Select Committee on Health Third Report

3 Solutions

151. In an article covering an interview with Melanie Johnson MP, Minister for Public Health, in November 2003, the Health Service Journal called her attitude towards the obesity issue "surprisingly sanguine" and "remarkably relaxed". The Minister described Government action on obesity as follows:

We are doing a lot of things on obesity already—we have a food and health action plan under way. We have the Five-a-day programme, the schools fruit scheme. I'm not sure you need a strategy because we are talking about some very simple messages—take a bit more exercise, eat a bit better, make sure your children do the same.[182]

152. In direct contrast to this, obesity experts from whom we received oral evidence repeatedly stressed the complexity of the problem of obesity, and the naïvety of approaching it in such a simplistic way. Dr Susan Jebb told us "one of my key points is there is no one simple solution. If there was, we would have done it by now."[183] Professor Jane Wardle, of the Health Behaviour Unit at University College London, argued that as "it has been multiple small changes in society which have contributed to the changing population weights", "we are going to have to intervene in multiple ways to push it back down again, there is not one simple answer."[184]

153. The causes of obesity are diverse, complex, and, in the main, underpinned by what are now entrenched societal norms. They are problems for which, as our expert witnesses have emphasised, no one simple solution exists. However, to fail to address this problem would be to condemn future generations, for the first time in over a century, to shorter life expectancies than their parents. A recent report by the Royal College of Physicians, Royal College of Paediatrics and Child Health, and the Faculty of Public Health emphasised the need for solutions to be "long term and sustainable, recognising that behaviour change is complex, difficult and takes time."[185] We believe that an integrated and wide-ranging programme of solutions must be adopted as a matter of urgency, and that the Government must show itself prepared to invest in the health of future generations by supporting measures which do not promise overnight results, but which constitute a consistent, effective and defined strategy.

154. Recent months have seen commentators remarking with increasing frequency on the need to transform the current provision of healthcare in this country from a national illness service to a true national health service, and a White Paper positioning public health as a central plank of this Government's health policy is expected later this year. Although it may not currently be delivering all it could in terms of preventative medicine, many of our witnesses explicitly stated that this country's primary care based health service puts the UK in a uniquely strong position to tackle obesity as a public health problem. We consider NHS provision for both prevention and treatment of obesity later in this chapter. However, while the NHS is clearly central to tackling obesity through providing specialist health promotion and treatment for people who are already obese, we believe that the most important and dramatic changes will have to take place outside the doctor's surgery, in the wider environment in which people live their lives. And while we recognise that individuals have a key role to play in determining their own health and lifestyles, as the main factors contributing to the rapid rises in obesity seen in recent years are societal, it is critical that obesity is tackled first and foremost at a societal rather than an individual level.

155. In his recent report Securing Good Health for the Whole Population Derek Wanless remarked:

Evidence-based principles still need to be established for public health expenditure decisions. Although there is often evidence on the scientific justification for action, there is generally little evidence about the cost-effectiveness of public health and preventive policies or their practical implementation.[186]

We acknowledge that this is the case. Clearly, it is not within our resources to attempt to cost the solutions we propose in this chapter; that is a matter for Government. We are however encouraged by Mr Wanless's own observation on the need for taking action even in the absence of a comprehensive evidence base:

The need for action is too pressing for the lack of a comprehensive evidence base to be used as an excuse for inertia. Instead, current public health policy and practice, which includes a multitude of promising initiatives, should be evaluated as a series of natural experiments.[187]

156. Obesity is a perfect example of an issue that demands truly joined-up government action, with the work of at least six separate government departments directly impacting on it. As well as the Department of Health, which retains lead responsibility for obesity as a public health issue, the Department for Culture, Media and Sport has policy responsibility for promoting sport and physical activity, and also for the media, including the advertising of foods. The Department for Education and Skills has responsibility for ensuring children receive adequate physical education at school, as well as responsibility for the food children have access to in school, and for children's education about nutrition and food preparation. The Department for Transport has responsibility for ensuring that transport policies support healthy transport such as cycling and walking; the Office of the Deputy Prime Minister has responsibility for promoting urban spaces in which people can pursue healthy travel and recreational activities; the Department for Environment, Food and Rural Affairs has an influence through its remit for farming and food production; and the Department of Trade and Industry has a stake in this debate through its responsibility for the food manufacturing and retail industries. The Department for Work and Pensions could also be influential, in that it oversees this country's increasingly sedentary working lifestyles. The list might be further widened were we to include other areas of Government on which obesity, if left to accelerate unchecked, is likely to have an impact in future years.

