Memorandum by Len Almond, Director, BHF
National Centre for Physical Activity and Health, Loughborough
University (OB 26)
| KEY POINTS | ACTION STEPS
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| 1. The role of physical activity in obesity management has been underestimated and it needs to be recognised as an essential part of all protocols to reduce weight and help to maintain weight loss in the long term. The high prevalence of inactivity in both men and women needs to be fully recognised. There is an acceptance that physical activity is important for health but many people in health promotion see it as a very low priority and fail to understand the substantial evidence outlining its benefits. The Chief Medical Officer's report may help to address this issue however it needs to be supplemented with clear guidance on how the recommendations can be implemented at local level.
| A strategic platform for physical activity promotion needs to be established to highlight the significance of frequent participation in physical activity of at least moderate intensity in the promotion of better health and well-being for everyone.
The CMO report should be made available as soon as possible together with clear guidance on delivery and monitoring for all Primary Care Trusts.
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2. At present there is no organisation that represents the interests of mass participation in health promoting physical activity in England. Consequently, there are no national strategic plans to promote physical activity for health and little organised efforts to ensure that physical activity is fully represented in any local obesity strategies. This lack of direction means that very little common ground or examples of effective practice can be disseminated.
| There is a need for an alliance of organisations promoting physical activity and health. Such an alliance needs to address the demand for strategic direction in the promotion of physical activity and particularly in the case of obesity.
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3. In schools a clear infrastructure through the School Sport Co-ordinator programme has been generated together with leadership from the Youth Sport Trust and Sport England. When this programme is up and running with more schools there will be an opportunity at local level to promote programmes which raise participation levels to a more acceptable standard. However, the Partnership Development Managers (PDM) may not see their role as addressing the growing problem of obesity in young people. Thus, there is a need to identify ways in which this can be addressed. Increasing the levels of participation in regular physical activity of obese and overweight young people must be seen as a key priority.
| Partnership Development Managers (PDM) need to recognise their role in raising participation levels and demonstrate that schools in their partnership have taken steps to provide opportunities for all obese young people to engage in more frequent physical activity (at least 60 minutes per day on most days of the week).
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| 4. The Sure Start programme operates in disadvantaged communities but needs to be mainstreamed. This initiative has the potential to provide insights into how organisations and health professionals work with families to promote more physical activity and address problems such as obesity. In the same way that we need to provide appropriate support to the School Sport Co-ordinator Programme, we should ensure that similar support is provided for infrastructures that can reach young families in all communities and promote more frequent physical activity.
| The role of physical activity in promoting better health and reducing levels of obesity in children between one and four needs to be recognised by all organisations working with children and their family. Practical suggestions for promoting physical activity should be easily accessible.
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5. The School Sport Co-ordinator and Sure Start programmes will generate a better, more co-ordinated programme for raising participation levels. However, we need to closely examine what the community can contribute to these initiatives with both young people and adults. What can active recreation services, youth service, faith communities, Primary Care Trusts etc contribute to a co-ordinated programme that addresses the need to increase participation levels and address the obesity problem.
| We need to provide these organisations with a support structure that will enable them to promote more physical activity, monitor their successes and provide us with learning about what works in practice.
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6. In the same way that an infrastructure with clear leadership has been established for schools to address participation levels with young people, there is a need to generate an infrastructure for post-16 young adults. The 1998 Health Survey for England clearly shows that obesity figures for males in the 25-34 age range triple from the 15-24 age range. At no time does a similar increase occur. There are many reasons for this sudden rise but physical activity levels are reduced considerably.
| The rapid increase in male obesity amongst the 24-35 age range needs to be addressed. An infrastructure based on leisure and recreation services needs to recognise its role in increasing physical activity for adults and ensuring that opportunities to engage in physical activity are clearly publicised and available to all workplaces, local community settings and Primary Care Trusts.
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7. One of the main mechanisms for promoting more physical activity is to change legislation to ensure that recreation services are a statutory responsibility rather than a discretionary service within local authorities. This will ensure better access to active recreation opportunities at local level. At present substantial funding is being directed into schools via NOF and other government funding bodies but we are losing out on adult facilities. This paradox needs to be addressed.
| Ensure that facility provision for young people is matched for adults.
