Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 300-319)

17 JULY 2003


  Q300  Chairman: Would you like briefly to introduce yourself. You wanted to come in on this point, I think.

  Dr Jebb: Thank you. Susan Jebb, I am an MRC scientist at the MRC Human Nutrition Research Centre in Cambridge. I trained as a dietician originally and now I very much specialise in the physiology of obesity. In addition, I am the Chairman of the Association for the Study of Obesity, which is a multi-disciplinary professional group dedicated to understanding and treating obesity. I am here really in both those capacities today. On that specific point about European comparisons, one of the issues I know Nick Wareham wants to touch on—and perhaps we should wait for him—is the very recent data from a pan-European survey of physical activity levels which I know shows that the UK is in the bottom quarter. But Nick would be able to give us much more specific detail on that. I know it is one of the pieces of evidence he wanted to submit.

  Q301  John Austin: Are there any discernible patterns in respect of social class

  Professor Prentice: These are very, very clear. The figures on number of hours television viewing are startling in relation to social class. We are using these proxy measures because very often we do not have good measures. They are not very satisfactory but I think at the end of the day they do give us the necessary information with which to start to act on the problem. Television viewing, for instance, if you do simple questionnaires of the type that have been done very well in this country actually, simply asking people: How often have you been physically active in the past month? then again we see a very strong social class gradient and education gradient.

  Dr Jebb: To add to that, if we then think about programmed, planned exercise, if you like, we have seen some increases of leisure time sport and physical activity in recent years, but those are very different in different social classes, and are being taken up, as perhaps one might expect, much more enthusiastically by people with high levels of education, high levels of income, and perhaps a greater understanding of the health issues.

  Q302  Dr Naysmith: I would like to start off asking a question of Tim Lobstein and others can come in if they want to. We have known quite a lot about healthy eating for a long time. Very early on Professor Prentice talked about some things are "blindingly obvious" but why is it that health education has not had more of an effect? Why has it not prevented this outburst of obesity that we are seeing now? Your organisation has been associated with this kind of thing for quite a long time.

  Dr Lobstein: Yes, it has. It is particularly concerned that too much reliance has been placed on health education and handing out the odd leaflet in doctors' surgeries over the last 20 or 30 years as the Department of Health's strategy. It is not adequate. The main reason it is not adequate, of course, is that for every pound the Health Education Authority used to spend on promoting health diets there is about £800 being spent by the food industry encouraging us to eat their products. Of those products, about 95% are ones that would have encouraged weight gain rather than a healthy diet. The imbalance between the promotion of lack of health and the promotion of health was enormous. I think that has now been recognised. I think even our own Department of Health now is beginning to see that something broader is going to be needed. Addressing what we are calling the obesogenic environment, the toxic environment that is encouraging obesity all the time, is going to have to be tackled rather than simply telling individuals to exercise willpower. Particularly for children, it is almost impossible to expect them to swim upstream against the flood of stimuli that is sending them rapidly downstream.

  Q303  Dr Naysmith: Is there any evidence that it has had any impact at all in health education and health promotion?

  Dr Lobstein: In terms of awareness, I agree with you. When I go and give talks to even low-income families, they are fairly well aware of the sorts of things they ought to be eating more of, but they are not doing it and they are not doing it for a variety of cultural and economic reasons—and also for children there are fashionable reasons and so on. There are a number of other pressures besides the health education message that is encouraging them away from healthy eating.

  Q304  Dr Naysmith: Are there any good ideas about, any innovations that you are trying to get onto the agenda to improve this situation?

  Dr Lobstein: Yes. You ought to examine, if you have not already Professor Fergus Lowe who is in Bangor university. He has run a very interesting scheme called the Food Dudes Scheme, where he goes into primary schools and, using the techniques of advertising—cartoon characters, jingles and food gifts and toys and so on—encourages children to take fruit and vegetables much more seriously into their daily lives, and finding they are, and, what is more, when he ceases the programme that there is some residual carryover. So using industries' methods, you can alter behaviour, but it is a fairly intensive programme, run for several weeks and so on.

  Q305  Dr Naysmith: Obviously the Government could do more but in what areas do you think the Government could.

  Dr Lobstein: You have a choice. Do you recommend the Government fights on equal terms the enormous barrage of difficult counter-education health education messages, or do you try to limit the effect?

  Q306  Dr Naysmith: Which would cost a fortune.

  Dr Lobstein: Exactly. One way is controlling how much that is happening and the other is to try to match it. I think to try to match it will cost the Treasury a huge amount of money. The alternative is to limit what is happening already on the other side.

  Q307  Jim Dowd: Are you serious? Are you saying we should treat it like tobacco advertising?