157. However, despite reassurances from Ministers, our evidence does not suggest that the Government is yet considering obesity in such broad terms, or even that those parts of government with a more obvious and immediate stake in the obesity issue have been working together successfully. Although Imogen Sharpe, Head of Cardiovascular Disease and Cancer Prevention at the Department of Health, told us about no fewer than seven separate boards, initiatives and meetings taking place across the Government to consider issues which might have an impact on obesity, in none of these did the issues of physical activity and diet appear to be linked together. Two Government Ministers from different departments have so far lent their approval to food marketing schemes aimed at children, whereby children are encouraged to purchase and consume high-fat foods, such as chocolate and crisps, in exchange for contributions towards school sports equipment. The Food Commission has calculated that "in order to obtain a 'free' basketball worth around £10, some £71 would need to be spent on 170 chocolate bars. A child would have to play basketball for 90 hours to expend the 40,000 calories and 2kg of fat from that amount of chocolate."[188] These initiatives were robustly condemned by the FSA, and we learnt that neither they nor the Department of Health were consulted prior to these schemes receiving ministerial endorsement, starkly revealing the contradictions that have arisen within policy concerning obesity.[189] Tim Lobstein, of the Food Commission, expressed extreme frustration with this:

I think top of your list is going to have to be a recommendation that governments bang each other's heads together, that is to say you need a cross-departmental nutrition and physical activity policy. I talked to Tessa Jowell quite recently and she could only see the sports side of her department and would not listen to any discussion about the media side, which is advertising.[190]

158. We were very surprised that when we sought oral evidence from officials from DEFRA to discuss aspects of food production policy and its potential impact on obesity we were repeatedly rebuffed by that Department, who maintained that they had no part to play in discussions concerning obesity. Eventually, after intervention by the Secretary of State, a witness from DEFRA did appear before the Committee, but through no fault of his own had not been briefed to talk about those issues we considered most central to his Department's influence on obesity, and had no responsibility in respect of the Common Agricultural Policy. We were later supplied with written information on the Common Agricultural Policy by the Secretary of State, which is discussed below.

159. We feel strongly that the problem of obesity needs to be recognised and tackled at the highest levels across government. We therefore recommend that a specific Cabinet public health committee is appointed, chaired by the Secretary of State for Health, and that one of its first tasks is to oversee the development of Public Service Agreement (PSA) targets relating to public health in general and obesity in particular, across all relevant government departments.

160. Experience in Scandinavia and in other countries where dietary change was needed has shown the value of having a public health co-ordinating council or other body which operates in the public domain and maintains the drive for cross-governmental action. It can also provide a regular overview of the determinants of diet and physical activity and the effectiveness of interventions. To that end, we recommend that the Government should consider either expanding the role of an existing body or bodies, such as the Food Standards Agency or Central Council of Physical Recreation (or linking these), or consider the creation of a new Council of Nutrition and Physical Activity to improve co-ordination and inject independent thinking into strategy.

Nutritional solutions

161. The previous chapter discussed the causes of obesity at length. Although the debate about whether nutritional changes or physical activity changes have been the main driver of the increases in obesity is still ongoing, it is clear that to tackle obesity effectively, whether through the treatment of existing obesity or prevention of future obesity, solutions need to be found that will address both sides of society's changing energy balance: that is to say to reduce the intake of calories through altering nutritional intake, and to increase energy expenditure through changing physical activity habits.

162. As we have noted, energy intake at the beginning of the twenty-first century is very different from that of 50 years ago. While people in Britain may technically be consuming fewer calories, they are overeating in relation to their energy needs, are eating far greater proportions of fats and are having their normal appetite control overridden by the increasing availability of highly energy-dense foods and soft drinks. At the same time lifestyles have changed dramatically, meaning that people rely heavily on convenience foods. The British consume the highest number of ready meals in Europe; snacking is up; eating out is up. These trends, driven by far reaching societal changes, are not ones that it would be possible or even necessarily desirable to attempt to reverse. But there are certain tools today's population need if they are to be able successfully to negotiate what several witnesses have termed an increasingly 'obesogenic' environment.[191]

Information and choice

163. Altering people's dietary habits would appear to be an obvious and simple starting point in tackling obesity, and in their evidence, the Department put considerable emphasis on their actions to date in addressing the nutrition side of the obesity equation. They cited ongoing work on a Food and Health Action Plan, which was announced in December 2002 as part of the Government's strategy for Sustainable Farming and Food, although no date has been set for publication. The Department also drew attention to the National School Fruit Scheme, and the Five-a-day health promotion programme, both of which aim to increase consumption of fruit and vegetables.

164. However, it is clear that, as solutions to the obesity epidemic, the fruit and vegetable promotion schemes favoured by the Government have significant limitations. First, although the consumption of five portions of fresh fruit or vegetables a day is accepted as being beneficial in its own right, it is difficult to see precisely how this will help tackle obesity, unless it is assumed that consuming more fruit and vegetables will displace calories from other sources. The Government's fruit and vegetable campaigns only stress the importance of consuming fruit and vegetables—they make no suggestion that these should be consumed as snacks instead of, for example, chocolate or crisps. The same holds true for the Free School Fruit scheme, which is currently only being made available to very young children aged between four and six.