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8. Primary Care Trusts (PCT) are addressing the obesity issue in different ways but it would be useful if they could have clearly defined challenges for each PCT and for individual Partnerships. A rough calculation of national obesity figures could be translated into the following figures:
| Each PCT needs to:
Set a challenge for each GP Partnership to increase by 5% (44 patients) the number of obese patients undertaking at least 150 minutes of moderate physical activity on most days of the week to generate health benefits
Set a challenge for each GP Partnership to show that 2% (18 patients) of their obese patients have significantly reduced their weight.
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Getting 5% of Obese Population to undertake at least 150 minutes of moderate physical activity on most days of the week.
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Identify the number of obese people who are reducing their weight by 10% and maintaining it over a 12 month period.
| | | |
Total Obese
(15-84 years)
7,737,503
| 5% of total
386,875 | Challenge
| |
Primary Care
Trusts | 302
| 1,281 per Trust | |
| Partnerships | 8,817 | 44 per
Partnership
| |
| Addressing these figures would enable Primary Care Trusts to demonstrate their effectiveness but signal also a deliberate policy to reduce overall obesity levels. More precise figures can be identified using local population data.
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| These action points represent only a starting point because a great deal more needs to be done to ensure that physical activity promotion can play a more significant role in obesity reduction and the promotion of better health well-being for everyone.
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| On 2 September a television programme (Channel 4: 9 pm) transposed today's students to a 1950s boarding school lifestyle for four weeks: with physical activity (60 minutes) every day and a 1950s diet there was substantial weight loss which pleased all the students. The implications of this programme are worth considering.
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Annex 1
Exercise Recommendations
The basic questions that need to be answered are the following:
"How does the ordinary person in the street know how much physical activity to do for their health?"
and
"How can we help him or her to do more physical activity each day?"
We have been unsuccessful in effectively communicating the answers to these questions.
At present the advice to the person in the street is to do the following:
Young people
| Adults |
Recommendation
60 minutes of moderate physical activity on most
days of the week
Highlight how to segment the day into separate
parts when activity can be undertaken and
provide cues as to what young people can do.
Opportunities:
Morning:
Walk the dog
Do a paper round
Walk (or cycle) to school (with siblings,
friends, parents)
Attend pre-school morning clubs
Be active at break time
Afternoon:
Be active at lunch time (playground activities
or club activities)
Walk home (pupils who walk home tend
to play more)
Attend out of School Hours clubs
Play at home (inside or out)
Evening:
Join a sports club
Attend youth service activities
Evening walk
Play out with friends (summer or good weather)
Promote more structured physical activity at
week-ends.
Reduce sedentary behaviour in the evenings
and week-ends.
60 minutes is 4.2% of a day: 6.2% of a waking day
| Recommendation
At least 150 minutes per week or 30 minutes of moderate activity on most days of the week.
Highlight how to segment the day into separate parts when activity can be undertaken and provide cues as to what adults can do.
Opportunities:
Morning:
Walk the dog
Park the car and walk to work
Get out of a public vehicle one or two stops early and walk to work
Go to the leisure club for physical activity
Afternoon:
Walk at lunch time
Go to the leisure club for physical activity
Gardening
Evening:
Sports club
Go to the leisure club for physical activity
Evening walk
Gardening
Take every opportunity to walk up stairs rather than take the lift or escalator
Promote more structured physical activity at week-ends.
Reduce sedentary behaviour in the evenings and week-ends.
30 minutes is 2.2% of a day: 3.2% of a waking day
|
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WHAT DO
WE NEED?
