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]
Workplaces
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
https://www.nice.org.uk/guidance/ng7 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 http://www.nice.org.uk/guidance/ng7/chapter/10-membership-of-the-public-health-advisory-committee-and-the-nice-project-team#/declarations-of-interests
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
http://www.cdc.gov/workplacehealthpromotion/businesscase/ Back
67
:http://www.nice.org.uk/guidance/ph22; http://www.nice.org.uk/guidance/ph13;
http://www.nice.org.uk/guidance/ph5; http://www.nice.org.uk/guidance/cg43
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
|
