Impact of physical activity and diet on health - Health Contents

2  Tackling physical inactivity and diet—guiding principles and key responsibilities

Individual and population level interventions

27. In their written evidence, the Government lists the Change4Life initiative, NHS Health Checks, and the National Childhood Measurement Programme as "key initiatives" in this area.[37] Change4Life is a social marketing campaign aimed at delivering health messages and getting people to change their behaviour; NHS Health Checks offer all adults aged between 40 and 75 a health check designed to assess their risk of various conditions; similarly the National Childhood Measurement Programmes provides the opportunity for babies and children to have their BMI assessed at different points in their childhood, and their families to be informed if there are concerns about their weight. However, all these interventions are focused on getting individuals to change their behaviour. While interventions at an individual level may have a role to play in improving diet and physical activity—and indeed NICE has found some interventions of this type to be cost-effective, including offering brief advice in primary care, and referral to lifestyle weight management services—which are discussed more fully in the next section—our witnesses were clear of the limitations of such individual approaches, and the need to also act to introduce population level interventions.

28. Dr Janet Atherton, President of the Association of Directors of Public Health, highlighted the "Move It" physical activity programme as an example of an intervention which can produce good outcomes, but acknowledged that this was "on a very small scale in terms of the numbers of children who are able to be supported through those routes."[38] Dr Alison Tedstone of Public Health England argued that

    Health campaigning can never match the industry. Change4Life spends about a tenth of what industry will spend on food advertising. We can never do that. It is important that we do it, but it must only be part of the approach.[39]

29. Professor Nick Wareham was amongst many to explain that there are no "silver bullets" for addressing these issues, and that sustained action would be needed on many fronts:

    Health behaviours are complex and there are no silver bullets for changing unhealthy patterns of behaviour to healthier ones. Physical activity is influenced by a combination of factors related to the individual, their social relationships, community, wider society and the environment (the 'socio-ecological model'). Influences are shown to be context and behaviour specific—e.g. influences on walking to work differ from those on cycling to work or walking for leisure. Therefore, strategies that target only a single aspect are unlikely to be successful: multiple barriers often need to be removed to achieve substantive change, and interventions need to be sustained rather than short term 'projects'. Furthermore, it is increasingly recognised that much behaviour is automatic, triggered outside of conscious awareness and cued by multiple influences. This explains why, for instance, simply using information to persuade people to change their health related behaviour has had—at best—modest effects. [40]

30. Dr Dagmar Zeuner, Director of Public Health at Richmond, argued that the balance between individual approaches to lifestyles and population approaches is "a little bit too tilted towards the individual, so in the end it is choice and individual responsibility", arguing that population­based measures, such as regulatory approaches, promotion and product design are generally faster, cheaper and help to tackle inequalities because they are universal.[41] Dr Janet Atherton agreed on the importance of population approaches in tackling inequalities, arguing that "often one-to-one interventions tend to be taken up by people who have more ability to take them up…sometimes that can widen inequalities, unless you are really careful about how you target those interventions".[42] Dr Jane Moore, Director of Public Health for Coventry, gave several examples from her local area:

    In the food environment, we have food deserts in our major cities where eating healthily at a reasonable cost is really difficult because it is very difficult to access that food using public transport or whatever. There is a real issue about our more deprived communities, with less access to green space and it being more difficult to get outside the home in ways that people feel safe about, and that is at both ends of the age spectrum…We are doing work with food banks and other organisations in Coventry about how we help people in the context of what are often very difficult things. Saying to people, "Eat healthily," when you are getting an unhealthy bag of food from a food bank is very challenging.[43]

31. While individual approaches may focus on encouraging people to make a conscious effort to change their behaviour—for example encouraging people to purchase a low-sugar drink instead of a high-sugar drink—population-based approaches aim to make a healthy choice the default, or automatic choice—for example, by introducing fiscal policies which make the low-sugar drink cheaper than the high-sugar drink, or by reformulating the high-sugar drink to reduce its sugar content. For physical activity, a comparable population-based intervention might be encouraging people to take the stairs rather than a lift by designing buildings with the staircase in a more prominent and accessible place than the lift. Professor Theresa Marteau provides further explanation:

    Most people value their health yet persist in behaving in ways that undermine it. This gap between values and behaviour can be understood using a dual systems model of human behaviour, a model that is well supported by recent evidence from behavioural- and neuro-sciences. This model describes behaviour as shaped by two systems. The first system, guided by conscious processes, is goal oriented and driven by our values and intentions. It requires cognitive capacity—thinking space—which is limited in all humans. Most traditional approaches to changing behaviour depend on engaging this system, for example, by providing information about the benefits of a healthy diet, not smoking, consuming less alcohol or being more physically active. At best these approaches have been modest in their effectiveness at changing behaviour. The second system, guided by non-conscious processes, is driven by immediate feelings and triggered by our environments. For example, despite intending to lose weight we still buy the chocolate bar displayed at the checkout till. Such environmental cues combine with the attraction of immediate and certain pleasure (having an extra mince pie) over larger less certain and more distant rewards (such as reduced weight and improved health) make unhealthy behaviours more likely. This second system guides the majority of human behaviour.[44]

32. It is clear from the evidence we have heard that interventions focused on encouraging individuals to change their behaviour with regard to diet and physical activity need to be underpinned by broader, population-level interventions. Individual interventions include provision of information about the health benefits of exercise, workplace incentives, or referral to a lifestyle weight management scheme. Broader measures include pricing and availability of unhealthy foods, and redesigning environments to promote physical activity, which aim to make the healthy choice the default choice. Population-level interventions have the advantage of impacting on far greater numbers than could ever benefit from individual interventions, and may also be more effective at tackling health inequalities than individual interventions.

NICE guidance on what works

33. NICE has produced a wide range of evidence-based guidance on how to support people to be more physically activity and eat a healthy diet. This guidance includes interventions on an individual level—including changing individual behaviour, and weight management programmes—and also more 'upstream' environmental interventions, such as changes to the local environment that may improve access to healthier foods or encourage active modes of transport such as walking and cycling. NICE guidance offers advice relevant to both central government, and to local government and health and social care commissioners, providers and practitioners with advice on implementing public health interventions to improve the health of their local community.[45] However, NICE state that since 2010 its work programme has focused on local interventions, and that they have not considered the cost effectiveness of national policies (such as tax or food labelling) since the publication of guidance on the prevention of cardiovascular disease in 2010.[46] NICE supplied a summary table of their guidance and recommendations in the areas of physical activity and diet in their supplementary written evidence. Very briefly, key recommendations and publications have included:

—  Brief advice given in a primary care setting to promote physical activity is cost effective

—  Exercise referral schemes are not cost effective compared to brief advice in primary care, for people who are inactive or sedentary but otherwise healthy, and should only be funded for people with pre-existing health conditions

—  Recommendations have also been made by NICE on local measures to promote walking and cycling, promoting physical activity for children and young people, promoting physical activity in the workplace, and physical activity and the environment.

—  Good evidence exists on the effectiveness of lifestyle weight management services, although evidence is limited on the maintenance of weight loss in the long term

—  Guidance on maintaining a healthy weight and preventing excess weight gain is due to be published shortly and is likely to recommend increasing walking and other incidental activities; reducing TV viewing and leisure screen time; reducing the energy density of the diet, including sugary drinks and foods eaten outside the home including takeaways. [NB this guidance has now been published][47]

—  Guidance on obesity—working with local communities—makes recommendations on strategic approaches, local partnerships, commissioning, training and evaluation.

