House of Commons - Health - Minutes of Evidence

Select Committee on Health Minutes of Evidence

Memorandum by the UK Public Health Association and Faculty of Public Health Medicine (OB 6)

JOINT SUBMISSION TO THE HOUSE OF COMMONS HEALTH COMMITTEE INQUIRY ON OBESITY

The UKPHA is an independent, UK-wide voluntary organisation which brings together individuals and organisations from all sectors who share a common commitment to promoting the public's health.

The UKPHA has three priority objectives: Combating health inequalities. Promoting Sustainable Development and Challenging Anti-health forces.

The Faculty of Public Health Medicine of the Royal College of Physicians aims:

(1) To promote, for the public benefit, the advancement of knowledge in the field of public health.

(2) To develop public health with a view to maintaining the highest possible standards of professional competence and practice, and to act as an authoritative body for consultation in matters of education or public interest concerning Public Health.

The form of this submission is to follow through the questions posed by the Committee in the pursuit of its Inquiry. The UKPHA and FPHM in their submission to the Inquiry will attempt to address each of the points set out in the covering brief and is prepared to make other forms of submission to the Inquiry and supply supplementary evidence, as requested.

*The health implications of obesity

What are the health outcomes of obesity in society? What are the economic and social costs? What efforts is the Government making to evaluate these?

1. Obesity is an excess of body fat frequently resulting in a significant impairment of health and longevity. For adults levels of overweight and obesity are generally established through the calculation of body mass index:

BMI = Body wt in Kg/(Ht in m)2

An overweight adult is usually defined as one with a BMI between 25 and 29.9, while an obese adult has a BMI of 30 or higher. It is useful to determine of a gradient body weight, from low to high, together with associated health risks.

CLASSIFICATION OF OVERWEIGHT AND OBESITY IN ADULTS ACCORDING TO BMI OBESITY IS CLASSIFIED AS BMI>30 kg/m2.

Classification	BMI (kg/m2)	Risk of co-morbidities
Underweight	<18.5	Low (but risk of other clinical problems increased)
Normal range	18.5-24.9	Average
Overweight	25.0-29.9	Mildly increased
Obese	>30.0
Class I	30.0-34.9	Moderate
Class II	35.0-39.9	Severe
Class III	>40.0	Very severe

2. The implications of obesity for mortality and morbidity are now widely understood. The pattern of excess mortality variation with relative weight is illustrated in men ages 15 to 39 in the following chart:[1]

Weight Relative to Average Weight

Mortality Ratio

65-75% 105%

75-95 93

95-105 (average) 95

105-115 110

115-125 127

125-135 134

135-145 141

145-155 211

155-165 227

3. The WHO projects that, by 2020, chronic diseases will account for almost three-quarters of all deaths globally, and that 71% of deaths due to ischaemic heart disease, 75% of deaths due to stroke.[2] There is a strong association between the prevalence of obesity and CVD risk factors. American evidence suggests that the prevalence of reported diabetes is 2.9 times higher in overweight than non-overweight persons. According to WHO 58% of diabetes mellitus, 21% of ischaemic heart disease and between 8-42% of certain cancers were attributable to BMI greater than 21kg/m2. WHO currently attributes one-third of all global deaths (15.3 million) to CVD, with developing countries, low-income and middle-income countries accounting for 86% of the DALYs attributable to CVD lost worldwide in 1998. Nevertheless, the full economic and social picture of nutrition-related and physical activity linked disease is by no means complete, although for the UK the National Audit Office's 2001 review (in England)[3] is a firm starting place. To develop a national picture of the issues, including the means to tackle them, it is important that further research is undertaken on a collaborative basis supported by the Departments of Health, the Treasury (perhaps incorporating in the current Treasury Review), specialist charities and researchers in the public health community. A Public Health Research Collaboration is one such model. This activity requires a major reorientation of research and development activity by national research bodies and the NHS to upstream factors and alternative policy pathways, as for example, the Fully Engaged Strategy as set out in Securing our Future Health (Wanless Report).[4]

4. What must be stated firmly is that preventing obesity and overweight requires a "whole society approach"; it is not simply, or even primarily, a medical matter, although the NHS can be helpful in dealing with a range of dietary or lifestyle problems and can assist with the diseases associated with obesity and overweight.

RECOMMENDATION

Securing our Future Health.

*Trends in obesity

What are the trends in obesity (including trends among particular groups, by social class, age, gender, ethnicity and lifestyle? What is the relationship between obesity and other health inequalities? What are the international comparisons? (EU, OECD, USA)?

5. Warnings of the impact of obesity are not new. In 1974, an editorial in the Lancet identified obesity as "the most important nutritional disease in the affluent countries of the world."[5] However only recently have such warnings mobilised official concern. Even so, the analytic and policy representations of this issue remain fed through a generally narrow media narrative due to a variety of factors: the immense lobbying power of the food industry, the attention in discussions of weight to give attention to personal appearance rather than health, the individualistic nature of the discourse around diet (and dieting) and health, and the inability of commentators to address the structural changes in society which, more so than individualistic factors, explain the patterns of diet and exercise, and consequential health effects, facing local populations. These latter influences range from changes in transport modes, entertainment, cultural and behavioural change, the reshaping of childhood an the empowerment of childhood "choice", the consequent underdevelopment of "health protection" for children in the light of the commercialisation of culture, and governmental involvement in private public partnerships which fail to fully address health consequences.

