Examination of Witnesses (Questions 360-371)
17 JULY 2003
PROFESSOR ANDREW
PRENTICE, DR
TIM LOBSTEIN,
PROFESSOR ADRIANNE
HARDMAN, DR
SUSAN JEBB
AND DR
NICK WAREHAM
Q360 Dr Naysmith: You are right,
there could be a number of other explanations for that.
Dr Lobstein: There are and it
is well worth looking at.
Q361 Dr Naysmith: There are general
health benefits so it is a good thing anyway.
Dr Lobstein: Put that on your
list of things to consider.
Professor Prentice: I would like
to make some very specific points, first to endorse the need to
attack both sides of the energy balance equation. We were invited
here to look at gluttony versus sloth. The answer is very clearly
that it has to be both so please let us keep sight of that. I
would like to see us turning this in a positive direction and
develop a strategy on healthy weight maintenance. Stop beating
obese people and stop beating all of ourselves about the problem
of obesity. Turn it positive. For instance, Dr Jebb as Chairman
of the ASO, has got an initiative at the moment called Leaner
Fitter Future. We can do things together, we can bring people
on board by saying, "These are the problems, we have all
been ambushed by changes in the environment, let's try and get
out of this together and see positive things to do." The
other advantage of that is it removes stigmatisation and concentrates
our minds on the fact that this is a nationwide issue. It is not
just fat people we are worried about because the health effects
kick in very early. Having said that we should be very positive—
Q362 John Austin: Can I just interrupt
you on that. I accept the general premise you are putting forward,
that it is a problem across the whole community, but if you look
at children you can identify very clearly that the young child
who is grossly overweight is probably associated with low self-esteem,
over eating, not exercising, whose self-esteem in punished even
further by the physical activity within the school because there
is nothing worse than being overweight and being humiliated in
front of your class mates in the PE gym or whatever. Quite clearly
young people at risk stand out so how do we tackle that?
Professor Prentice: We do indeed
but the way you phrased your questions exactly brings out this
stigmatisation of a particular sub-group. The point I am trying
to make is it is all of us, we are all in this together, no child
becomes fat without first of all being a little overweight and
the same goes for adults, so we need to tackle it earlier. Also
what we need to get across is that the health risks associated
with excess weight kick in at a very small incremental weight.
If you look at the risks for diabetes—and this was not clearly
brought out by the evidence last week—with people with a
BMI that does not classify them as clinically obese (a BMI of
around 28 in women) the increased risk of diabetes is 18-fold.
That is a huge risk relationship in even moderately overweight
people. In terms of doing the numbers game of where you get the
impact that is very important. Coming back to my other points
we have got to be brave and apply a bit of the "Occam's razor"
and say a lot of the things we need to do are very clear and let's
get going on those and apply the precautionary principle. I see
the CMO is arguing this very strongly already that we should start
to get going. I get very worried by accusations of the nanny state.
We are prepared to go to war against Iraq against the population's
better judgment and wishes, we are prepared to wear our seat belts
and stick to speed limits, by and large, because we know they
are good for us, and I think there is something that could be
done. My final point is we have got to work with the food industry
to tackle the rogue elements because they are creating as much
of a problem within the food industry as they are to us. There
is a lot of the food industry who are very keen to sort this out
with us and we need to separate out those who are not and move
forward with those that are. The analogies with tobacco are quite
strong. McDonald's never intended to create a product that would
harm children or make us all fat but the fact is the evidence
is pretty strong that it does and they now have a moral responsibility
to join us in doing something about it. Similarly with Coca Cola
and soft drinks, we need to name and shame them in order to get
them on board and get them to start to listen to a dialogue.
Dr Wareham: I would like to suggest
that the biggest thing government can do at the minute is to engage
in a public debate about individual and collective prevention
versus the further medicalisation of society. I do not think most
people are aware of the rather insidious way in which the boundary
between normality and abnormality for many obesity-related disorders
is being shifted so that we are all being defined as being diseased.
The specific example I want to give is of diabetes where maybe
4% of people in Britain have diabetes but maybe 20% have a precursor
condition pre-diabetes, and there is a move to have that proportion
of society medicalised and given drugs and the drug companies
are queuing up to make drugs that will benefit those individuals.
We have a stark choice because all these individuals will be overweight
and that proportion of people in that sector is going to increase
with time. The stark choice is do we move that boundary of normality
and abnormality further down to medicalise people and to treat
our way out of this problem, which we may not be able to afford,
or do we tackle the problem at the root by individual and collective
proactive action, and I think we need that debate.
Q363 Mr Burstow: One picks on the
point about joined-upness in terms of government policy and approach
and the reference which was made to the Cadbury's Eat Chocolate
Get Fit campaign which did cause some concerns earlier on. What
I want to try and get is an idea of where you all might suggest
that the lead responsibility ought to be placed for taking forward
strategies within government and also at a local level. Where
is the lead, which is the organisation, who is the person within
government who ought to co-ordinate this? Is it the Department
of Health or somewhere else? We now have a Minister for Children
who in terms of children's obesity might well be the person to
take this lead role. I would be interested to hear who should
have the lead in government, both locally and nationally.