—  Guidance of relevance to both diet and physical activity has included recommendations about behaviour change at an individual level; and guidance on preventing type 2 diabetes and preventing cardiovascular disease

34. NICE does not have the responsibility for evaluating the extent to which its guidance is implemented; this is done by independent researchers or may be understood through official statistics on for example prescribing patterns. Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, told us that compared with the other types of guidance NICE issues, very little research has been carried out into the implementation of NICE guidance on public health issues.[48] She also discussed NICE Quality Standards, which are now being developed by NICE, as potentially providing a clear way in which progress in implementing NICE's guidance could be measured.[49]

35. NICE has produced a comprehensive raft of guidance on cost-effective interventions that can be introduced, either by the NHS or by local government, to improve diet and physical activity. These have included interventions on an individual level—changing individual behaviour, and weight management, and also more 'upstream' environmental interventions, such as changes to the local environment that may improve access to healthier foods or encourage active modes of transport such as walking and cycling.

36. While we welcome NICE's guidance, it is disappointing that there has to date been little assessment of how far these guidelines are being implemented. We have heard that NICE's forthcoming Quality Standards will produce a clear framework against which progress towards implementing NICE guidance can be measured. We recommend that the next Government shows its commitment to improvements in this area by auditing progress against Quality Standards in the areas of diet and physical activity across the country to allow benchmarking and drive progress.

Local authorities—key to improving public health

37. Responsibility for almost all local public health commissioning and delivery has now been transferred to local authorities, although the Department of Health retains overall responsibility for public health policy, with Public Health England providing local authorities, the Department and the NHS with advice on what works best in protecting and improving public health.[50] Our witnesses largely described the transfer of public health to local authorities as a positive step that was already yielding benefits. Dr Janet Atherton reported that Directors of Public Health are "finding that being within local authorities is a much better environment from which to influence things that we need to be influencing, such as transport policies…"[51] However, the limited funding available to local authorities was frequently raised. Dr Jane Moore told us that "being in the council has been incredibly valuable and it is exactly the right place … but the timing is wrong in the face of councils having to make difficult decisions about how they protect core services."[52]

38. Local Authorities have to provide certain 'mandated services' from within their public health budgets. The following tables show how overall public health budgets are allocated to different priorities, and how the allocations have altered, although we heard that in fact these figures may not represent the totality of investment[53]:

39. The following table, taken from a recent NAO report, shows how spending on specific priorities, including for example obesity, varies substantially between different local authorities[54].

40. Dr Jane Moore described efforts to use their "leverage" to get other parts of the system to deliver change "on their behalf", giving the example of work they have been doing with workplaces where they have not needed to invest any resources at all.[55] However Dr Dagmar Zeuner argued that local authorities need more resources to be able to "take prevention seriously";

    We have been very crafty with rather humble money, and our position in the local authority has certainly helped us to develop relationships and make the most out of them. But there is no doubt that austerity is a really serious enemy to any prevention and the pressure on local authority funding is no secret. If we want to take prevention seriously we do need to scale up, but the funding at the moment is humble.[56]

41. Dr Zeuner went on to ask "why don't local authorities turn around and say, 'actually, we have tried our very best and we will continue, but we have very little. We need more.'"

42. Our witnesses also repeated the call made in the written evidence for stronger powers around planning, in order for example to limit the numbers of fast-food outlets in certain areas.[57] Dr Alison Tedstone of Public Health England agreed that there are "challenges in planning" and reported that PHE have many communities asking for help with getting fast food restaurants "under control".[58] She went on to point out that when there is a very high density of fast-food outlets, they compete on just two things—price and portion size.[59] It is not hard to see the potential for a negative health impact, making ever larger portions of unhealthy food available at cheaper prices.

43. We welcome the transfer of public health functions to local authorities, which has the potential to enable Directors of Public Health to work creatively to get health embedded into other council functions. However, the public health funding that local authorities are able to invest in measures to tackle diet and physical activity was described by one of our witnesses as "humble". There is a danger that the current financial pressures on local authorities will lead them to deprioritise all but the mandated public health services to the detriment of prevention and health improvement. We recommend the next Government prioritises prevention, health promotion and early intervention and provides the resources to ensure it happens.