6. In low-income countries, obesity is more common in urban areas and amongst people of higher social class. In more the developed or more affluent countries, obesity has been common in older age groups, particularly women, though is becoming increasingly common in poorer populations. However, over several decades a new pattern has formed based upon spectacular increases in weigh across the population, allied to changes in food and drink consumption and lifestyle changes. These trends are shown into sharp relief in the US in particular and seem related to a pattern of social, economic and cultural changes in that country. These bear examination, in part because of the spread of US culture to the UK, but also because of governmental and commercial responses which may provide lessons for the UK and Europe. As a WHO expert group has noted: "In many countries, perhaps most typified by the USA, changes in family eating patterns and the consumption of fast foods, pre-prepared meals and carbonated drinks, have taken place over the past 30 years. Likewise, the amount of physical activity has been greatly reduced both at home and in school, as well as by increasing use of mechanized transport."[6]

7. Health care costs in the US. Health economics has poorly addressed public health issues. The traditional preoccupation of American health economists has not been with the determinants of health—such as diet or level of exercise, or the social and economic costs of avoidable illness—but rather health care costs, more accurately the costs of the medical care system, which are now nevertheless linked overwhelmingly to lifestyle based chronic diseases. One explanation for the dearth of such studies that the causes of ill-health, and the economic calculation of the field of effects, are often complex and require explanations outside the realm of health economics, as traditionally conceived; in contrast, data on medical costs is easily available and relatively clear-cut, particularly in a country where cost accounting for medicine is so well developed. What is known is that health care spending in the United States will reach $2.8 trillion in 2011, up from $1.3 trillion in 2000, and it is growing at an average annual rate of 7.3%. Expressed as a percentage of Gross Domestic Product (GDP), spending is expected to reach 17% in 2011, up from 13.2% in 2000.[7] (Also bear in mind that almost 40 million Americans in 2000—approximately 14% of the population, remain outside health insurance.) This projected level of spending will produce a heavy burden on the US economy, since the majority of costs are born by employers and the federal and state governments. Expenditures on prevention in the US are a tiny fraction of the amount spent on medical care, and, apart from the recent injection of funds due to fears of bio-terrorism, have been falling over the last 20 years.

8. Within this picture the total economic burden of CVD has officially been estimated at $498 billion for 2001, accounting for 61% of all health care spending. In 1998 CVD claimed nearly 1 million lives and accounted for 40% of all deaths. Current estimates are that more than 60 million Americans have one or more types of CVD. According to the US Surgeon General, approximately 300,000 U.S. deaths a year currently are associated with obesity and overweight (compared to more than 400,000 deaths a year associated with cigarette smoking). The total direct and indirect costs attributed to overweight and obesity amounted to $117 billion in year 2000—around 10% of total health care costs.[8] One recent study has suggested that obesity is associated with a 36% increase in inpatient and outpatient spending and a 77% increase in medications, compared with a 21% increase in inpatient and outpatient spending and a 28% increase in medications for current smokers and smaller effects for problem drinkers.[9] Other US research has indicated that there is a clear association between body mass index and health care costs, largely due to the link between BMI and coronary heart disease, hypertension, and diabetes, on a range between 25% greater and 44% greater, depending of level of BMI.[10] In 1998, there were some 400,000 liposuction procedures in the United States. Over 100,000 Americans per year now receive gastric bypass surgery, the "last ditch" technique for halting further symptoms, such as those associated with diabetes.[11] The total cost of such surgery, ranging from $17,000 to $45,000 per operation, is very considerable, with US total expenditures on obesity treatment exceeding the total health care expenditures of many developing countries, where of course obesity is almost totally absent. Nevertheless it does not seem that the growing numbers of US citizens who are overweight and obese has appeared within overall longevity trends.