165. The Government has recently invested £7.5 million on an advertising campaign aimed at stopping people smoking. By contrast, although we were told by the Public Health Minister that obesity commanded the same priority as smoking,[192] there have to date been no public health education campaigns directly aimed at reducing obesity through nutritional changes, or by any other means.

166. Research suggests that the recent anti-smoking advertising campaign has already had a small, but significant impact.[193] It is interesting to note that this campaign has relied heavily on shock tactics, employing unashamedly graphic depictions of arterial fat accumulation caused by smoking. While smoking and nutrition have obvious differences, this suggests that negative messages are capable of generating a powerful impact.

167. While we strongly endorse the Government's efforts to reduce smoking, it seems odd that so much sustained effort and investment has been put into this while no steps at all have been taken to tackle obesity, despite its occupying, according to the Public Health Minister, joint top priority with smoking. Indeed, the Government has also invested substantially in other health education campaigns on issues which, although clearly important, have not been identified by Government as a top public health priority, during the time that obesity has received none. For example, £40 million has been targeted towards reducing teenage pregnancy between 2003-06, and £4 million spent on a sexual health education campaign over two years.[194]

168. We in no way wish to imply that any of these areas of public health are undeserving of the attention and funding that the Government has invested in them. Indeed, our own recent inquiry into Sexual Health identified this as a very important and neglected area of public health.[195] However, what it does seem to suggest is that the Government's approach to public health education over the past few years has been responsive rather than pro-active, and has not been informed by any kind of sustained strategic prioritisation.

169. In his recent report into public health, Derek Wanless argued convincingly that since the demise of the Health Education Authority (HEA), no single body has held strategic responsibility for public health education campaigns. When we put this to the Public Health Minister she told us that the Health Development Agency was carrying on the HEA's work successfully. However, we received no evidence at all from the Health Development Agency for this inquiry into a major public health issue, a fact that we feel speaks for itself. We strongly endorse the Wanless Report's recommendation that the Government must assign clear responsibility for the health educational role, previously played by the Health Education Authority, a fact made clear in correspondence from the Department to the Committee.[196]

170. We were very surprised that despite its occupying 'joint top priority' on the Government's public health agenda, there have been no health education campaigns aimed at tackling obesity. Although we acknowledge its benefits, we do not accept the Government's view that the Five-a-day fruit and vegetable promotion campaign is either designed for, or capable of, addressing the nutritional aspects of obesity. In recent years the Government has funded health education campaigns around, amongst other things, smoking, teenage pregnancy and sexually transmitted infections. The order in which other public health issues have been addressed, and the exclusion to date of obesity from this list, make the Government's actions in this area appear haphazard rather than strategic.

171. If the Government intends seriously to address obesity through health promotion, it must adopt a health education campaign dedicated exclusively to tackling obesity, which should follow the model used in the recent anti-smoking campaign, plainly spelling out the health risks associated with being overweight or obese, and also highlighting those nutritional and lifestyle patterns which are most conducive to weight gain. It should specifically identify 'high risk' foods and drinks, and should also emphasise the fact that consuming alcoholic drinks, like any other high-calorie food or drink, can also be conducive to unhealthy weight gain. At the same time, it should highlight the importance of physical activity both in preventing obesity and reducing weight levels. Part of the campaign should emphasise the crucial links between obesity and diabetes, and between obesity and cancer (which we have heard is barely known by the public as a whole). We recommend that such a health promotion campaign should be launched as soon as possible, with the Food Standards Agency advising on the nutritional content of such promotion, and the Activity Co-ordination Team, if this remains operational, or alternatively Sport England through its links with Move4Health[197] advising on the physical activity dimension.

172. An awareness of the importance of healthy eating is useless without the practical skills to translate this knowledge into action. As well as understanding what constitutes a balanced diet, people need to know how to identify healthy foods and how to prepare them healthily, in order to reverse the increasing reliance on ready-prepared meals which require minimal cooking skills. We have heard evidence that cookery teaching has been progressively eroded by pressure to focus on other areas of the curriculum, and that, where food technology is taught, practical lessons have largely been replaced by theoretical learning about food manufacturing and marketing.[198] For many schools the only source of practical cooking lessons is through voluntarily provided initiatives such as cooking buses. The Rt Hon Margaret Hodge MP, the Minister for Children, argued that provision of food education was now better than ever:

In our days we were not really taught about the ingredients and the nutritional content, or otherwise, in any great detail or the impact on our health. That link between being able to cook and linking it back into the healthiness of the ingredients you choose to cook is much stronger today than it was in the past, in some ways it is better than it was.[199]

173. Mrs Hodge also felt that food education was widely available: "food technology, as it is known today, is on universal offer in every primary school and it is available in 90% of our secondary schools."[200] However, although she told us that 100,000 students take GCSE food technology per year, this only represents approximately 16% of GCSE students.[201]

