Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 340-359)

17 JULY 2003


  Q340  Jim Dowd: Four billion not four?

  Dr Wareham: The point I am getting at is the decline is rather drastic.

  Q341  Chairman: Professor Hardman, one or two of us here meet a colleague in a particular part of the House, I will be very careful how I describe which particular part of the House, at around half seven each evening. This particular colleague produces something from his waistline that tells him how far he has walked in any particular day. I suspect he does it prior to ordering his calories over the bar, shall we say. Is that in common use? I do not know what it is called. He tells me that you can acquire it from Boots for about £20. If people do want to take seriously the amount of exercise they are getting—and I am looking at how we can encourage people to be more aware of exercise or lack of exercise—is this in fairly common usage nowadays and what do you feel are the merits of that kind of approach?

  Professor Hardman: My suspicion is it is not in common usage yet. Some of the early ones were used in Japan where they had an index of how many steps can you achieve in a day. Rather like Susan said earlier, it could be one of a number of different approaches to help people increase their awareness of how much activity they have done. One of the advantages is that sort of accelerometer or pedometer will give you an indication of total energy spend and that is a point we should emphasise in this setting because that is what affects the contribution of activity to weight regulation and prevention of gain. It is not the intensity of activity in its own right, it is the amount of energy expended. I think they are useful. Again, I do not think they are going to be a used by a very large proportion of the population. Like the food labelling issue, it is there to provide information if somebody has the mind-set to seek that.

  Q342  Chairman: There is no mechanism whereby something similar to that also enables a person to do calculations on their diet, in other words what they have taken in and what energy they are using?

  Professor Prentice: Yes, there are. Some of them are programmed in with one's metabolic rate and they do that calculation for you. I am not sure that is the most useful use of it. These are being used very widely in the United States at the moment. It started in the state of Colorado in a programme called Colorado On The Move—and many of us are familiar with this—in which people were given pedometers and asked to record how many steps they have taken and add on 2,000. What we have heard very recently is that it has now been rolled out across the country into Walk America, so we will soon get some data on that I guess. Again, it is very useful because it raises awareness, and I do not think we should be discouraged. I am a bit worried about Tim's comments that things seem not to have worked. I do not think we should make those judgments. I think everything is important. We have got a juggernaut to turn around. No one of these things will work and we should not downplay their importance and significance by saying they do not seem to have worked.

  Dr Wareham: Andrew is right, these technological devices increase awareness and for some individuals that will be sufficient. For many others that awareness of their own activity needs to be incorporated in an overall behaviour change programme. That introduces personalised messages about how one can increase activity. That is being started in Holland where pedometers can be downloaded to the Internet and then a personalised health message comes back to that individual. I know that is being trialed by organisations like KLM who presumably have an occupational health reason for wanting slim employees but it could be generalised to other situations too.

  Q343  Chairman: One of the issues we need to look at in what we recommend is whether there is a role for the Health Service to consider encouraging people to use this kind of mechanism.

  Dr Jebb: Again, it is another thing which is a step in the right direction—a bit of pun there. There is a whole variety of these things. You can buy them costing a couple of pounds and they simply count steps. They are not wildly accurate but they give you a broad idea. I think they are the best because they have one button, stop, start, clear. As soon as you get into the more sophisticated ones for £20 or even £100 you get into endless equations and it gets ridiculously complicated. Even more, it encourages people to make these quantitative comparisons between how many calories they have eaten and how many they have burnt off and we simply cannot do that precisely enough. The only way it knows how many calories you have eaten is because you enter that data and of course people "forget" some of the things that they have eaten. I think it is a useful strategy but if you are talking about doing this at a public health level, through the NHS even, I would go for the simplest, most basic, cheapest way of doing it and get as many people doing it as possible. It will not help everybody but for those who are into self-monitoring and understand the significance it is a step in the right direction.

  Professor Prentice: May I make what I think is an important point in this respect. We can perhaps build on synergy with the energy expenditure inside the equation here. In fact, Coca Cola are investing a vast amount of money into Walk America. Sceptics would say that is a diversionary tactic and of course we need to be very careful to keep our eye on that ball as to what is going on because I think it is helpful that they are doing that. I know that one of the major supermarkets in this country is considering giving pedometers out after you have gained a certain number of points from purchasing fruit and vegetables. I think that is helpful, let them go ahead, I thoroughly encourage that, as long as—

  Q344  Chairman: —Can you name which supermarket?

  Professor Prentice: Sainsbury's. As long as they do not allow that to—and this of course is not a comment in relation to Sainsbury's or any other supermarket—deflect attention from where they need to take individual actions on the food supply side of the chain.