9. Between 1991 and 2000, obesity levels in the US, according to the accepted definition, rose 60%. About 61% Americans are overweight and one in five is obese. 13% of children ages 6-11 and 14% of those 12-19 were "seriously overweight" in 1999. If attention has now focused on obesity, rather than CVD generally, it is partly because of its sheer visibility as an outward sign of the problems associated with diet and sedentary lifestyle. In particular the rising consumption of energy-dense, micronutrient poor foods, which are high in fat (such as fried foods), sugar or starch has taken the place of energy-dilute foods with a high water content (such as fruits and vegetables). According to US Department of Agriculture data for 2000, the most recent available, the national food supply provided 280 pounds of fruit per person. Adjusted for losses and waste, that amounted to less than half the per person per day minimum consumption of fruit as recommended by the US Department of Health. Only 3% of the population meet at least four of the five government dietary recommendations for the intake of grains, fruits, vegetables, dairy products, and meats. In contrast consumption of added sugars reached 31 teaspoons per person per day, far above the six- to 18-teaspoon maximum recommended. Many of these sugars, for younger age groups, came from the consumption of soft drinks. As regards the latter there is a strong connection between rising consumption of these drinks and obesity.[12] Most of the evidence relates to soda drinks but many fruit drinks and cordials are equally energy dense and may promote weight gain if drunk in large quantities. In terms of physical activity less than one-third of Americans meet the federal guidance to engage in at least 30 minutes of moderate physical activity at least five days a week, while 40% of adults engaged in no leisure-time physical activity at all. Research has shown that there is a strong age, sex, ethnic and social class dimension to these both dimensions with "Latino" and Black communities seeing the most severe representation. However given that almost two in three Americans are overweight or obese the problem necessarily stretches across all social groups.

10. The rise in obesity contrasts with changing patterns of smoking prevalence, another determinant of CVD risk. US smoking rates have been cut roughly in half since 1964. Based on comparative treatment costs, the case is now being made to treat obesity with equal seriousness as tobacco has been by the government and by society generally. The significant fall in smoking rates is a positive sign that the determinants of health can be changed. It does not indicate, however, that the combination of approaches applied to tackling the tobacco epidemic will necessarily work for diet and sedentary lifestyle.

11. Europe, unlike the US, is divided by language and national histories, and therefore does not evidence a similar degree of cultural homogenisation as the US; nor is the conversion to the fast food/television entertainment lifestyle as pronounced. European data collection is also more diverse. Nevertheless, Europe too is witnessing changes in diet and physical activity in ways, which appear to follow the pattern set by the US. The result is shown in the varying prevalence of obesity across a number of European countries.

Prevalence of obesity (BMI > 30) in a selection of European countries

	% Men BMI > 30	% Women BMI > 30		% Men BMI > 30	% Women BMI > 30
England	17	20	France	9.6	10.5
Scotland	15.9	17.3	Germany	17.2	19.3
Italy	6.5	6.3	Finland	19	19
Sweden	10	11.9	Belgium	12.1	18.4
Netherlands	8.4	9.3	Denmark	10	9
Spain	11.5	15.2	Czech Republic	16.3	20.2
Russia	10.8	27.9
Table compiled by the IOTF, 1999.

12. The UK, like the US, shows growing, though comparatively recent, trends towards obesity and overweight as well as a strong age, sex, social class and ethnic dimension to the problem, as shown in the table. The issue of adult obesity and overweight has been much discussed but a major focus of any strategy should be on children. It is believed that levels of obesity in Britain are increasing at an appreciable rate in primary school children.[13] Surveys indicate little change was found in the prevalence of overweight or obesity from 1974 to 1984. From 1984 to 1994 overweight increased from 5.4% to 9.0% in English boys and from 6.4% to 10.0% in Scottish boys; values for girls were 9.3% to 13.5% and from 10.4% to 15.8% respectively.[14] BMI is not considered by many researchers to be a reliable measure for children and waist circumference has been used as an alternative measure. Research using this measure suggests that waist circumference in British youth has increased over the past 10-20 years at a greater rate than body mass index, the increase being greatest in females.[15]

13. Prevention costs are money well spent. Each year about 74 billion Euro are spent on treating cardiovascular disease (CVD) in the European Union. But CVD also costs an additional 106 billion Euro a year in lost production of goods and services because of premature death and disability. In total CVD costs the European Union about 180 billion Euro a year. (These estimates are based on four separate costs of disease analyses carried out for the UK, the Netherlands, Sweden and Germany.) The WHO also recommend that fat intake should be less than 30% of total energy but the dietary survey data shows that 21 out of 26 countries fail to meet this goal. There are paradoxes too, however. In Spain overweight for children aged six to seven is above that of the USA, while adolescent overweight levels are among the highest in the world. Nevertheless, CVD mortality is low, as with Italy and France, and the cancer mortality rate is lower than Italy and France.[16] Some European states, such as Sweden have taken child health protection seriously and have enforced an advertising ban on products sold to children. On food the Swedish National Institute of Public Health have reviewed the EU Common Agricultural policy and have issued important recommendations for reform. Their proposed recommendations include those with important implications for obesity and overweight, including: phasing out all consumption aid to dairy products with a high fat content, promotion of fruit and vegetables in schools, redistribution of agricultural support to favour the fruit and vegetable sector and increased consumption.[17] These policies bear closely consideration for adoption in the UK and EU-wide.

RECOMMENDATIONS:

— Overweight and obesity are worldwide problems, which require a global, European and UK-wide perspective. At the global level the UK should be fully involved in the development and implementation of the WHO strategy on Non-Communicable Diseases. At the European level it must be involved in the reform of the Common Agricultural Policy to stimulate reform based upon public health principles and lobby to ensure that health protection is given the highest prominence. At the UK level the Departments of Health across all four nations must take the lead to stimulate cross-governmental working.