174. Understanding the importance of healthy eating is meaningless without the skills to put these messages into practice. The huge demand for initiatives such as the Focus on Food Cooking Bus is a testimony to the extremely limited opportunities for cooking and food training within schools, and also to the desire of both pupils and teachers to have access to this type of training. While we fully support these initiatives and acknowledge the good work they are doing to bring this training back within reach of school pupils, we feel that learning about how to choose and prepare healthy meals should be an integral part of every young person's education, not an optional extra delivered only periodically. This is currently not the case. We recommend that the Government takes steps to reformulate the Food Technology curriculum, so that children of all ages receive practical training in how to choose and prepare healthy food which they can put into practice in their daily lives. As well as practical cookery lessons and classroom lessons about nutrition, children should also be taught how to understand food labelling and how to distinguish food advertising and marketing from objective fact; they could put their knowledge to the test in visits to a local supermarket. Healthy Schools initiatives have demonstrated the additional value of engaging children in projects to grow their own fruit and vegetables, fostering an understanding of where foods come from as well as reinforcing their motivation to eat more healthily. This should also form part of the food curriculum in schools. In order to achieve this, steps will need to be taken to strengthen teacher training in these areas.

175. We recommend that delivery of the Food Technology curriculum should be rigorously inspected by Ofsted.

176. Although it is clearly vital to educate individuals and equip them to choose healthy options, whether in the classroom or through wider health promotion campaigns, making healthy decisions can be difficult even when people are well aware of what is good for them and what is not. The Food Commission argued very strongly that:

The obesogenic environment needs to be tackled at the highest levels. It is not adequate to focus on the individual, especially the child, and expect them to exercise self-control against a stream of socially endorsed stimuli designed to encourage the consumption of excess food calories.[202]

177. The central tenet of this argument was in fact backed up by the Department's own written submission to our inquiry, in which they acknowledged that while many of the determinants of obesity risk were controlled by personal choice, other, wider circumstances also played a significant part:

People's exposure to risk reflects, in part, the choices they make about how to live their lives. But these are also heavily influenced by the circumstances in which they live—people do not have equal opportunities to make healthy choices.

Industry has a responsibility to make it easier for consumers to choose a healthy diet, remove some of the barriers that can make it difficult to do so and provide clear and consistent information about their products.[203]

178. Recent comments from the Secretary of State for Health and the Minister for Public Health imply a belief that the public must share the responsibility for their own health, rather than rely entirely on government.[204] Given this, it is perhaps not unreasonable to speculate that the forthcoming White Paper on public health may adopt an approach that gives government the responsibility for educating people about the dangers of obesity and how they might be avoided, and leaves people to make their own decisions. However, there are serious doubts about whether such an approach would be sufficient to reverse trends in obesity, underpinned as they are by the current obesogenic environment. Evidence suggests that the vast majority of people are amply aware of the importance of healthy eating, but, as Tim Lobstein for the Food Commission told us, cultural and economic pressures outweigh the healthy eating messages they receive. According to Jackie Cox, Joint Chair of TOAST (The Obesity Awareness and Solutions Trust), there is a great misunderstanding of the problem of obesity:

It has been seen as just a food problem—so if you teach somebody how to cook a low-fat chocolate cake, they will be cured; whereas most people in this country are quite knowledgeable about whether they should have an apple or a Mars bar, and that they should walk about more and so on.[205]

179. Professor Prentice also argued that the impact of health education was limited:

I have gone through a transformation myself of thinking that we could do it all through education and have come to the conclusion that that is not working. I am not a nanny-statist but I am a health professional and I do think we have a responsibility to look after the health of the population.[206]

180. This diagram, shown to us by Professor Pekka Puska of the Finnish Health Institute, provides a helpful illustration of the individual's challenge to live a healthy life, in the face of a rising gradient of societal pressure to live unhealthily. While ultimately individuals must meet this challenge themselves, government can play a role both by providing individuals with support as they climb, and by lowering the gradient against which they are climbing.

181. Health promotion campaigns, as the recent anti-smoking advertising campaign has demonstrated, can play a successful role in raising awareness of the risks associated with particular behaviours, and to this end we have recommended that a health education campaign targeting obesity is launched as soon as possible. However, our evidence suggests that obesity has increased rapidly despite the fact that the benefits of a healthy diet have been well known for over 20 years. While we accept that individuals have the right and the responsibility to make choices about their own health and lifestyle, and we accept the importance of health education in enabling them to do so, we believe that to tackle obesity successfully education must be supported by a wider range of measures designed to remove the key barriers to choosing a healthy diet. We therefore recommend that the Government should concentrate its efforts not solely on informing choice, but also on addressing environmental factors in order to, in its own words, make healthy choices easier to make.