  Q345  Jim Dowd: Would it not be better to give it out on less healthy foods? People who buy the healthier foods are probably the ones who are going to benefit least from it.

  Professor Prentice: Unfortunately, that would encourage the consumption of the less healthy foods.

  Chairman: To get the pedometer.

  Jim Dowd: If you are giving it away, you are just giving it away.

  Q346  John Austin: We had an exchange earlier on with Professor Hardman about the reduction in physical activity amongst children and young people and a more sedentary lifestyle and the importance of children and young people maintaining a healthy weight and a good foundation for a physically active adulthood. Do you think schools are doing enough to promote physical activity. Sometimes I get the impression that pressures on the curriculum mean that there is less physical activity in schools than there used to be rather than more, which seems to be required?

  Dr Wareham: The simple answer is if one looks at the product of physical inactivity being obesity and its complications, one would have to argue that not enough is being done and that therefore more needs to be done across all aspects of life that impact on children of which schools is one part. Obviously there is major pressure on curriculum space but there is clearly a need to increase the amount of activity that is undertaken by children during school time. One area—and I do not know if it has been touched on this morning already—is transport to school because I see this as a big issue. Certainly in secondary schools and also in primary schools there has been a massive reduction in the number of children walking to school over a very recent time period. In the last 20 years there has been a halving in secondary school children walking and a doubling in the number being taken to school by car. That is partly a safety issue, it is partly a function of distance that children have to go to school, which has increased in that time period, but not by the same degree. Yes, there is a need to increase activity during school time, I would be all in favour of that, but I think schools can play their part in contributing to healthier routes to school.

  Q347  Dr Naysmith: Could I follow that up. Both you and Professor Hardman have referred to Holland as being a place where there are many more children going to school on bikes and walking and so on. Apart from the obvious factor that there are not nearly so many hills in Holland as there are here, why should there be that difference between this country and Holland? Have they actively promoted it?

  Professor Hardman: I think it is a long-standing cultural thing. Personal experience says that cycling in Holland or for instance in Denmark (which I have done myself) feels safe. The physical layout of the roads separates the cycles from the cars and the cars by law have to give way to the bicycle at a junction. Those two countries do not have vastly better weather (but I take your point about the hills and that increases the load a lot) but I think feeling safe on a bicycle and using a bicycle for ordinary transportation as opposed to sport is something we need to use every means we can to encourage. Again, I make the point it is often, regular, frequent activity.

  Dr Jebb: There was a piece of evidence I saw recently, I am desperately trying to remember who by, which showed interestingly that when they measured activity patterns in children who were driven to school versus children who walked to school, what they found was not only was there an increase because they were doing the walking but there was a very significant increase in their physical activity after school because they did not walk directly home, they went via the park or they stopped off to play with a friend, so it had greater than anticipated impacts in term of contributing to activity. It was like creating a more active child and they get into the habit of walking so maybe they walk more at the weekend.

  Q348  Dr Naysmith: On this point there have been a number of initiatives by local authorities for quite a few years now like Walk to School which have shown minimal changes during the periods of the campaign, which may run for several weeks, and then they very quickly slip back into the old patterns. What can we be doing which would substantially cause a shift? What are the factors we need to really focus on in terms of trying to make a difference at a local level that would enable people to make this shift out of the car and back on to two legs?

  Dr Lobstein: There are 101 things that the organisation Sustrans have come up with, things like the Walking Bus for example where in order to ensure safety, particularly for younger children, you have them come to school in a crocodile, monitored by some poor staff member who has been volunteered to do it, or a volunteer parent.

  Q349  Chairman: Some schools pay people to do it as part of the Healthy Schools initiative.

  Dr Lobstein: And lollipop ladies to ensure safe crossing of streets could be extended beyond the immediate school gate so you are encouraging it at junctions further away. I do recommend you talk to Sustrans, the sustainable transport NGO, who have 101 suggestions for increasing road safety and sustainable transport.

  Q350  Jim Dowd: What about the computer games business and consoles? A lot of kids not only go to school by car and they are taken there and brought home, when they get home they sit in front of a screen for hours on end. Is there any means of putting pressure on the companies to put messages up on the screen every half hour saying get up and "walk about for 20 minutes"?

  Dr Lobstein: Or make the hand-held thing impossible to hold.

  Q351  Jim Dowd: Or make it operated by treadmill or bicycle?

  Dr Lobstein: I do not know if this has been done carefully. I know TV watching is closely linked to weight gain but I am not sure if video and game playing is. You have to ask: book reading good/watching a video bad. Is that really the case? We do tend to approve of our kids reading books. My question is whether it is not something about the TV watching, for example the advertising or increased snack consumption that goes with TV watching that might be more significant than simply the fact they are playing a game rather than reading a book.