44. We also heard that local authorities need more powers to limit the proliferation of outlets serving unhealthy foods in some areas; Public Health England told us that they too had concerns about this. We recommend that the next Government works closely with the Association of Directors of Public Health and the Local Government Association to ensure local authorities have the planning powers they need for the control of food and drink outlets and for the preservation of open spaces for physical activity for public health purposes.

Role of NHS

45. The NHS also has a role to play in providing services in this area, both preventative services—for example the simple, low-tech intervention of providing brief advice about increasing physical activity in a primary care setting—and treatment services—for example referring patients to weight management programmes—two interventions which have both been identified by NICE as cost effective. Professor John Wass of the Royal College of Physicians told us that in each locality there should be a clinician with a special interest in weight and weight management, leading a team of people focused on this. However, in their recent research RCP found only four out of 32 London CCGs had this, something Professor Wass described as "a hugely missed opportunity".[60] Professor Susan Jebb, Professor of Diet and Population Health at the University of Oxford, and Chair of the Food Network of the Government's Responsibility Deal[61], suggested that physical activity and diet interventions are lagging those focused on smoking:

    We now have a situation where the GPs or practice nurses of most patients who smoke will talk about their smoking in their consultation. That is not happening in relation to people who are inactive or people who are overweight.[62]

46. Since this inquiry concluded taking evidence, NHS England and Public Health England have announced a national diabetes prevention programme which will involve "supporting people to lose weight, exercise and eat better." It will initially target 10,000 people at high risk of diabetes, with the initial phase of the programme beginning in seven demonstrator sites across the country.[63]


47. The NHS 5 Year Forward View highlighted workplace-based initiatives as a promising way forward in tackling obesity and physical activity:

    Workplace health. One of the advantages of a tax-funded NHS is that—unlike in a number of continental European countries—employers here do not pay directly for their employees' health care. But British employers do pay national insurance contributions which help fund the NHS, and a healthier workforce will reduce demand and lower long term costs. The government has partially implemented the recommendations in the independent review by Dame Carol Black and David Frost, which allow employers to provide financial support for vocational rehabilitation services without employees facing a tax bill. There would be merit in extending incentives for employers in England who provide effective NICE recommended workplace health programmes for employees. We will also establish with NHS Employers new incentives to ensure the NHS as an employer sets a national example in the support it offers its own 1.3 million staff to stay healthy, and serve as "health ambassadors" in their local communities.[64]

48. Simon Stevens, Chief Executive of NHS England, described initiatives in the US where employees were offered incentives to lose weight, and Jane Ellison MP, Parliamentary Under-Secretary of State for Public Health, also gave examples of companies who were already offering things like subsidised gym memberships, walking groups, and programmes for minority groups within their work force.[65] Some companies in the USA provide workplace health promotion schemes as part of their package of health care insurance for their employees. To support companies in the USA, the Centers for Disease Control (CDC) provides resources.[66] In the UK there is a suite of NICE guidance on diet, physical activity, mental well being and smoking cessation in the workplace.[67]

49. Public Health England flags up NHS England's determination to set a national example in the support it offers to its own 1.3 million staff to stay healthy, including keeping a healthy weight, and serve as "health ambassadors" in their local communities. NHS England, on request from the Committee, have provided the following information about workplace incentives:

    We are examining the potential to extend incentives for employers in England who provide effective NICE recommended workplace health programmes for employees.