— Investment must be made in prevention. The Chancellor should give consideration to extra taxation of high fat, high salt and high sugar processed foods and drinks. A hypothecated tax may be able contribute towards the costs of the National Fruit in Schools schemes and support further initiatives of this kind, particularly focussed on poorer communities.

*What are the causes of the rise in obesity in recent decades?

What has been the role of changes in diet? To what extent have changes in lifestyle, particularly moves to a more sedentary lifestyle, been influential? How much is lack of physical activity contributing to the problem?

14. The dietary evidence for good health is clear. The World Health Organisation (WHO) and the UK's Committee on Medical Aspects of Food and Nutrition (COMA) recommend eating at least five portions 400g) of fruit and vegetables a day.[18] The World Health Organisation have summarised a range of factors that might promote or protect against weight gain and obesity (see chart below).[19] It has been shown that consumption of antioxidant vitamins through dietary sources such as fruits and vegetables, oily fish and fibre from fruits and vegetables (in particular from cereals and grains) can protect against the development of CVD.[20] The key issues in maintaining weight control and improving health are not mysterious: a balanced and varied diet and an active lifestyle. Dieting should be avoided because it leads to behaviour swings rather than balance. Most people in Britain know this. Why therefore is the situation worsening?

Summary of strength of evidence on factors that might promote or protect against weight gain and obesitya

Evidence	Decreases risk	No relationship	Increases risk
Convincing	Regular physical activity High dietary intake of NSP (dietary fibre) b		Sedentary lifestyles High intake of energy-dense micronutrient-poor foodsc
Probable	Home and school environments that support healthy food choices for chidrend Breastfeeding		Heavy marketing of energy-dense foodsd and fast-food outletsd Sugar-sweetened soft drinks and fruit juices Adverse social andeconomic conditionsd (in developed countries, especially for women)
Possible	Low glyacemic index foods	Protein content of the diet	Large protion sizes High proportion of food prepared outside the home (developed countries) "Rigid restraint/periodic disinhibition" eating patterns
Insufficient	Increased eating frequency		Alcohol
a Strength of evidence: the totality of the evidence was taken into account. The World Cancer Research Fund schema was taken as the starting point but was modified in the following manner: randomised controlled trials were given prominence as the highest ranking study design (randomised controlled trials were not a major source of cancer evidence); associated evidence and expert opinon was also taken into account in relation to environmental determinants (direct trials were usually not available). b Specific amounts will depend on the analytical methodologies used to measure fibre. c Energy-dense and micronutrient-poor foods tend to be processed foods that are high in fat and/or sugar. Low energy-dense (or energy-dilute) foods, such as fruit, legumes, vegetables and whole grain cereals, are high in dietary fibre and water. d Associated evidence and expert opinion included.

15. The answer can be found in starkest form in the US. One leading culprit is the "fast food-high fat-soft drink" diet and the constant pressure on individuals to consume—which makes the attempt to secure a balanced diet socially deviant. According to Eric Schlosser in "Fast Food Nation", Happy Meals were introduced by McDonald's Corporation in 1979—just one year before childhood obesity rates began to climb. About 90% of America's children between three and nine years visit a McDonald's every month. In the US over the last 30 years average portion sizes in hamburger chains have doubled as well as has the consumption of fizzy, sugary drinks. In the case of the US schools are no longer protected areas and children are marketed to extensively—with McDonald's advertising budget alone exceeding one billion dollars. According to Fortune magazine $4.5 billion a year is spent by the food industry on advertising and $50 million a year is spent on lobbying in Washington, DC.[21] The US Surgeon General reported that that school foods had the highest saturated fat density of all food outlets. The key economic importance of screen based entertainment (television, videogames) and private motor transportation means that rates of exercise have declined.

16. British culture has been following the US in many respects. Young adults (aged 19 to 24 years) are the group most likely to have adapted to the new commercial cultural influences and to consume energy-dense fast foods, typically fried chicken, burgers, kebabs, savoury snacks, together high sugar carbonated soft drinks. One large government survey indicated that nearly two-thirds of men, and one-third of women, aged 19 to 24 years had eaten burgers and kebabs during the recording period, compared with one in 10 of the oldest group of men and women. Over half of all respondents, 54% of men and 57% of women, had eaten chocolate confectionery during the seven-day dietary recording period, and about a fifth, 20% of men and 25% of women, had eaten sugar confectionery. On the healthier food ranges 30% of men and 43% of women aged 19 to 24 years had consumed leafy green vegetables compared with 64% of men and 70% of women aged 50 to 64 years.[22] Data would appear to indicate that younger people are adopting less healthy diets than the older generation, and comment has already been made in the US that older people are getting on average healthier while younger people are experiencing substantial growth in asthma and diabetes.[23] The diet of the poorer people in the UK provides cheap energy from foods such as meat products, full cream milk, fats, sugars, preserves, potatoes, and cereals but has little intake of vegetables, fruit, and whole wheat bread. According to one assessment: "Households in the bottom tenth of the income distribution spend on average 29% of their disposable income on food (after allowance for housing costs); those in the top tenth spend 18%. In families with children, expenditure on food per person in the bottom fifth of income is extraordinarily low (£1.64/person/day in lone parent families). Low socioeconomic groups, however, buy more efficiently than high-income households : the bottom tenth spends far less on alcohol (£1.85/person/week v £7.73 in the top tenth) and sweets (£0.46 v £0.68). But these efficiencies lead to the purchase of foods richer in energy (high in fat and sugar) to satisfy hunger, which are much cheaper per unit of energy than foods rich in protective nutrients (like fruits and vegetables). The purchase of healthy options within mainstream eating patterns is likely to increase the food bill by 6-13%."[24] Food poverty must be part of the understanding of population weight gain, but it is only one. If health inequalities are to be tackled food poverty must be an essential component of the national strategy.

