Examination of Witnesses (Questions 340-359)
17 JULY 2003
PROFESSOR ANDREW
PRENTICE, DR
TIM LOBSTEIN,
PROFESSOR ADRIANNE
HARDMAN, DR
SUSAN JEBB
AND DR
NICK WAREHAM
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 gettingand
I am looking at how we can encourage people to be more aware of
exercise or lack of exerciseis 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 Moveand many of us
are familiar with thisin 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 directiona 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 toand this of course
is not a comment in relation to Sainsbury's or any other supermarketdeflect
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 areaand
I do not know if it has been touched on this morning alreadyis
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 itand I will not go into the details of
the contradictionthere 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 sectorsemployers, 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.
|