. The problem was we have
been force fed, if you like, the head side of education. It has
become cerebral and we have had this body of "mind jewellers"
and it is all about children's heads, cramming as much in as possible.
We actually now should be attending to their bodies.
Professor Peto: I would recommend
that children are weighed and measured every year or two at the
school and a leaflet sent home to their parents saying what their
body mass index is with some information on what the long term
implications of that are. We should also have the change compared
to the previous year because it is very important that people
see which direction they are moving in.
Professor Lacey: A recognition
of the importance of providing adequate treatment for those that
are severely affected, a recognition that there are treatments
that have been shown to be effective in adjacent conditions, and
a recognition that the harnessing of these in multi-disciplinary
teams is probably the best way forward, including surgical techniques
for those that are severely affected, those that are massively
obese. I would like to append that comment onto what was just
said because we were talking about very active approaches in how
to deal with food. I think it is very interesting that Sweden,
where they have laid a great deal of emphasis, as we were talking
about on the danger of gaining weight and also weaning school
children off sugars, is also the country which has seen the most
rapid increase in eating disorders over the same period of time,
so we have to be careful on how it is done.
Professor Wardle: At the risk
of reiterating, I guess I would agree with a whole number of things
which people have said already, Professor Peto's point about surveillance
is tremendously important and what one needs is continuing surveillance
because when you see about age 10 BMIs progressing upwards then
it is very unlikely that is going to spontaneously remit by that
kind of age. Secondly, engaging with industry in the idea that
what we are trying to produce in a safer food environment for
the whole society is important. It is not engagement by what we
are going to ban or not going to ban, whether it is providing
information or modifying constituents of food, it is this notion
that part of the world that we are all responsible for is not
just emissions from cars and safety of water, it is also the broader
food supply to which people are exposed. Similarly I think the
same issue applies to physical activity. We need health impact
assessments on all kinds of environmental changes which look at
the extent to which they either depress or facilitate physical
activity. For the most part the physical activity of the future
that is probably going to change things is not going to gyms,
it is the amount people walk or the amount they cycle. Of course
these things are on everybody's agenda but I think we would all
agree they should be increased. Lastly, I would agree we need
to have specialist clinical services because what you want is
an approach which recognises the need to treat people who have
already become obese as well as a need to prevent obesity in those
that have not yet got there.
Professor Sir George Alberti:
Again agreement with quite a lot of the things. Starting in schools
is absolutely vital and doing more there. When you get to our
stage of life the odds of behavioural change are limited. Even
if our Secretary of State managed to stop smoking, not many of
us do manage that. So schools, adult physical activity, more emphasis
on better facilities for it are all very important. I think better
education of health professionals is important. It is something
that does not come through well in medical schools or in post-graduate
teaching at all. I think that needs to come in. Food labelling,
but with the associated information so people know what it means.
I think we have got to get our heads round that and it is important.
I did wonder as a slight tease whether perhaps we should performance
manage our strategic health authorities on the rates of obesity
or rates of increase in obesity on their patches and they lose
a star if they are not doing well. That really focuses the mind.
Q273 Mr Burstow: That has been very
helpful. One final thing, the thread that has come through in
the discussion so far has been this issue of stigma, whether it
is a good thing or bad thing and I thought it might be useful
to get witnesses' views about whether to stigmatise or not to
stigmatise as a way to address this issue?
Professor Lacey: As a representative
of a profession that has had to deal with stigma, particularly
in medicine with psychiatric illnesses, I would be very vehemently
against the whole notion of stigma. What we have heard is that
the responsibility of the individual is only one part of it, parents,
et cetera. If we are to be effective we have to work with the
grain and I do not think you do that by pointing fingers at any
particular group and you certainly do not get it by pointing fingers
at parents. They often feel guilty enough as it is. They need
education and guidance, they do not need to be pilloried.
Professor Sir George Alberti:
Certainly medically it is anti-Hippocratic to stigmatise a patient
and it is anathema as far as I am concerned. Over and over again
you find if you treat something positively rather than negatively
you stand some chance of success. We are all around to help our
fellow men and I think we should be helping not labelling.
Q274 Chairman: Thank you very much
indeed, it has been a very interesting and informative session
this morning and I would like to say thank you to all our witnesses.
If there is anything you want to add to what you have said in
writing or
Professor Peto: I would like to
add something about data protection. It is essential to British
medical research and particularly essential to an issue like this
where you want to monitor the population and see what happens.
I would very much welcome a general comment about the damage that
is being done to medical research by data protection, particularly
medical confidentiality legislation. It is an extraordinary innovation,
it has transformed the work we do in a catastrophic way. I do
not know if other people would agree
Q275 Chairman: I see some nods of
agreement from some of your colleagues but it is verbally on the
record and it will be in the minutes. If there is nothing further
Professor Peto: I was asking you
to headline it.
Chairman: Thank you very much
for your attendance.
|