17. The other side of the coin to dietary problems is declining physical activity. There is a dispute, particularly present in the US, that the decline in physical activity is more significant for health than changes in diet, although this suggestion is most loudly voiced by organisations and researchers financially supported by the food industry. We suggest that both factors are important and that they are linked. In the UK there is ample evidence that rates of "passive exercise"—physical activity undertaken as part of everyday life—has declined. Government studies show that the number of trips per person on foot fell by 20% between 1985-86 and 1997-99.[25] The principal cause for the decline in walking was, as argued by the House of Commons Select Committee on Environment, Transport and Regional Affairs, that "the convenience and comfort of car travel; land use planning policies; the truly awful conditions for pedestrians; and increasingly the fear of being attacked or robbed. These factors are heavily influenced by the extraordinarily low status accorded to pedestrians. As a result walking is seen by many as the mode of transport for those who have no alternative".[26] It is probable that London's traffic congestion charge, which has reduced traffic levels in central London by 18%, will have also boosted levels of exercise by shifting people to public transportation and to walking. An implication that may be drawn is that policies, which make good sense on environmental grounds, also make good sense on health grounds. According to a briefing Parliamentary Office of Science and Technology, the facts behind the decline in physical activity are the following:

— Reduction in occupational physical activity.

— Greater use of the car.

— Decline of walking—personal safely especially of children women and older people.

— Increase in energy saving devices in public places—escalators, lifts automatic doors.

— Reduction in physical education and sport in some schools.

— Adults fears of childrens' safety in unsupervised play.

18. The result is that in the general population in England, only one-third of men meet the current guideline for recommended participation in physical activity. Within this general picture there is considerable variation by ethnicity and sex. Surveys using age-standardised ratios indicate that Black Caribbean men are more active than average and most other minority ethnic groups less than average, in particular Chinese and Bangladeshi men. For women however, only just over one in five of the general population met the guideline. Again, Black Caribbean women were more active, but other groups, Chinese, Indian, Pakistani, and Bangladeshi were far less active. The statistics on the Bangladeshi community are notable, Bangladeshi men are almost twice as likely than the general population to be classified as sedentary and Bangladeshi women almost three times.[28] A study commissioned by Sport England, showed that young people spend less time doing PE in school than they used to (in 1994, 46% did two or more hours per week compared to 33% in 1999).

19. One major feature of physical inactivity is the pervasiveness of screen-based entertainment in a variety of forms, ranging from television to computer games. There are two sides to the issue. People watching television are physically inactive: children who watch television five or more hours a day are five times as likely to be overweight as those who watch less than two hours a day. Time spent playing computer games and surfing the Internet is time lost playing outside and being physically active. Secondly, children watching television are influenced by food advertising, which is invariably linked to the unhealthier range of food products. Young children are unable to distinguish programme content from the persuasive intent of advertisements. It might be noted that parents are very concerned about the influences of television on their children. ITC research has noted: "There was a widespread belief that children are affected by advertising on television. This manifested itself through pester power, direct copying of behaviour, and a more subtle and gradual effect on attitudes. The concern was felt most strongly for children without much family support."[29] Television advertising to children makes food into "fun" and presents to them that food choices are "their choices" (in fact the advertiser's) rather than those of their parents.

RECOMMENDATION:

— A national strategy for obesity and overweight requires interventions right across society, engaging industry and the food sector, television and the media, schools, and communities.

*What can be done about it?

What is the range of "levers" and drivers (food industry, marketing, education, family life, genetics, drugs, surgery)? Within that range, what role can the food industry, marketing and advertising, transport, schooling play? What are the responsibilities of the food industry in respect of marketing? How influential is the media? How can the amount of physical activity being undertaken be increased? To what extent can and should Government, at central and local level, influence lifestyle choices? How coherent is national and local strategy? What is international best practice?