    …All NHS employers should take significant additional actions in 2015/16 to improve the physical and mental health and wellbeing of their staff, for example by providing support to help them keep to a healthy weight, active travel schemes and ensuring NICE guidance on promoting healthy workplaces is implemented. To reinforce local action, we will be launching a new broad-based task force charged with achieving a healthier NHS workforce. To support early progress, the 2015-16 NHS standard contract now requires providers to develop and maintain a food and drink strategy in accordance with the Hospital Food Standards Report.[68]

50. Public Health England have recently announced a bespoke weight loss pilot scheme for NHS staff which is to be introduced to Imperial College Hospitals, which "could provide a blueprint for national roll out."[69]

51. But the Royal College of Physicians suggests that NHS Trusts themselves are falling short in this area:

    The RCP recommends that all employers should have a duty to promote the health and wellbeing of their staff. NHS organisations should be supported to be exemplar employees in this respect, particularly as improved staff health and wellbeing of staff has a proven association with better patient outcomes and experience. Recent research by the RCP found that only 28% of NHS trusts in England have an obesity plan, and the many NHS staff who work unsociable hours or night shifts have poor healthy food choices. While trusts are getting better at promoting opportunities for increasing physical activity, there is little monitoring of uptake by staff. Only 44% of trusts have a physical activity plan although this has increased from 24% in the first year that the audit was conducted. The NHS must lead by example and disseminate strategies for what works, but we must see action from employers across the wider public and private sector.[70]

52. Professors Susan Jebb and Theresa Marteau express the same view in even stronger terms:

    Unlike smoking—where the NHS is now effectively a smoke-free environment—the NHS has done little to promote healthy diets on the NHS estate. The new requirement in the NHS Operating Contract for 2015/16 for hospitals to have a food and drink strategy provides an opportunity to address this.[71]

    It is at best anomalous and at worst negligent that NHS properties continue to serve foods high in sugar, fat and salt (as exemplified by McDonald and Burger King outlets in some of our most prestigious hospitals, including Guy's Hospital in London and Addenbrooke's Hospital in Cambridge). Conversely, providing environments that facilitate healthier behaviours (e.g. by providing only foods compatible with healthy, sustainable diets) can signal that these are congruent with health and provide opportunities for those unused to eating healthier foods to sample such foods.[72]

53. One commentator told us that in her view, it is "at best anomalous and at worst negligent" that that NHS properties continue to serve foods high in sugar, fat and salt, with some hospitals even having fast-food outlets on their premises. The NHS should lead by example and manage its estate in a way that stops promoting the over-consumption of energy dense nutritionally poor food.

54. Beyond the NHS, workplaces are where working age people spend the majority of their time and as such can represent a powerful resource for health promotion. We urge the next Government to work with NICE and Public Health England to find the best options for achieving this in a range of workplaces, including the use of financial and other incentives.

55. While local authorities now have the lead public health role, there is an ongoing need for the NHS to provide both prevention and treatment services but greater focus needs to be given to discussing inactivity or overweight. The NHS is this country's largest employer and has a crucial role to play both in terms of promoting the health of its workforce, and in setting a wider example. More broadly, there is clearly potential for other workplaces to do more. We recommend that Primary Care takes the lead, as it has does for smoking cessation, in promoting physical activity and preventing obesity—these topics should not be off limits during consultations.

Cross government working

56. Dr Dagmar Zeuner told us that in her view "the crux of the matter is that it is neither the local authority nor the NHS; it is a whole societal issue if we want to get prevention embedded."[73] Given the need for interventions at both an individual level, and at a broader, population level, it is clear that effective cross-Government working is essential, to span health, local government, education, transport, planning, food standards, industry and advertising. The Minister gave us assurances that this was already taking place.[74] However, our witnesses were not convinced and argued that better cross- Government working was needed. Professor John Wass of the Royal College of Physicians told us that in his view:

    …at the moment, there is a complete lack of any co­ordination between various Government Departments in this whole issue of obesity such that we need a healthy environment in the health service; we need to educate our children; we need to grow healthy food; we need to have healthy transport with bicycles; and Work and Pensions need to take on all of this as well, just to mention a few Departments. If there was somebody—perhaps a Cross Bencher in the House of Lords who had experience of inter­governmental responsibilities and action—who could be put in charge of a co­ordinated Government programme, it seems to me that we would run the serious risk of being the first nation on the planet to solve the problem.[75]