Food advertising and promotion

182. While there is clearly a role for well designed and targeted health promotion schemes, one of the main doubts about their effectiveness centres on the huge financial weight of the food industry which is, by and large, directed at promoting entirely the opposite message, as articulated by Tim Lobstein of the Food Commission:

Too much reliance has been placed on health education and handing out the odd leaflet in doctors' surgeries over the last 20 or 30 years as the Department of Health's strategy. It is not adequate. The main reason it is not adequate, of course, is that for every pound the Health Education Authority used to spend on promoting healthy diets there is about £800 being spent by the food industry encouraging us to eat their products. Of those products, about 95% are ones that would have encouraged weight gain rather than a healthy diet.[207]

183. Particular concern has been voiced about advertising food to children, which has been shown to have a demonstrable effect not only on brands but also on the categories of foods children eat. So how far is it desirable or possible to stem the seemingly continuous stream of messages children receive promoting unhealthy foods? The solution posited by Tessa Jowell MP, Secretary of State for Culture, Media and Sport, in her evidence was that, rather than imposing restrictions or controls on the promotion of unhealthy foods, these should be countered with the promotion of healthy foods. Equally surprisingly, she went on to suggest that it should be the advertising agencies and the food industry themselves who made this investment. While we are strongly in favour of the industry being part of the solution to this problem, the Secretary of State's view struck us as rather naïve.

184. Advertising agencies are commercial businesses and cannot be expected pro-actively to fund the large-scale promotion of healthy foods for the public good. They will clearly only be able to put their 'creative genius' to good ends if they are commissioned and paid to do so, which raises the question of who might reasonably be expected to provide such funding. Government health education campaigns are one answer, but we have already seen the insignificance of Government health education budgets compared to the advertising budgets of multinational food and drink companies. Even with sustained new investment it is difficult to see that the Government would be willing or even able to match this year on year. The other option would be to rely on the food industry itself, but given that currently the fruit industry spends on advertising just 2% of the amount spent on advertising unhealthy snacks, achieving equality between healthy and unhealthy foods does not seem a realistic aim.

185. While we would clearly support an expansion in the promotion of healthy foods to redress the balance which currently lies entirely in favour of unhealthy foods, this alone seems to be an idealistic and ill thought-through notion, one which we are surprised that the Secretary of State for Culture, Media and Sport was prepared to espouse.

186. In the absence of this as a realistic option, the other way to redress the balance would be to impose some degree of control on the promotion of food to children. While the industry position on this is clear, this option is already under active consideration by the Government, who identified the role of regulation, particularly in relation to advertising, as an important area for consideration in the Department of Health's public health consultation, published in March 2004. The Secretary of State for Culture Media and Sport has already expressed her "scepticism" about measures targeting the advertising of food to children:

Why am I sceptical? Well, first of all, of course I recognise the very powerful alliance that has come out today in support of a ban. Of course we will await the advice of the Food Standards Agency later this month and I will receive advice in the summer from the media regulator, OFCOM [Office of Communications], about whether or not codes that regulate food advertising on children's television are sufficiently robust. This is an extremely complex issue … The reason that I am sceptical is that we have got to come back to the evidence. Why are we getting fatter? We are getting fatter because we are less active. [208]

187. However, the FSA has already accepted that evidence suggests that promotional activity influences children's eating habits. In the FSA's action plan, it argues that "action to address the imbalance in TV advertising of food to children is justified", and goes on to say that "action on advertising during children's TV slots would be likely to have some beneficial effect, and wider action might also be justified."[209]

188. There are recent precedents for advertising bans, both in the UK and abroad. The Co-op supermarket has already taken unilateral action in this area, by stopping all its advertising of 'unhealthy' foods and drinks during children's television programmes, as has Cadbury's.[210] Several countries have also introduced statutory regulation, or made government recommendations for strengthened voluntary controls:

  • Sweden does not permit advertising aimed at children under 12, does not allow programmes to be interrupted by advertising and does not permit advertising before or after children's programmes.
  • The Canadian province of Quebec prohibits all marketing aimed directly at children aged under 13.
  • Norway is seeking a ban on advertisements before, during or after children's programmes.
  • The Flemish region of Belgium does not permit advertising five minutes before and after programmes for children aged under 12.
  • In the Netherlands the public broadcasters are not allowed to interrupt programmes aimed at under 12 year olds with advertisements.
  • In Denmark, Finland and the Netherlands, characters or presenters from children's programmes cannot appear in advertisements.
  • In Finland, McDonald's cannot promote toys in its advertisements.[211]

189. The Broadcasting Committee of Ireland is reported to have drafted a code whereby fast-food advertisers will be obliged to warn children that their products should only be eaten in moderation and as part of a balanced diet; advertisements for cakes, biscuits, sweets and chocolates will have to show a toothbrush symbol. Advertisements for food and drink will not be able to portray or refer to celebrities or sports stars.[212]

190. A counterargument we heard employed frequently by those who opposed restrictions on advertising food and drink to children was that no evidence yet existed that such restrictions directly yielded reductions in childhood obesity.[213] It is also the case that many children watch programmes aimed at adults such as Coronation Street, which is actually sponsored by Cadbury's (although advertising slots during such programmes are considerably more expensive). In addition, children may also be exposed to messages promoting unhealthy foods through many other media such as the internet and satellite television.