20. The food industry is not monolithic. Farmers and grower produce fruit and vegetables which should be consumed more, but which are in decline; but farmers and food processors, soft drink makers and other produce products which should consumed less, but which are profitable. In the case of the former advertising in minimal; in the case of the latter they are subject to high advertising budgets. It is particularly relevant and meaningful that numerous sports stars at the peak of activity are connected to products, which are unhealthy. The link between David Beckham and Pepsi Cola and Gary Lineker, former footballer and trusted commentator, and Walkers Crisps (also a Pepsi product) is symptomatic of the issue.

21. In the UK, the market for biscuits, chocolates and sugar confectionary alone in 2001 was £1.79 billion for biscuits, £3.89 billion for chocolate confectionery and £1.75 billion for sugar confectionery.[30] These are significant industries with significant advertising budgets. The advertising industry, for whom children's advertising is part of their staple income, naturally opposes advertising controls: "To advocate arbitrary restrictions on food advertising to children is to misunderstand fundamentally the role of advertising in the context of the media as a whole, family life, individual choice, programme funding and market competition."[31] Other organisations, such as the Social Issues Resource Centre, oppose more thorough restrictions on the food sector, such as taxation related to fat content. Coincidentally, this charitable organisation has received funding from Kelloggs, Mars, the Biscuit, Cake, Chocolate and Confectionery Alliance, HP Danone, the Sugar Bureau, among others. These companies "share SIRC's basic interest in promoting better understanding of health and social issues"[32] We merely observe that not all organisations which purport to offer advice to government or to the public do so in the interest of public health. There are many things that can be done working with industry. But the involvement of industry should operate within clear guidance and clearly set out principles, recognising that if industry is willing to finance public campaigns this partnership may undermine the independence of governmental advice and furthermore that its primary agenda is financial returns to investors

22. On the other hand, some parts of the food industry take the issue of obesity extremely seriously in the light of the threat of US-originated legal actions. Following massive legal actions brought by US States and consumers against the tobacco industry litigation has begun to focus on the link between fast foods and obesity, particularly around children. As Fortune magazine notes: "Fast food, snack food, and soft drink companies focus their marketing on children and adolescents through Saturday morning TV commercials; through cuddly characters like Ronald McDonald (the second most recognised figure among children after Santa Claus); through contracts to advertise and serve soft drinks and fast food in schools; and through ever-changing toys included in Happy Meals."[33]

23. This trend is a warning to the food industry and government. The assumption by much of industry is that it can it protect its interests by financially supporting physical activity initiatives, as in the case of Cadbury/Youth Sports Trust voucher scheme. Such schemes may ultimately be self-defeating in both publicity terms and in health terms, since critics point out that any benefits are reduced by the requirement of extra sales of high fat products.[34] The question for government support for such schemes is whether it is willing to split physical activity benefits from health losses due to the consumption of fatty foods. We must be emphatic: the state has a duty to protect the health of young people and should not place itself in the trading off benefit for losses; in any case, as noted, by nutrition and physical activity are mutually interrelated.

24. The rise of diet related disease in this new century may be as serious as recent (and continuing) epidemics, where the state was also slow to act—eg tobacco—and prevaricated over critical public health measures, such as advertising bans. In the case of food choices/dietary problems among young people, however, these tend to persist throughout life unless something is done in the earliest stages. Chronic disease risks frequently begin early in life (in fact in the womb). Adult chronic disease reflects cumulative differential lifetime exposures to damaging physical and social environments. A life course analysis indicates that actions can be taken from the earliest phase of life to its last phases: from the encouragement of breast feeding, for which there is increasingly strong evidence suggesting that a lower risk of developing obesity,[35] to old age, where exercise can appreciably influence a range of factors, from quality of life to risk of osteoporosis and reduced less risk of CVD.[36] There is a role for individuals and communities, for the commercial sector and for the state, but the respective interaction between each should be part of a national strategy and should not be decided on an ad hoc basis by one department of government (for example education or sports) without being part of an overall framework monitored either by the Department of Health or else through a cross-departmental body such as the Cabinet Office.

25. Individuals and communities have an important role to play in maintaining their health. Highly motivated individuals can significantly reduce the risk of becoming obese or their risks of developing type 2 diabetes through a daily brisk walk, by reducing the hours they watch television, or making minor adjustments to their diet.[37] [38]On the other hand for the population as a whole rejuvenating the household "food culture" or restoring exercise in their daily lives will not be easy—for reasons addressed by the earlier mentioned report of Commons Select Committee on Environment, Transport and Regional Affairs. British towns and cities have been increasingly redesigned for cars, leading to a life-threatening level of exercise deprivation. Our future health depends on creating neighbourhoods that are conducive to walking, strolling, running and bicycling. The challenge is to redesign our communities and to build in "health regeneration" into all schemes for town planning, making public transportation the centrepiece of urban transport, and augmenting it with bikeways or footpaths. This also means replacing parking areas with parks, playgrounds, and playing fields. Unless Britain can design society to systematically restore exercise to our daily routines, the obesity epidemic—and the health deterioration associated with it—will continue to spread. The House of Commons Health Committee will doubtless be presented with many examples of societies, not so dissimilar to our own, which give a far higher commitment to the dietary health of children, the "health protection" of children from advertising and the pervasive marketing of unhealthy foods, which build daily life around exercise, such as walking or cycling. Unfortunately there is no national debate over the potential for introducing these desirable features into British life. On the contrary, even public sector broadcasters like the BBC are more eager to make programmes on the virtues of driving fast cars, as ironically indicated by the expanding girth of their presenters. To the question of whether there is a coherent, government-wide, and economically and media grounded strategy, the answer must be that for diet (or for exercise) there is none.[39] This matter must be urgently redressed.