Dr Lobstein: I do not know enough
about your constitutional structure to be sure that it would work
but I would assume if it is going to be cross-departmental you
have to start with a Cabinet Office approach or something like
that. You are better at judging these things than I am. It has
to extend quite far down to things like Ofsted criteria for evaluating
schools' pastoral care and whether it includes a nutritional policy,
let alone the Minister of Sport's behaviour when he discusses
his support for particular companies' products and so on. I can
only assume that the Cabinet Office would be the starting point
for a cross-departmental policy.
Q364 Mr Burstow: Does anyone else
want to add about the local level or the national level?
Dr Jebb: I know less about the
local level. At the moment there is a real problem with obesity
between DH and the Food Standards Agency. I absolutely accept
that lots of other departments are involved but it is useful to
focus on the DH/FSA responsibilities because they will both tell
you very firmly that obesity is a Department of Health responsibility
and in terms of treatment I am sure that it is appropriate that
they should be taking the lead. I am less convinced in terms of
prevention that it is most appropriately there because the Food
Standards Agency takes primary responsibility for healthy lifestyles
and healthy eating and that is the foundation for prevention of
obesity (pulling in all sorts of other people as well). It is
possible it seems to me that the prevention side is really falling
between the two and I would like to see that issue clarified with
some urgency. I support Nick's comments about not wanting to medicalise
this further, particularly in relation to children. We need an
all children approach to this because most children are not fat
but many of them will become fat later, so we need to target all
of them in terms of healthy eating/healthy lifestyles, and I do
not think that necessarily is best with the Department of Health
taking the lead. I think treatment issues are very, very different.
We have not touched on those at all today. Clearly seriously obese
children need active treatment.
Q365 Mr Burstow: In your paper that
you submitted some time ago now you make reference to the Health
of the Nation initiative and the targets that were set then which
were meant to be coming to fruition by 2005. What evaluation was
ever done to know whether or not those targets were likely to
have been hit? Do you have any information you can share with
us on that?
Dr Jebb: From the moment they
were set most people in the obesity field realised that they were
unachievable because the scale of the increase was so rapid, but
they were important because they were targets. They were probably
unachievable targets which maybe is not helpful but they were
targets, which is useful. What Health of the Nation did do was
set up task forces for food and nutrition and physical activity
which brought together diverse groups. The trouble is they did
not have any teeth, they did not really go anywhere. What we need
now is not a task force but something at a much higher level because
the scale of the problem is three times bigger than it was and
growing every day.
Q366 Mr Burstow: My final question
is about messages. Earlier on there was reference to the point
that you cannot turn this into sound bites but in terms of trying
to achieve a whole society type change, which is what in a way
we have been told has happened—a shift in the population's
weight and we now want to achieve a shift in the population's
weight the other way—what would be the key messages that
would be part of trying to educate and inform and change opinion
on this? That is really a question for everybody.
Professor Prentice: John Garrow
has coined a phrase "treat obesity seriously", and I
think that is very important. That is a sound bite, although I
did not intend to give a sound bite. The mere existence of your
Committee is enormously helpful. It is getting onto the agenda
now and you need to keep it up on that agenda and move in every
direction we possibly can. I congratulate you for the work you
have done so far, keep going.
Q367 Jim Dowd: I do not know if you
mentioned it in the few moments before I got here, and if you
did I apologise, I will look at the record. I came across an article
in the Sunday Telegraph last Sunday about something called
opiods for the first time. I think this was some work all of a
piece with a BBC programme on Tuesday, which I have not seen yet,
work at the University of Wisconsin saying that these make you
eat more and they have been deliberately used by food manufacturers
to put in their products. I do not know whether that occurs naturally
and they know about it and are doing nothing to stop it. I just
wanted your view on that work.
Dr Jebb: Professor Blundell, who
unfortunately is not able to be here, I know would want to comment
very specifically on that. I would suggest that you ask him for
some evidence later. I thought it might come up so I asked him
what he was going to say and his message in simple terms was food
gives pleasure, many foods give pleasure when eating and there
is a physiological mechanism for that which is through the brain.
The mechanisms are similar mechanisms to those stimulated by addictive
drugs. The fundamental mechanism is through a similar pathway.
However, he then went on to say that quantitatively they are dramatically
different and you simply cannot compare food with addictive drugs.
He was very much against the concept of food addiction whilst
acknowledging that there are physiological pathways whereby food
stimulates pleasure. What he agreed is that the pleasure and the
positive reinforcement, the feedback we get from eating food,
can lead to a situation in which food becomes very highly desired
and there can be a compulsive element to food consumption which
is fostered not only by the taste of food but by the whole aura
surrounding food, the marketing, the lifestyle that you buy into,
and there can be compulsive elements, but he was strongly against
the concept that there was addiction in the sense that we think
of addiction to hard drugs.
Q368 Mr Burstow: Does anyone else
have any suggestions around the messages that we should be talking
about that would start to have some effect in terms of moving
the population?
Dr Jebb: I would say do not super-size.