A national Co-ordination team who can generate a communication
strategy which provides clear guidance on:(a)how much physical
activity/exercise will generate health benefits, how much is appropriate
and how such messages can be tailored and individualised to account
for the variety and range of individual needs and circumstances;
(b)how to encourage the irregularly active to do more and accomplish
150 (5 x 30) minutes of moderate activity each week;
(c)how to reach sedentary populations and attract them to regular
physical activity/exercise; and
(d)how to support a commitment to physical activity/exercise and
maintain it over long periods. Annex 2Health Select Committee:
Obesity Summary of Action StepsWe need:(1)A National Strategic
framework which acts as a driver for local action. There is a
National Strategy for Physical Education and Sport which will
provide a driver for the School Sport Co-ordinator programme to
implement local action and raise participation levels of young
people. The value of this process needs to be monitored closely
so that it can inform plans for promoting more physical activity/exercise
for adults.(2)A National Alliance of Organisations who can help
to deliver initiatives at local level for adults.(3)A national
Co-ordination team who can generate a communication strategy which
provides clear guidance on:(a)how much physical activity/exercise
will generate health benefits, how much is appropriate and how
such messages can be tailored and individualised to account for
the variety and range of individual needs and circumstances;(b)how
to encourage the irregularly active to do more and accomplish
150 (5 x 30) minutes of moderate activity each week;(c)how to
reach sedentary populations to attract them to regular physical
activity/exercise;(d)how to support a commitment to physical activity/exercise
and maintain it over long periods.To tackle the obesity problem
we need to:(1)Ensure that:(a)an infrastructure to promote physical
activity/exercise is in place;(b)an alliance of organisations
who can deliver relevant innovations at local level, and(c)appropriate
physical activity/exercise guidance is available for the public
together with physical activity/exercise and health professionals
are in place before we can successfully tackle obesity in the
long term.(2)In the short term, we need to provide comprehensive
and authorative advice on how Primary Care Trusts (PCTs) can take
immediate action to (1) promote more physical activity/exercise
with obese patients so that they can gain relevant health benefits,
and (2) reduce the weight of obese patients. The progress of this
work needs to be monitored so that we can learn about the successes
(or failures) of their implementation and what lessons can be
learned which can inform the practice of others.
Memorandum by Sustain (OB 84)
1.BACKGROUND
Sustain advocates food and agriculture policies and practices
that enhance the health and welfare of people and animals, improve
the working and living environment, enrich society and culture
and promote equity. We represent over 100 national public interest
organisations, and are independent from the agri-food industry.
Current work includes:—Promoting citizens' participation
in policy-making processes;—Reforming UK farming and food
systems, CAP and WTO;—Tackling food poverty;—Promoting
five portions of fruit and veg a day;—Facilitating a sustainable
London food economy;—Encouraging sustainable food supplies
in public sector catering; and—Improving food labelling
and marketing practices.This evidence is offered on behalf of
the organisations supporting our campaign to protect children
from unhealthy food advertising. At time of writing 83 national
organisations (see attached) supported our policy statement calling
on "the UK Government to introduce legislation to protect
children from advertising and promotions, targeted directly at
children, which promote foods that contribute to an unhealthy
diet" (see http://www.sustainweb.org/labell-protect.asp).
2.THE HEALTH
IMPLICATIONS OF
OBESITY
Sustain understands that the health implications of obesity have
been well-covered in evidence by others to the Committee so will
not repeat them here. However, it may be worth emphasising that
if, as a result of obesity, a young person becomes diabetic, they
will have the disease for life and the medical complications of
this condition (such as blindness, and risk of limb amputation)
become more serious, the longer the person has diabetes. This
contrasts with smoking where, after being smoke-free for several
years, the health risks diminish and, at a certain point, resemble
those for a non-smoker. In other words, the risks of smoking are
potentially reversible, whereas some of the health risks associated
with obesity are permanent.
3.TRENDS IN
OBESITY
As above, Sustain understands that the trends in obesity have
been well-covered in evidence to the Committee by other expert
organisations so will not repeat the evidence here. We are not
aware of any organisation that challenges the view that obesity
can cause serious damage to health and well-being, and there appears
to be few countries in the world where obesity rates are falling.
4.WHAT ARE
THE CAUSES
OF THE
RISE IN
OBESITY IN
RECENT DECADES?
Sustain acknowledges that obesity has a complex range of causes
but notes that, commonly, these are summarised as consumption
of energy from food and drink in excess of physical requirements.