  Dr Lobstein: Yes, I am serious. Of course I am serious. Particularly for younger children. If you look at TV ads during young children's programming, you will find that every five, six, seven minutes there is another ad for food—and of those foods they are 95% for fatty, sugary or salty foods. They are causing an enormous amount of damage. Children are sitting watching television for more hours on average over the year than they are sitting in a classroom. If children are watching television and every few minutes they are having another ad for a snack food or soft drink, I think that is a huge cause for concern.

  Q308  Chairman: On the Bangor work, who has resourced that initiative?

  Dr Lobstein: I do not know actually. I am sorry.

  Q309  Chairman: Perhaps you could get back to us with that information because we are interested in what you have described there.

  Dr Lobstein: Yes, of course.

  Q310  Dr Naysmith: We are getting in a very interesting area which involves banning things, which is always an area which causes problems.

  Dr Lobstein: Controlling, I would say: responsible control over how foods are promoted.

  Q311  Dr Naysmith: Do you think it is feasible, given—-

  Dr Lobstein: Yes, I do.

  Q312  Dr Naysmith: —the problems we have had with banning tobacco advertising.

  Dr Lobstein: You have had problems but it has happened eventually. I am not saying it will happen tomorrow, because there will be an enormous reaction from the advertising industry as well as the food industry. I think the food industry have already been told by investment banks that they are going to have to think carefully what their strategy is. Indeed, if they went down an advertising control strategy they would all suffer equally and would save money in the process—they would not be advertising so much—so it is actually the advertising industry which is going to be the one to suffer to the most.

  Professor Prentice: I would agree with that. I have gone through a transformation myself of thinking that we could do it all through education and have come to the conclusion that that is not working. I am not a nanny-statist but I am a health professional and I do think we have a responsibility to look after the health of the population. There are many previous examples (vaccination, cleaning up water supplies, removing the pump handles to stop cholera epidemics) where we have done this and it has proved immensely beneficial to the population and the world, so I do not think we should be frightened. I think Government does have to stand up to vested interests within certain rogue elements in the food industry and that the time is right to do that, because, as Tim has said, I think they are on the run at the moment. We have turned corners. McDonald's, for instance, are diversifying their interests greatly. They are spending a large amount of money. For the first time this year ever their profits have not increased as much as before. They are very seriously concerned about the future. And we see changes. We see the Kraft Food initiative. I think the time is right to press that home.

  Dr Jebb: As soon as anybody starts talking about advertising, people will jump up and say, "Surely you cannot be suggesting a ban on the promotion of all foods." I think, given where we are now, that is going too far, but one of the arguments which is often put forward, and has been used previously by the tobacco industry, is the issue of not increasing overall consumption but influencing brand choice. I am not sure whether I buy that argument or not, but, regardless, one simply cannot use that as a case for marketing to pre-school children who are not choosing brands themselves. If one really focuses—if you want to take a first step—on the issues of advertising and direct marketing to pre-school children, I find it difficult to find any justification for that. The food industry of course do work currently within the regulatory framework laid out by the Advertising Code of Practice and so forth, and I would suggest that that framework needs to be reconsidered to reflect contemporary issues and contemporary concerns. I think that, given the climate we are in today, is long overdue.

  Q313  John Austin: Apart from advertising, there are other ways in which food manufacturers promote themselves if not their products. A number of schools have Coca-Cola machines in them. Walker's Crisps—which I think is Pepsi-Cola—is involved in education sponsorship programmes. Do you think food manufacturers such as McDonald's, Walker's, Pepsi should be involved in our schools in sponsoring education?

  Dr Jebb: I am glad you have mentioned that because one of the reasons why I think it is hard to make the case against advertising and television per se is because it is only one of a multiple of influences on children's eating habits. I think when we are thinking about marketing, we have to think about the whole panoply of factors. To my mind, these loyalty schemes with schools are an absolute Trojan horse. Schools are getting huge immediate short-term benefits out of it. If you ask schools what their major priorities are at the moment, it is the funding crisis, it is teacher shortages, it is all of those pressures, and they put those ahead of the longer-term potential effects on children's health. I really think that is an area where Government has a responsibility to take a particular concern and to give schools very clear guidance. I have heard it said that it is down to individual schools and individual governors, and maybe it is in the end, but I think we give governors so much advice on how they should operate, how they should do this or that, we really should be giving them a much clearer framework for how they should deal with these schemes, which of course are initially extremely attractive.

  Q314  Chairman: Do you detect any shift in thinking at Government level, national level, on the health roles of schools? We are seeing a period of change in relation to departmental responsibilities between the Department of Health and DfES on, for example, child protection, as you clearly appreciate. I get the impression there is more thought being given to what schools can do in local communities as a focus on wider issues than just the immediate educational input. Is that a picture that you would share from your experience?

  Dr Jebb: I think it is beginning to happen but it is still very small, so I am reluctant to be too enthusiastic.

  Q315  Chairman: It is a process you would obviously encourage.