191. However, logic dictates that if advertising has an effect on the categories and quantities of foods that children eat, then removing that advertising would mean that this effect was gradually lessened, although the impact of this might not be felt immediately. Furthermore we strongly endorse the view taken by Derek Wanless that lack of evidence should not of itself be a reason for inaction.

192. Given the scale of the public health hazard the country is confronted by, it would seem appropriate to employ a precautionary approach where evidence is contradictory. As we have said previously, we are committed to long-term solutions to the problem of obesity. The Hastings Review offered stark evidence of the extent to which advertisers of less healthy foods were saturating broadcasting slots targeting children, who are often watching without any adult present. While we would not want to go so far as to call for an outright ban of all advertising of unhealthy food, given the clear evidence we have uncovered of the cynical exploitation of pester power we would very much welcome it if the industry as a whole acted in advance of any possible statutory control, and voluntarily withdrew such advertising. There is clear evidence that the majority of parents do not favour such advertisements during children's television.

193. In one crucial sense, however, we share a concern about the effectiveness of banning or controlling television advertising: as noted above it is only a small part of the enormous food marketing effort that is aimed at children. If television advertising were to be banned, the marketing effort would simply be displaced to other areas—money previously spent on television advertising would, for example, be diverted to point of sale or internet promotion.

194. We gather that the Secretary of State for Culture, Media and Sport is in discussion with OFCOM over the marketing of less healthy foods. We would like her to review the whole marketing function. In particular, we would like her to address some of the issues the Irish Broadcasting authorities are looking at, namely the impact of product endorsement of less healthy food by sports stars, and other celebrities; guidance on how these products can actually fit into a healthy diet, perhaps linking into nutritional information; and their impact on the energy equation in terms of the activity needed to displace the calories they add. Assuming the food and advertising industry is genuine in its desire to be part of the solution, a starting point for this would be for companies to agree clear public health targets.

195. As we noted earlier, we were disturbed at the ineffectiveness of the Advertising Standards Authority, which is an industry self-regulation system. We recommend that OFCOM be asked to review the role of the ASA with a view to improving its effectiveness. This is not the first occasion on which the Health Committee has found the performance of the ASA to be disappointing.[214]

196. Children are subject to an onslaught of food promotion in many aspects of their daily lives, and the school environment appears to be no exception, with sponsorship by food companies and vending machines selling only unhealthy products now commonplace. When we put this to Margaret Hodge, the Minister for Children, she replied simply that this was a matter for individual schools and headteachers:

I think it would be wrong for us in the DfES or for us in Government to prescribe from the centre what individual schools should do in relation to where they seek sponsorship. What we have done is to give guidance to say that they should measure the advantages and make sure that the educational advantages gained from a particular form of sponsorship outweigh the disadvantages and that has to be a decision for them … the individual headteacher ought to decide himself or herself what vending machines to have or what other form of promotion he or she chooses to have within their institution, and weigh up the economic and educational benefits against the disbenefits.[215]

197. However, there seems to us no logic at all in assuming that children in some areas might 'benefit' from exposure to such commercial pressures while others would be harmed. This is surely an area crying out for central guidance and direction.

198. Margaret Hodge went on to suggest that the impact of school was limited compared to the messages children received at home, arguing that "the greatest influence on children and the outcomes they achieve is the quality of parenting in the home" and that her priority would lie in "seeing how we can better support parents". However, we believe that the school is a crucial environment in which messages about nutrition—whether healthy or unhealthy—can be learnt and reinforced, sometimes resulting in children introducing to their parents healthier eating patterns learnt at school. Indeed, this is a central tenet of the Government's free school fruit campaign. We have also received evidence suggesting that children respond positively to the availability of healthy options. Where they have been trialled, vending machines selling only healthy foods have yielded a high turnover.[216]

199. We feel that the school environment can have a strong influence over children's developing nutritional habits, and that the Government must not neglect this crucial opportunity to promote healthy eating to children and help them develop sound lifelong habits. Healthy eating messages learnt through the national curriculum and Government healthy eating initiatives such as the schools fruit campaign will be contradicted and undermined if, within that same school environment, children are exposed to sponsorship messages from unhealthy food manufacturers, and given access to vending machines selling unhealthy products. There is evidence that parents are keen to see unhealthy influences removed from schools, with recent research finding that as many as 70% of parents were in favour of banning vending machines in schools.[217] Recent research by the FSA also indicates that children are willing to purchase healthier drinks from vending machines when they are given the option. Given the worryingly steep rise in levels of childhood obesity, we feel that parents, teachers and school governors must all be fully engaged in tackling it, and that obesity should command a high priority on school board agendas.

200. We therefore recommend that all schools should be required to develop school nutrition policies, in conjunction with parents and children, with the particular aim of combating obesity, but also of improving nutrition more generally. In conjunction with this, the Government should issue guidance to all schools strongly recommending that that they do not accept sponsorship from manufacturers associated with unhealthy foods or install vending machines selling unhealthy foods. If Government insists that this is a matter for local determination, we believe that governors should permit such practices only if these are shown to be supported by a clear majority of parents. The guidance should also give firm support for the replacement of existing vending machines with ones selling healthy foods and drinks.