57. Similarly, Sue Davies of Which? argued that "there is no joined-up approach across Government Departments, so a longer-term issue is about making sure that there is consistency, and clear priorities that go across all Government Departments.[76] Jane Landon of the UK Health Forum suggested health impact assessments of Government policies:

    We have the tools available to us; we have dietary guidelines; we have CMO physical activity guidelines. We are only really using them when we talk to the individual, but these should be perhaps guiding decisions and policy decisions across Government Departments, whether it is transport, business and trade as well as health. We are kind of reframing some of the discussions. One of the things we are not doing is any kind of health impact assessment on Government policy; we are not looking at the impact on the food environment or the physical environment when we make decisions across Government as routine. This could be something that could be much more effectively carried through and we would start to pick up those pressure points when things start to go wrong, which they have done over the last 30 years, and respond to those at the time that new policies are being put in place because it is very difficult to retrofit.[77]

58. Finally, Dr Mike Knapton of the British Heart Foundation argued that "the scale of the prevention challenge means that all political parties should make this a priority, and we feel it should be led by the Prime Minister".[78]

59. While there now is widespread recognition of the health impacts of diet, obesity and physical activity, and the scale of the problems we now face in these areas, these problems are not "owned" by a single Department or agency. A successful strategy for tackling these problems needs to mirror the successful strategy on tobacco, and be multi-level, spanning national and local government down to every citizen. A successful strategy may to need to incorporate elements as diverse as public education, regulation, fiscal measures, legislation, messaging and campaigns, evidence based behaviour change, changes to the school curriculum, and changes to planning arrangements.

60. Given the breadth of these issues, it is essential that the strategy must be cross-governmental and integrated laterally and vertically, and given the importance of these issues, led from the very top of government. We call on the next Government to introduce a co-ordinated government-wide programme to tackle poor diet and physical inactivity; this programme should be given the resources and authority necessary to secure collaboration with all relevant Departments and bodies, and should report at regular intervals on health improvements to the Prime Minister, and to Parliament.

37   Department of Health (IDH0078) para 27 Back

38   Q201 Back

39   Q218 Back

40   Centre for Diet and Activity Research (IDH0069), para 1.3 Back

41   Q170 Back

42   Q184 Back

43   Q202 Back

44   Professor Theresa Marteau (IDH0073) para 1 Back

45   NICE (IDH0098) para 26 Back

46   NICE supplementary (IDH0105) p3 Back

47  Back

48   Q51 Back

49   Q2 Back

50   National Audit Office, Public Health England's grant to local authorities (December 2014), paras 2-3 Back

51   Q162 Back

52   Q150 Back

53   David Buck, Public health gains despite slimmer budgets, Public Finance, 25 November 2014; see also Janet Atherton, Q147 Back

54   National Audit Office, Public Health England's grant to local authorities (December 2014), p22 Back

55   Q147 Back

56   Q146 Back

57   Q107; Q207; Q154 Back

58   Q226 Back

59   Q227 Back

60   Q210 Back

61   Professor Jebb's declaration of interests can be found at  Back

62   Q57 Back

63   "National diabetes initiative launched", Department of Health press release, 12 March 2015  Back

64   Q282 Back

65   Q281 Back

66 Back

67   :;;;  Back

68   NHS England (IDH0101) paras 8-9 Back

69   "National diabetes initiative launched", Department of Health press release, 12 March 2015  Back

70   Royal College of Physicians (IDH0043) para 12 Back

71   Professor Susan Jebb (IDH0100) p3 Back

72   Professor Theresa Marteau (IDH0073) p5 Back

73   Q149 Back

74   Q220 Back

75   Q174 Back

76   Q141 Back

77   Q128 Back

78   Q143 Back

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Prepared 25 March 2015