Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 260-275)

26 JUNE 2003


  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 know—and many people do not—that 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.

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