There is almost nobody in the UK who needs super-size portions,
our energy needs are lower than ever.
Q369 Chairman: This is a very important
point and this struck me when we were talking before the meeting
started. I have got teenage children and you cannot get a small
coke. Why have we suddenly gone there? When did it happen?
Dr Jebb: I will tell you why.
The answer is manufacturers, particularly in the fast food outlets,
discovered that people did not like going to buy a second burger,
they felt embarrassed at the idea of having a second one, so the
marketeers came up with the idea of offering them a bigger one
to start with, and it worked a treat.
Professor Prentice: Another aspect
of this is that the actual cost of the ingredients of food has
come down so much because of agricultural improvements. We spend
about 11% of our disposable income on food now whereas 30 or 40
years ago we spent 33-35%, so it is now extraordinarily cheap,
and it is very easy to use that as a marketing tool, "bigger
is better". I am glad we have touched on this because I think
it is very important and would be an area where you could perhaps
try and get voluntary agreements not to market on the basis of
super-sizing, to regulate this. You could try the voluntary agreement.
My understanding in speaking to the food industry is that they
would be open to quite a lot of things if there were a level playing
field and if their competitors were forced to do the same thing;
they would not be averse to certain of these moves. The difficulty
is that it is very difficult for one of them to break ranks first,
such as Kraft have actually done, which indicates the pressures
upon them. It is difficult for one of them to break ranks because
they will lose their competitive edge if they do it.
Dr Wareham: I want to go back
to one thing Andrew said which was to do with the nature of the
association between levels of obesity and future risk of disease.
For most of the conditions that one is concerned about, the public
health burden lies most with the vast majority of people who have
got moderate degrees of overweight and who are, therefore, at
moderate degrees of risk rather than in the relatively small group
of people who are at very high risk and are very obese. I suppose
my message would be that it is about all of us, it is not just
about seriously overweight and obese individuals, it is about
moderate increases in levels of BMI and obesity in the whole society.
Q370 Mr Amess: Our Chairman reckoned
that he was too embarrassed to ask our final question because
we are going to end with sex. Is there a need for body weight
or shape to be remodelled as a health issue rather than a social
or sexual issue? In other words, we are thinking of the huge pressures
for people to look wonderful, and that is the emphasis rather
than the fact that being overweight and not taking exercise is
not a bright thing to do.
Dr Jebb: Of course there is. We
are a society obsessed with super-thinness and this actually is
not about healthy weights at all. I have a BMI which is close
to the bottom end of the healthy weight range and yet most people
would probably think I was somewhere in the middle, I am not particularly
thin. We have got to get people to understand the concept in health
terms of what is a healthy weight, which is not the media stereotype
of glamour which is associated with BMIs which are ridiculously
low and levels which are unachievable for the population and which
would require them to constrain their food intake to levels at
which they may well compromise their intake of assorted essential
vitamins and minerals. We need to get over the message of a healthy
weight which is higher than the social stereotype. Also, I think
there is a bit of a range. There is not one weight which is perfect
for everybody, there is a natural range in which there is very
little difference in health risks and it depends on all sorts
of other factors like fitness and family history and so forth.
Yes, that would be helpful. It illustrates the role of the media,
which we have not really touched on. The media are important players
as another stakeholder in all of this, both because of their ability
to transmit messages and because of the way that they contribute
to culture and the culture that we have which drives food habits,
exercise habits and notions of beauty.
Professor Prentice: Can I just
add a corollary to that. I agree entirely with everything that
Susan has said. The pressures have been a useful brake and without
them I dread to think what the body mass index and state of obesity
of our countries would be. When that brake is released, as it
is starting to be in the United States where everybody now has
very fat friends and parents who they love dearly, and there is
much greater acceptance of fatness, then that is likely to accelerate
obesity. We just need to factor that into our future projections
of where the epidemic may go. I am not supporting it in any way
but, paradoxically, it has been a useful brake.
Chairman: Do any of my colleagues have
any further questions?
Q371 Dr Taylor: Professor Blundell
in his absolutely excellent paper did slip this in: "The
four characteristics of successful weight losers from the American
Weight Loss Registry could become the gold standard for personal
change". I am not entirely clear what those four characteristics
are, could you just list those four?
Dr Jebb: The National Weight Control
Registry is a US register of people who have lost 14 kilos or
more and maintained that weight loss for at least a year. When
they survey them to find out what they do and compare it with
the population at large a number of factors come out. They self-monitor,
so most of them weigh very regularly, every day or very regularly.
They eat less fat, significantly less fat, than the general population.
They are much more physically active. They recognise that they
use both a low fat diet and regular physical activity as weight
control mechanisms. Offhand, I cannot think what the fourth one
is, I always tend to think of three: self-monitoring, activity
and diet. We could press John Blundell about what the fourth one
is.
Chairman: If my colleagues have got no
further questions, can I thank you all for a most interesting
session. It is our last session before our summer recess, and
I will not say you have cheered us up but you have certainly given
us something to think about. We are very grateful. Can I wish
my colleagues a peaceful recess. Thank you very much.
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