  Dr Jebb: I would absolutely encourage it. Schools are part of the wider community. You cannot expect schools to solve this on their own. One of my key points is there is no one simple solution. If there was, we would have done it by now. The problem is that if you look at each thing individually, you always think, "Well, they are maybe not going to be very effective." We have to put the whole lot together. Schools can be a focus for that, but if they can do that by linking up with parents, by linking up with the wider community—throwing open their sports facilities to the community at the weekend, this kind of thing—then you begin to get a move for change, and we have to involve them in that.

  Q316  Chairman: One or two of us are thinking through some parallels with a previous major inquiry we did on sexual health, where of course a number of schools have initiated what I term "clinic centres" within the school environment which, in our view, will prove very successful.

  Dr Jebb: One other example would be things like the breakfast clubs which are beginning to happen. I think that is a very positive step forward because it recognises the pressures that are on parents, it recognises some of the reasons why children are not having breakfast and seeks to deal with them. With things like the 5-a Day campaign in schools we are beginning to see those things happen. We have to push forward on that much harder and much faster than we are doing at the moment.

  Q317  Mr Burstow: We have partly covered some of the ground I was going to ask about, so I would like to try to build on some of the points that have already been made. In terms of advertising, regulation control, however one might want to frame it, could Dr Lobstein and others perhaps say a little bit more about whether or not there is any way in which one can target this in particular with respect to children, on whether that in practice is going to be possible, and on what particular areas of advertising we should focus our attention if we were framing recommendations in this area or, indeed, if we wanted to look at this further when we have other witnesses before us. It would be useful if we could hear a bit more from you.

  Dr Lobstein: I do recommend that you look at it further and I do recommend that you start to look at how other countries have tried to tackle the same problems. There are various different schemes. For example, in the Flemish part of Belgium they do not permit ads within five minutes of any child-oriented programme. In Sweden they do not permit ads to programmes that are deemed to be unsuitable for . . . I forget the logic of it, but, anyway, not below the age of 12, I think, is the issue. Then you have Debra Shipley's recent Bill—and I am not sure what stage it is at now—which was targeting pre-school children and saying it was possible to define the pre-school patch and said there should be no food advertising in that period. So there are various approaches that are being considered.

  Q318  Mr Burstow: In terms of those approaches, has there been follow-up research to ascertain how effective they have been? Given that the viewing hours of children go well outside of the hours of children's programming, therefore how does one not get into the realm of controlling advertising not just for children but actually for everyone?

  Dr Lobstein: The short answer is no. If you start saying, "We cannot do anything until it is evidence-based" . well we are going to have to do it first because no one has done it. And because it is something that affects the population, not just a few individuals, you are going to have to find somewhere else where they have attempted to introduce these regulations to ensure that children are not exposed and then see if it has changed the market, or do it here first. There is a rumour that in Poland two years ago some controls were introduced on advertising to children,and the effect was a reduction in soft drinks' consumption, but I have not been able to confirm that.

  Professor Prentice: In addition to the advertising, there are many other strategies that companies use to increase consumption: proximity placing of products; issues in terms of the pricing structure of foods to encourage larger portions; the super-sizing; the large portions. I think we need to bring all of those into the argument as well as advertising. I would entirely agree with the advertising but it goes much deeper and further than that. One of the issues, as soon as you start to debate this, is that people would say, "How are you going to define those foods that either you say cannot be advertised or to which you might want to apply fiscal policies or certain regulations?" We have some help there from the European Union, with the new labelling laws that are being drafted at the moment which will help to clarify and set out lists and categories of foods. So there will be a tool available soon, and we could start to apply different levers to different sectors of the food chain.

  Q319  Mr Burstow: In terms of that tool—and we are looking at the possibility of going to Brussels to look at the Commission's work on that—can you give us some examples of how labelling could be improved within domestic law, let alone within EU law, to start to make it easier for consumers to make really informed choices about foodstuffs that they are purchasing?

  Professor Prentice: I have put a little bit about this in my background as well. Again there are several angles to this. One is the control of health claims, which is perhaps a different issue. The other is simply the advertising of products and the labelling of the content. I would like to see that labelling is enforced on all foodstuffs and in all food outlets prominently. I have come down on the train today. I found empty McFlurry pots and huge empty Coke containers from Burger King and everything. There is tons of room on those packages and they had absolutely no labelling whatsoever. The consumer has not the faintest idea what is in them. In that respect it is also very important to give the consumer a reference, because these numbers do not mean much to people. In the United States they have a daily amount which is put on the back. This is a fairly nominal average requirement of calories and fat and carbohydrate for a woman and a man. They list that at the top of every column and then they list the content of this individual food. If you expressed the content of the food as a proportion of this daily amount, it would become very clear to people that certain foods have virtually 100% of your daily fat allowance in a single food item. That, I think, would start to have an impact.

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