26. This response has suggested the usefulness of on international perspective on obesity and overweight, In the US official recognition of the severity of the economic, social and health costs of obesity has led the US Surgeon General to issue a Call to Action.[40] The US Surgeon General's strategies include the following:

— Ensure daily, quality physical education for all school grades. Currently, only one state in the country—Illinois—requires physical education (for school children) while only about one in four teenagers nationwide take part in some form of physical education.

— Ensure that more food options that are low in fat and calories, as well as fruits, vegetables, whole grains, and low fat or non-fat dairy products, are available on school campuses and at school events. A modest step toward achieving this would be to enforce existing US Department of Agriculture regulations that prohibit serving foods of minimal nutritional value during mealtimes in school food service areas, including in vending machines.

— Make community facilities available for physical activity for all people, including on the weekends.

— Create more opportunities for physical activity at work sites.

— Reduce time spent watching television and in other sedentary behaviours. In 1999, 43% of high-school students reported watching two hours of TV or more a day.

— Educate all expectant parents about the benefits of breast-feeding. Studies indicate breast-fed infants may be less likely to become overweight as they grow older.

— Change the perception of obesity so that health becomes the chief concern, not personal appearance.

— Increase research on the behavioural and biological causes of overweight and obesity. Direct research toward prevention and treatment, and toward ethnic/racial health disparities.

— Educate health care providers and health profession students on the prevention and treatment of overweight and obesity across the lifespan.

27. For the most part, these are sensible suggestions some of which have UK relevance. Unfortunately, these strategies are mostly at the level of exhortation and, without powers of implementation, resemble a wish list. In devising a UK strategy in the light of the challenge this implies that more than "modest steps" are needed.

RECOMMENDATIONS

— Advertising to children. There is a case to be made for proper analysis and action around the Health Protection needs of children. One part of this must be the review of restrictions on food advertisements. We propose that all advertising for foods during television programmes watched by children under the end of ten years should be halted. For older age groups the Department of Health and Food Standards Agency should formulate guidance with industry.

— The NAO 2002 report on obesity recommended that the Department of Health should lead the development of a new cross-Government strategy to promote the health benefits of physical activity. This is now promised. This must be focussed on matters far wider than encouragement of exercise and should be accompanied by guidance to planners across government and local authorities to stimulate a physical activity culture. Recognition should be given to the value of alternative forms of physical activity such as the Green Gyms programme.

— Transport and recreation policies promote, support and protect physical activity. For example, urban planning, transportation and building design should give priority to the safety and transit of pedestrians and safe bicycle use. Policy innovations range from congestion charging to reduced speed limits in urban areas. Safe routes to School programme rolled out to include all schools.

— Food in schools. Nutritional guidance on school meals neglects the general question of what children are actually eating in schools, the evidence being that they are eating unhealthy food—while under the supervision of the State. Greater regulation of free school meals to ensure that they provide a healthy meal for all recipients. Provision of free healthy breakfasts for all primary school children. All schools-based commercial promotions of foods should be ended and schools encouraged to adopt model school foods policies, which for, example, end the link between income generation and the operation of school tuck-shops. Price differentials should be introduced in schools to encourage the consumption of the healthier range of foods. Free drinking water should be provided in all schools to provide an alternative to carbonated sugary drinks.

*Are the institutional structures in place to deliver an improvement?

What is the role of the Department of Health (DoH) and of the NHS, including that of primary care, hospitals and specialist clinics? How effective are the structures for health promotion? Can health promotion compete with huge food sector advertising budgets? To what extent can the food industry be part of a solution? To what extent is the Food Standards Agency influential? How well is the DH liaising with, and what is the role of, other central and local government departments and bodies? What is the role of schools, including sport in schools? Who should "own" and, drive delivery? Have we the appropriate institutional structures, budgets and priorities?

28. All public authorities, including the NHS, Transport, Education, Defra, etc., as well as private bodies, ranging from public health to voluntary organisations, should fully address the seriousness of this new situation. What must be considered however, is the appropriate strategy they should adopt towards those companies and practices, which are "fattening the nation". The role of individual departments of government has to be set within an overall cross-governmental strategy led from the highest reaches of government, based on the advice of the Chief Medical Officer, in concert with the Department of Health and the Food Standards Agency. Many voluntary organisations and professional organisations can play a role, particularly in developing innovative programmes focused on young people (such as the NHF Young at Heart Campaign). It is essential that government is open to innovation from outside.