  Dr Jebb: I think this discussion is in a way symptomatic of the discussion which is going on out there which is that we generally agree that more physical activity would be a good thing, we are all behind that and there are no vested interests arguing against that. There are all sorts of little initiatives and you can discuss for hours on end all the possible ways and we could do this and we could do that. I think many of those are happening, at least at a local level. Of course there could be more, of course they could be better, of course they could be more integrated, but I think that ball is rolling really quite well at the moment and the Government and this Committee do not need to do a lot more to keep that moving. Instead what I really urge you to do is to get the ball moving in relation to food related issues where it is much harder to start thinking of these relatively modest initiatives because you come up against barriers the whole time. I really think that is where we need to apply ourselves in terms of trying to think of local initiatives because the physical activity initiatives are terribly important but they are happening, there are loads of ideas out there.

  Q352  Dr Naysmith: That is very interesting because quite a lot of people concentrate on things like the sale of school playing fields that has taken place over the last 20 years or so and saying that is a bad thing and that means reduction and also some people concentrate on these new gyms you can go to, but they are very expensive and you rule out whole sections of the population. What you are saying is that they are not really very important and that there are compensations taking place for that already?

  Dr Jebb: I am not saying they are not important. I am saying all of the issues in relation to physical activity are moving in the same direction. Some of them appeal to some sectors of the population, some to others. It is impossible for us to quantify the individual impact of any one on obesity and I do not think that matters. We do not demand that level of evidence because we know there are health benefits to being more active. It may help control your weight but there are independent health benefits anyway, it is a good thing. With diet we do not seem to be prepared to take that step and/or when we start coming up with ideas we hit up against barriers.

  Q353  Dr Naysmith: I am not disagreeing with you that the thing to do is to concentrate on diet, we may well come to diet in the end, but I am just trying to evaluate how important encouraging physical activity is.

  Dr Jebb: Tremendously.

  Q354  Dr Naysmith: I am not sure I agree with you that everything is rolling nicely in the right direction.

  Dr Jebb: It is not rolling nicely but it is rolling. Of course more needs to be done, and in other circumstances I would be a profound advocate for more physical activity, but I come back to the point it is difficult to quantify the impact of any one particular initiative. No one thing is going to meet the needs of all sectors of the community so we need to move forward on a number of fronts in parallel.

  Q355  Jim Dowd: The evidence we took at the last session and what I have detected this morning from yourself and colleagues is that the quickest way into this is to reduce consumption. We consume too much food, more than we need. The message used to be three square meals. Is that still an effective message? It occurs to me having listened to you and having listened to other people a couple of weeks ago that we have far more food available to us now than we actually need.

  Dr Jebb: Three meals a day could be a very effective way depending on what you put in those three meals. It is not the number of meals we need to focus on but the quality of food that is consumed at those times. What we also have to recognise is eating habits have changed. The whole culture of society is different. We do not sit down to three regular meals a day, so there is no sense in trying to enforce that pattern on everybody. We have to go with the secular change in eating habits, eating patterns, eating behaviours but within that framework we need to look at the quality of food that is being consumed, and by "quality" I mean nutritional quality of food.

  Q356  Dr Naysmith: I wanted to finish off by asking Dr Wareham what he thinks about the need for physical exercise.

  Dr Wareham: I think it is important in the context of a committee which is focusing on the effects of obesity to remember all the other diverse beneficial effects of physical activity. It impacts on diabetes risk through a pathway independent of obesity, it impacts on cardiovascular disease, on some cancers, on many other disorders. I hear what Susan is saying and I do not disagree with her premise that a lot needs to be done on reducing consumption but we must not forget there is a major secular decline in physical activity. It is associated with multitudinous adverse health impacts and we have not turned the corner and started to improve things, certainly in this country.

  Professor Prentice: The CMO is about to publish a report on the diverse health effects and I think that will be an extremely important document. I am on the board that looks after that.

  Q357  Mr Amess: All of this leads us very nicely into the final subject, implementing strategies to tackle obesity. Doctor Jebb's enthusiasm has spoken volumes, I do not know whether she speaks for everyone, but we will pursue it. At our first evidence hearing we had a number of people from the Department tell us how the Government was attempting to tackle this problem, if indeed it is a problem. It was very clear as we listened to it—and I will not go into the details of the contradiction—there just was not joined-up government. I think it was Professor Prentice about an hour ago who mentioned Tesco's and the computer vouchers, or was it Dr Jebb? It seemed to us that there were government departments not singing the same song and obviously it is crucial to introduce interventions to both diet and physical exercise and likewise to the environment to try and get people to change the way they behave. As far as government is concerned, what should be their priority, where do you think they should put resources, what do you think is the biggest impact they could make, if you actually think that the government are the right people to tackle this?