Due to Sustain's remit (see "Background" above), our
evidence must focus on only one part of that equation—consumption
of energy from food and drink. We agree, of course, that there
would be a wide range of health and other benefits if more people
were more physically active, more regularly. However, a good deal
of effort is being expended, principally by the food industry,
on promoting the view that measures to tackle obesity should focus
mainly on physical activity and not on food and drink. We disagree
with this false dichotomy.Energy and fat consumption is falling?Although
official government figures indicate that energy and fat consumption
may be falling, it is also widely acknowledged that these figures
underestimate actual consumption for two reasons. First, the data
do not adequately capture the volume and type of food and drink
eaten outside the home. This is becoming increasingly problematic
as it is broadly agreed that the proportion of a person's daily
diet eaten outside the home is high and rising. There is also
evidence that the type of food eaten outside the home is higher
in fat (and, therefore, higher in energy) than that eaten at home,
compounding the problem of this "missing" evidence.
Second, evidence indicates that people routinely under-report
their consumption in surveys, and that this under-reporting may
be as high as 20% of their total energy intake[1].A
further indication of the scale of this problem comes from data
analysed by the Food Commission[2].
Industry sales data for confectionary in the mid-1990s indicated
some 250 grams sold per person per week, whereas adults' reported
consumption was only around 80 grams per person per week. Similarly,
industry sales data for soft drinks showed consumption at 2,300ml
per person per week in the mid-1980s, but self-reported consumption
at 800ml.It is possible that the problem of under-reporting is
higher in children, and that this problem is compounded by the
volume of fatty and sugary snacks eaten by children outside the
home. Thus energy and fat consumption may not be declining and
may actually be rising.
5.WHAT CAN
BE DONE
ABOUT IT?
Although we have been asked to focus our evidence on childhood
obesity and on schools, we would like to emphasise to the Committee
that this forms only one part of the much broader problem of the
"toxic environment"[3]
which predisposes to obesity, in which we all now live. In this
context we believe government should eliminate this toxicity for
children by both:—reducing negative influences on children's
diets, particularly "junk"[4]
food marketing, through whatever media; and—enhancing positive
influences on children's diets, particularly food education and
provision in schools.Protecting children from unhealthy food
marketingOur rationale for calling on government to regulate
to protect children from unhealthy food marketing is summarised
in the document referred to in the "Background" section
above. However, we would draw particular attention to the fact
that the brand awareness resulting from marketing hits low income
families particularly hard, in two ways. First, parents often
try to make ends meet with cheaper, non-branded goods, but risk
upsetting their children (and having uneaten food) as children
are keen to avoid being stigmatised by "cheap" products.
Second, if parents try to help their children "belong"
by purchasing the same branded products as their children's friends,
then this takes a bigger slice out of a budget that is already
fully stretched.[5] Thus
legislation to protect children from unhealthy food marketing,
through whatever media (including in schools), would contribute
not only to improving children's health overall, but also to reducing
health inequalities.Food education and provision in schoolsSome
of the negative influences of marketing could, potentially, be
mitigated by high quality food education and food provision in
schools. Private companies have even sponsored an initiative—Media
Smart—that claims to help children understand advertising.
Leaving aside that Media Smart confirmed that food and nutrition
was not covered as a specific issue in their programme[6],
the effectiveness of the initiative has, as far as we are aware,
not been independently monitored or evaluated. Moreover, it remains
highly debatable that, even if children can "understand"
advertising and marketing, this makes them a legitimate target
for this activity. This is not to say that high quality media
literacy has no value. Some voluntary organisations have produced
some excellent curriculum materials[7],
but they are far from universally used.In addition, many schools
no longer teach domestic cooking and food budgeting skills. Food
technology is included in the National Curriculum under the remit
of Design and Technology. The curriculum for Food Technology includes
learning about food preparation and handling skills, food hygiene,
analysing existing products and designing and making food products.[8]
Up until the age of 11, Food Technology is compulsory; thereafter
it is not statutory, the time dedicated to food technology is
not stipulated, and the method of teaching is not specified. For
many children therefore, their learning about food is through
theoretical study with little opportunity to find out where food
comes from or practice cooking skills. Indeed the Qualifications
and Curriculum Authority state that: "As there is a technological
focus to the subject rather than a domestic one, there is an emphasis
on manufacturing and processing of food rather than practical
cooking skills, nutrition and health. . ."[9].
Concerned teachers report that many children are more likely to
learn how to design a pizza box and food marketing campaign than
they are to learn how to put together a healthy meal from fresh
ingredients. [10]Even
those who may get the chance to pick up food knowledge and skills
often find the messages about health undermined by what gets served
for school lunches or is available in vending machines and tuck
shops.[11] Although the
Government established minimum nutrition standards for school
meals in April 2001[12]
there is no requirement to monitor these standards. Reports of
poor nutritional quality tend to be anecdotal, although one study
has examined the issue and found low standards[13].