Food labelling

201. Food labelling is a tool that could potentially enable consumers to choose healthier foods and negotiate their way through today's 'obesogenic society' more successfully. However, current labelling appears to fall far short of this aim. To begin with, the absence of legislation in this area means that nutritional labelling is often entirely absent from foods, and where it is present, is often complex, difficult to interpret, and in illegibly small print. Nutritional information panels are often overloaded with information, much of which may be irrelevant to the needs of today's consumers. For example, Dr Mike Rayner, Director of the British Heart Foundation, Health Promotion Research Group, argued that although when the 'Big 8'[218] standard nutrition label was devised protein deficiency was still a problem for some people in this country, almost no-one suffers from this problem any more, making the inclusion of protein on nutrition labels largely redundant.[219]

202. As well as the absence, inconsistency and irrelevance of information, the crux of the problem lies in the intelligibility of nutritional information on food labels. Sue Davies, for the Consumers' Association, told us that:

Part of the problem is that even if you had the most comprehensive nutrition information, it is very difficult—and I have difficulty, as a consumer—to know how much fat I am supposed to have and what is a high amount of salt or a high amount of sugar. When people are shopping in a hurry, they do not want to be doing all of those calculations in their head, do they?[220]

203. Dr Mike Rayner told us that "everybody agrees that the nutritional labelling panel is completely incomprehensible, and people cannot make sense of the numbers, and there are too many numbers."[221] According to the Consumers' Association, research suggested that consumers liked to see simple, bold claims such as 'low fat' on products, because it helped them make decisions when shopping in a hurry, without having to negotiate the nutrition panel.[222]

204. However, a problem frequently brought to our attention during the course of this inquiry was the impact of misleading nutrition claims, when products marketed as healthy failed to live up to that claim. We heard numerous examples, often relating to the fat content of foods, and in particular we were struck by the example of the cereal Frosties Turbos, advanced in evidence from the Consumers' Association. Using a series of eye-catching symbols on the front of the packet, Kellogg's claim that Frosties Turbos are good for bones, good for concentration, good for heart health and low in fat. What is not mentioned is that they are made up of 40% sugar, and that other, less sugary breakfast cereals might provide similar benefits with fewer calories.[223]

205. Andrew Coslett, for Cadbury Schweppes, argued compellingly that "an average supermarket can carry about 20,000 lines, and to try to get mum to understand every one of those in making a balanced diet is a challenge."[224] Besides improving the consistency and transparency of nutrition claims, our evidence suggested that consumers also need a simplified system of nutritional labelling for choosing foods to make up a balanced diet. The difficulty consumers may have in researching and understanding the calorie content in different foods is perhaps reflected by the fact that commercial weight management programmes often provide their customers with far simpler alternative systems for making nutritional decisions, such as the Weight Watchers Points system. However, devising a universal food classification system such as this goes to the heart of the argument surrounding whether or not any foods can reasonably be deemed 'good foods' or 'bad foods', 'healthy foods' or 'unhealthy foods'.

206. Food manufacturers have attempted to draw a clear distinction between food and tobacco, arguing that while there is no such thing as a safe cigarette, there is no such thing as a food which, seen in isolation, is dangerous:

I think health warnings are for dangerous things. Whilst we recognise the problem I do not think that a Curly Wurly is a dangerous thing.[225]

207. This argument has been expanded and repeated by almost all those working in or concerned with the food industry presenting evidence to us, namely that there is no such thing as a healthy or unhealthy food, only healthy and unhealthy diets.[226] This was also the view expressed by the Secretary of State for Culture Media and Sport, and Sue Campbell, Chairman of UK Sport and Chief Executive of the Youth Sport Trust.[227] However, Dr Mike Rayner told us that in his opinion this myth was beginning to be broken down, ironically by the very actions of government and industry. Citing schemes by government and industry to promote fruit and vegetable consumption, he argued that:

If we are going to eat more of good foods like fruit and vegetables, then surely we have to eat less of some bad foods like confectionery, fizzy drinks and so forth? The labelling of good food … is quite often used by the industry anyway. They quite often have "healthy eating" ranges, so they are quite content to have this notion of good food. However, again, if we are going to be eating healthy foods, then there must be, conversely, just on a logical basis, some bad foods out there.[228]

208. The Public Health Minister also accepted this point:

Mr Burstow: Do you accept that some foods can be classified as junk foods?

