Select Committee on Health Minutes of Evidence

Memorandum by Len Almond, Director, BHF National Centre for Physical Activity and Health, Loughborough University (OB 26)

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.

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.

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).
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.

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.

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.

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.

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.

Getting 5% of Obese Population to undertake at least 150 minutes of moderate physical activity on most days of the week.

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)


5% of total

Primary Care
302 1,281 per Trust
Partnerships8,81744 per
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.

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.
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.

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?"


"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

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.



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


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)


Join a sports club

Attend youth service activities

Evening walk

Play out with friends (summer or good weather)

Promote more structured physical activity at


Reduce sedentary behaviour in the evenings

and week-ends.

60 minutes is 4.2% of a day: 6.2% of a waking day

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.



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


Walk at lunch time

Go to the leisure club for physical activity



Sports club

Go to the leisure club for physical activity

Evening walk


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


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)


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


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.


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.


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.


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.


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.


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.


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: Back

12 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 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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