It is difficult to see how nutritious meals can be provided routinely,
when some schools are required to produce two course lunches while
spending only around 40p or less per child on the ingredients
for the meal[14]. Moreover,
vending machines and other snacking services are not covered by
the nutrition guidelines and, although a minority of schools use
these to sell healthy snacks, the majority focus on raising much
needed funds by selling fatty, sugary or salty products.It does
not have to be like this. Sustain has recently completed the pilot
phase of the Grab 5! project to increase fruit and vegetable consumption
among primary school children, particularly those in low income
areas. The evaluation report[15]
indicates that the integrated, whole school approach to the project—incorporating
curriculum work, offering fruit and veg in the context of wide
variety of events, and involving the wider community—has
been successful in significantly increasing consumption of fruit
and vegetables, and also in reducing consumption of high fat snacks.We
recommend, therefore, that the Health Committee urges the Government
to:—stipulate that an integrated school food policy, along
with mechanisms for implementing it, become part of OFSTED's inspection
criteria;—introduce curriculum requirements that ensure
that all children leave school with food knowledge and skills
which will equip them to choose a healthy and sustainable diet;—increase
the funding available to school food services (including vending,
tuck shops and other services as well as meals) and specify arrangements
(such as regular monitoring and, if necessary, penalties) for
ensuring these meet high health and environmental standards.
6.ARE THE
INSTITUTIONAL STRUCTURES
IN PLACE
TO DELIVER
AN IMPROVEMENT?
Despite the very wide range of initiatives to try to improve the
social (including health) and environmental sustainability of
the farming and food system by the public, private and voluntary
sectors, at present the whole of these efforts amounts to very
much less than the sum of the parts. Indeed government's own policies
are often mutually inconsistent. One recent example illustrates
the case: Richard Caborn, Sports Minister, publicly welcomed the
Cadbury's Get Active initiative whereby children are encouraged
to collect tokens from chocolate wrappers in exchange for sports
equipment for schools. The Food Commission calculated that to
obtain a "free" basketball worth around £10, some
£71 would need to be spent on 170 chocolate bars. A child
would have to play basketball for 90 hours to expend the 40,000
calories and 2kg of fat from that amount of chocolate. Meanwhile,
the Department of Health made no public comment on the matter,
the Department for Education and Skills could see no problem with
the scheme and only the Food Standards Agency helpfully and publicly
expressed its disappointment with the initiative.Depressingly,
this incident took place this year, only two years after the National
Audit Office report on obesity had called for stronger guidance
to schools about commercial initiatives like these that could
run counter to public health. National Food Policy Councils, and
similar bodies at regional and local level, have been successful
in taking an integrated approach to improving diets and reducing
heart disease rates in several Scandinavian countries[16].
There are several agencies that could take on this role in the
UK, each with their own merits. Whatever the pros and cons of
the various options for a UK Food Policy Council or similar body,
Sustain is clear that there is a long-overdue and pressing need
for a food policy co-ordination mechanism.
7.RECOMMENDATIONS FOR
NATIONAL AND
LOCAL STRATEGY
Our summary of the recommendations made under 5 and 6 above is
as follows:—Establish a national food policy council to
take an integrated approach to the development and implementation
of a sustainable food and agriculture system.—Introduce
legislation to protect children from the promotion of unhealthy
food, through whatever media.—Make an integrated school
food policy, along with mechanisms for implementing it, part of
OFSTED's inspection criteria.—Introduce curriculum requirements
that ensure that all children leave school with food knowledge
and skills which will equip them to choose a healthy and sustainable
diet.—Increase the funding available to school food services
(including vending, tuck shops and other services as well as meals)
and specify arrangements (such as monitoring and, if necessary,
penalties) for ensuring these meet high health and environmental
standards.