  Dr Jebb: Why government is important is because it has to take a lead on this and it has to take a lead in recognising firstly that this is a major problem and to in a way, put to bed the idea that this maybe is not such a big deal. This is a serious health issue. That is why it is important. Government has also got to set an example by joined-up working, exactly as you illustrated. This is not just down to the Department of Health, particularly in relation to prevention, because it impacts across a whole raft of government departments, and until they can start working together it is difficult for the government to start telling everybody else to work together. We need a very clear government strategy which makes this a priority and which then begins to put in place those areas in which government can intervene in terms of regulation or whatever but then firmly calls upon all the other interested parties to develop appropriate action plan strategies and to hold them accountable for it. Interestingly, if we look at the salt issue, which has been in the ether with debates going on for years and years and years, it is only recently when the CMO and Food Standards Agency have come out extremely strongly in relation to the need to cut the salt content of food that we are starting to see the food industry beginning to engage in the process and beginning to look towards reducing the salt content instead of arguing against the evidence. I think the government has a responsibility to take that lead and to make it a priority. If you look in the NSFs, for example, obesity is in there and I am sure the Department of Health will say, "Of course it is there", but it is pretty subtle. It should be in there explicitly and accountably, which it simply is not at the moment. They need to take the lead and in some areas in relation to regulation maybe they can do some specific things. Actually I think government's role is to get everybody else to start moving because most of the solutions lie in other sectors—employers, food industry, schools, and so forth.

  Professor Hardman: I would like to go on record, first of all, as saying rather as Nick did, that we definitely should not lose sight of the fact that this inactivity issue is a very big contributor. My simple mind says that if we concentrate only on the food then we are asking people to consume less food to decrease their energy intake. Given that we know that regulation is better when you have got a higher level of energy expenditure and that you tend to match your intake better to your expenditure, that is not good news. We should make sure that we push forward on all fronts and every opportunity to increase activity which governments and other agencies can take should be taken. I agree with Susan to the extent that it is necessary that a number of different departments are involved. I have already made the point that I think the Department of Transport needs to develop priorities that allow safe movement for pedestrians and cyclists. I think that is a very important starting point. Sports facilities and the encouragement of young people into sport is vital and that is going to interest a lot of people, but the public transport issue is one that affects most people's lives and that should be one of the big priorities.

  Dr Lobstein: I think top of your list is going to have to be a recommendation that governments bang each other's heads together, that is to say you need a cross-departmental nutrition and physical activity policy. I talked to Tessa Jowell MP quite recently and she could only see the sports side of her department and would not listen to any discussion about the media side, which is advertising. We had a great problem with her, and you can talk to Debra Shipley about the discussion that happened. You need to get to Culture, Media and Sport. If you will remember, it was Richard Caborn who was involved in the Cadbury's tokens for schools debacle. I noted Hazel Blears MP at the time did not say anything, which I guess was very pointed, and of course John Krebs at the Food Standards Agency was quite critical of the lack of joined-up thinking in nutritional policy and sports policy.

  Q358  Chairman: I am quite surprised at what you said about Tessa Jowell because she was a Public Health Minister and I would have thought if anybody could make the link she could.

  Dr Lobstein: Huge disappointment, sorry about that. She was not that strong on tobacco advertising either. There was a bit of a problem there. You have got to look at all the steps including agriculture. Food supply is a lot of the push towards why our diets have been shifting over the last few years. The surplus amounts of sugar and butter and vegetable oils, which have been created under the Common Agricultural Policy, have to find a home somewhere. Surplus foods are disposed of and destroyed but the extra fats and oils all go into our food supplies so you have to look at every department's contribution to how our food supply and physical activity and environment are being created. Can I throw in one we have not talked about which affects childhood obesity, and that is breast feeding policy and breast milk promotion because I suspect that certainly the last 40 or 50 years of formula milk usage has been quite significant in the rise in obesity in children and adults over those years and I think that needs to be reconsidered and much more effort put into it.

  Q359  Dr Naysmith: What is the evidence about that?

  Dr Lobstein: There have been several large-scale surveys showing increased obesity in children who were bottle fed instead of breast fed and various factors that could have explained that had been ruled out, so we are left with bottle versus breast, given that bottle feeding has been heavily promoted in the 1950s, 1960s and 1970s and we are now having overweight adults 20 or 30 years on.

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