29. From the centre the Department of Health has devised a variety of schemes to improve nutrition in schools (principally the National Fruit in Schools Scheme) and is the Departmental Sponsor, with the Education Department, of Healthy Schools. The Five a Day initiative and other schemes, hold considerable promise—although we have witnessed two supermarket groups failing to offer their support. The bigger picture is that the Department's work faces almost insuperable odds: industry marketing of fatty, sugary or salty foods is far better funded and its marketing is far more influential, particularly at a time when centrally the Department of Health is being reorganised and personnel downsized by one-third. The critical issue for the Department is its capacity to provide leadership across government, in concert with the Food Standards Agency.

30. The NHS, within the general framework of the DH, has an extremely important role to play and National Service Frameworks should offer a strong guide to effective clinical practice. Primary care trusts in England, and their devolved counterparts, also have a role to play and leadership in nutrition and physical activity should be vested through Directors of Public Health, working closely with local authorities. Far more can also be achieved by Environmental Health Departments, and more should be asked of them. The aim must be engage all local bodies in locally-owned activities to promote not just individual behaviour change but the everyday frameworks through which people operate their lives. Healthy choices in diet and physical activity must be made the automatic choice, not something—like dieting—that people have to consciously think about and where they usually fail. There is a further, and more difficult question for the NHS. How many of its large staff are given opportunities to improve their diet and increase their physical activity? In other words, how far in the NHS a health service for its staff?

31. The support and protection of children through healthy pathways to adult life is particularly important. Unfortunately the Education Department (DFES) has been "symbolically compromised" through its involvement in cause related marketing initiatives such as with Walkers Crisps (a division of Pepsi-Cola) in their "Free books for School" campaign. This scheme was criticised by the Consumer's Association as poor value and by the National Audit Office as compromising the government's general health message to young people. To its credit, the Education Department has introduced nutritional standards for school meals in 2001 to improve children's diets. Unfortunately, this approach has been shown to be far too narrow. Which? found that the schools visited indicated that the caterers are meeting the standards, which specify how frequently certain foods must be offered. A wide variety of foods, including vegetables, salad and fruit were on offer every day. However, the children usually opted for the less healthy dishes. In 2003 Which? asked 246 children to keep a food diary. The diaries were filled with details of crisps, chips and chocolate bars, but rarely mentioned fruit or vegetables. Diets were typically lacking many vital nutrients, and often high in saturated fat, sugar and salt.[41] The Education Department must do better. Children and their families should not be used a fodder for marketing schemes of the junk food manufacturers. This said the protection of children must extend beyond the school gates, particularly since some evidence suggests that The question is: who will protect society from large companies whose are adapt at marketing and whose very business engages the sales of fatty sugary or salty foods? The answer, as yet, does not seem with the Education Department, the Department of Health or the Food Standards Agency. They must be given the powers and political support to do so.

32. The Department of Work and Pensions should work with the Department of Health and Food Standards Agency to examine the link between benefits and diet. Clearly, if poverty related problems in food and access to physical activity are to be addressed DWP can be a substantial source of help. Pathways to Work notes the rise in people receiving incapacity benefit, and that a rising part of incapacity is associated with mental health problems. It is critical to find ways to help people out of work or in receipt of incapacity benefit to establish the means of leading healthier lives. What mechanisms can be built within the framework of DWP activities to encourage healthier lifestyles, which can play an important part in improving well-being and hence stimulate a return to work?

RECOMMENDATIONS:

— Actions are required right across government. We propose the formation of Task Force, involving bodies outside government, to assemble a national strategy, having the power to make recommendations to government. This Task Force should report back to the Prime Minister within six months.

— The proposed local Food Action Plans (in England), operated through Local Strategic Partnerships, should be adequately funded and closely linked with Physical Activity Strategies. There is a strong leadership role here for Directors of Public Health, but their work must be integrated through Local Strategic Partnerships and must engage Environmental Health Departments and other departments in the Local Authority (leisure, planning, housing, education).

*Recommendations for national and local strategy

How can the Government's strategy be improved? What are the policy options? Can they be better integrated? What are the priorities for action?

33. The key issue is that human diet and fitness, particularly for children, must be made a matter of national urgency. It is not simply a matter for the Government, indeed early leadership in this area has come from professional bodies, non-governmental organisations, and others. Nutrition forms part of the NHS Plan, but note, this was a plan for the NHS—not for society or for government—as along the lines of the previous Our Healthier Nation: Saving Lives initiatives (for England, with differences in name and emphasis for the devolved administrations). The UKPHA and the Faculty of Public Health Medicine emphasises that action should be taking place across government and that there should be regular evaluation reports on progress issued by the Health Development Agency. At present it appears that the HDA can evaluate activities in the field but that it cannot evaluate the activities of the Department of Health. To the question of who evaluates the work of the Department of Health or the success of coordination across government the answer must be "no one".

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3 National Audit Office. (2001). Tackling obesity in the UK. London: National Audit Office. Back

4 HM Treasury. Securing Our Future Health: Taking a Long-Term View. London, 2002. Back

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