Annex
Protecting children from unhealthy food advertising
Support confirmed (as at 24 July 2003) in writing from:Action
Against Allergy Foundation for Local Food Initiatives
Allergy Alliance General Consumer Council for Northern Ireland
Arid Lands Initiative Gingerbread
Autism Unravelled Guild of Food Writers
Baby Milk Action Haemolytic Uraemic Syndrome Help (HUSH)
Biodynamic Agricultural Association Health Education Trust
Blood Pressure Association Human Scale Education
British Allergy Foundation Hyperactive Children's Support
Group
British Association for Community Child Health International
Society for Food Ecology and Culture
British Association for the Study of Community Dentistry Land
Heritage
British Cardiac Society Latex Allergy Support Group
British Dental Association Maternity Alliance
British Dietetic Association McCarrison Society for Nutrition
and Health
British Heart Foundation Migraine Action Association
British Heart Foundation Health Promotion Research Group National
Children's Bureau
British Hypertension Society National Council of Women
British Institute for Allergy & Environmental Therapy National
Consumer Council
British Society for Cardiovascular Research National Consumer
Federation
Centre for Food Policy National Federation of Women's Institutes
Chartered Institute of Environmental Health National Heart
Forum
Child Growth Foundation National Obesity Forum
Child Poverty Action Group National Oral Health Promotion
Group
Children's Society Northern Ireland Chest, Heart and Stroke
Association
Coeliac UK Positive Parenting
Co-operative Group (CWS) Ltd Royal College of General Practitioners
Community Health UK Royal College of Physicians
Community Nutrition Group Royal College of Surgeons
Community Practitioners' and Health Visitors' Association Royal
Institute of Public Health
Consensus Action on Salt and Health (CASH) Royal Society for
the Promotion of Health
Coronary Artery Disease Research Association Scottish Heart
and Arterial Disease Risk Prevention
Coronary Prevention Group Soil Association
Day Care Trust Soroptimist International of Great Britain
Diabetes UK Stroke Association
Digestive Disorders Foundation TOAST (The Obesity Awareness
& Solutions Trust)
Elm Farm Research Centre UK Public Health Association
Faculty of Public Health Medicine UNISON
Family Heart Association Vega Research
Family Welfare Association Weight Concern
Federation of City Farms and Community Gardens Welsh Food
Alliance
Food and Chemical Allergy Association World Cancer Research
Fund
Food Commission Young Minds
Food and Health Research
1
Department of Health presentation on 28 July 2003 to the National
Forum of Non-Governmental Public Health Organisations. Back
2
"Are the calorie counters getting it wrong?" The
Food Magazine, Issue 62, July/September 2003. Food Commission:
London. Back
3
Ebbeling, C B, Pawlak, D B, Ludwig, D S. "Childhood obesity:
public-health crisis, common sense cure" pp 473-482. The
Lancet, Vol 360, 10 August 2002. Back
4
The term "junk" is used as a shorthand to describe food
and soft drinks which are high in one or more of the following
nutrients-fat, saturarated fat, trans fats (artificially hydrogenated
fat), sugar, and salt-are low in fibre and micronutrients, such
as vitamins and minerals-and often contain artificial colourings,
flavourings and sweeteners. Back
5
Watson, A et al (2002). Hunger from the Inside: The experience
of food poverty in the UK. Sustain: London. Back
6
Personal communication with the Food Commission (2002). Back
7
Seeing through the spin. Education pack (undated). Baby
Milk Action: Cambridge. Back
8
Department for Education and Skills (2000). National Curriculum. Back
9
Personal communication with Sustain (2002). Back
10
Personal correspondence with the Food Commission (2002). Back
11
SNAG: www.healthedtrust.com/pages/SNAG.htm. Back
12
www.dfes.gov.uk/schoollunches. Back
13
J C Marsh, Assessing the Implications of the New Food-Based
Nutritional Standards for School Meals, School of Biomedical and
Life Sciences, University of Surrey, March 2002. Back
14
Vann L, School Meals: There is an alternative. Guild of
Food Writers, 2003. Back
15
British Heart Foundation Health Promotion Research Group (In press).
Evaluation of the Sustain Grab 5! school fruit and vegetable project.
Oxford. A summary is available at http://www.sustainweb.org/pdf/g5-evaluation.pdf. Back
16
Lang, T. Intersectoral Food and Nutrition Policy Development:
A Manual for Decision Makers. 2001. Centre for Food Policy.
Thames Valley University. Back
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