Miss Johnson: I think we would all, in common parlance, accept that there are some foods that would be regarded as junk foods … I think we all know what sort of food stuffs are being referred to, broadly speaking. It is true, of course, that a small amount of any of these foods or these foods taken in on an irregular basis will not particularly harm you in themselves. It is the degree of frequency and the size of portions that is the issue.[229]

209. Sue Davis, for the Consumers' Association, supported this view:

We have got to get over this issue about "there is no such thing as 'good' food and 'bad' food." There are definitely foods we need to be eating less of and foods we need to be eating more of, and it needs to be made clear on the front of the pack.[230]

210. Our witnesses were clear about the need for an integrated system, on the front of food packaging, to enable consumers to make an overall judgement about the food they were about to purchase. However, they did not feel that the extreme measures feared by the food industry, such as putting health warnings on high energy density foods, or labelling them with a skull and crossbones, were either reasonable or necessary. They felt strongly that food labelling and classification did not need to be pejorative, and Dr Mike Rayner instead suggested the possibility of introducing a symbol to demarcate "fun foods" or "treat foods", highlighting the need to eat them sparingly rather than regularly.[231] As Sue Davies argued, the point of such a system would be "to highlight the good, bad or in-between foods. It is not saying 'do not eat this food', it is saying 'do not consume it very often; do not eat it all the time.'"[232]

211. We also heard the suggestion that in order to link calorie consumption to energy output, food labelling could include a requirement to state how much exercise would be required to burn off the calories in a particular product—for example, a Mars bar would require four miles of walking for an adult.[233]

212. In Sweden, a simple system is already in place to enable consumers to identify foods that are lower in fat and higher in fibre. Under the Swedish 'Keyhole' system, a green keyhole symbol appears on the front of foods that are lower in fat or high in fibre, although it is not included on produce which is naturally lean or high in fibre, such as lean meat and fruit and vegetables. The symbol appears on, amongst other things, low-fat sausages, cheese, ready-meals and fibre-rich breads. Products must meet strict criteria about the proportion of fat, sugar and dietary fibre they contain before they are able to use the symbol.[234]

213. The FSA told us that they believed that the law relating to food labelling needed to be reviewed and changed.[235] These changes, in their view, should include making the provision of nutritional labelling compulsory.[236] They also supported a 'high/medium/low' format of labelling as the approach that worked the best with consumers, and agreed with the concept of nutritional signposting on the front of food packaging.[237]

214. Nutritional labelling is intended to help consumers make sound nutritional decisions when buying food, but the current state of such labelling seems to be having, if anything, the opposite effect. We have repeatedly heard the argument, both from the food industry and from the Government, that there are no such things as good or bad foods, only good or bad diets. However, both the food industry and the Government have embraced the concept of labelling certain foods as 'healthy' with great enthusiasm, inviting the obvious conclusion that other foods must be, by definition, less healthy.

215. Dr Mike Rayner told us that the Co-op had improved the nutritional panelling on foods and now used the categories "high" "medium" and "low" on the panel, a measure which we strongly commend.[238] Indeed, the Co-op's labelling as a whole struck us as exemplary in comparison with what most supermarkets managed. Dr Rayner also suggested that a voluntary scheme to improve labelling was only likely to be effective if all the major supermarkets agreed on a common scheme.[239]

216. The Government must accept the clear fact that some foods, which are extremely energy-dense, should only be eaten in moderation by most people, and we therefore recommend that it introduces legislation to effect a 'traffic light' system for labelling foods, either 'red—high', 'amber—medium' or 'green—low' according to criteria devised by the Food Standards Agency, which should be based on energy density. This would apply to all foods. Not only will such a system make it far easier for consumers to make easy choices, but it will also act as an incentive for the food industry to re-examine the content of their foods, to see if, for example, they could reduce fat or sugar to move their product from the 'high' category into the 'medium' category.

217. Bearing in mind Derek Wanless's suggestion that greater effort needs to be made to measure the effectiveness of different interventions, we believe that this recommendation would lend itself well to objective assessment. If the scheme we propose is accepted, it would be relatively simple to measure the impact on the range of relatively healthy and unhealthy foods offered by supermarkets, and any shift in the patterns of consumption from relatively unhealthy to relatively healthy products.

Food composition

218. It is indisputable that high energy density foods have a particularly pronounced impact on weight gain. The Department stated in its memorandum that the NHS Plan included commitments to initiatives with the food industry to improve the overall balance of diet including salt, fat and sugar in food, working with the FSA. However, the Department's memorandum does not suggest that this has been pursued as a high priority or that significant progress has been made:

Discussions with the food industry and retailers are underway on reducing the level of salt in processed foods. These discussions have demonstrated that industry have made some steps towards reducing salt in processed foods but there is scope for further action. The situation is likely to be similar for fat and added sugars. Options for working with industry on these areas will be considered through 2003-04.[240]

219. Describing the progress made so far in this area in oral evidence, Imogen Sharpe, for the Department, told us that liaising with industry to reduce salt levels, which contribute to high blood pressure although not to obesity, had been tackled as a priority over and above fat and sugar levels under specific instructions from the Chief Medical Officer.

220. The Rt Hon Alan Milburn MP, the previous Secretary of State for Health, has recently issued forthright demands for the Government to tackle food composition as a priority:

Specifically an ultimatum needs to be placed before the industry that unless it voluntarily cuts fat, sugar and salt in food within a specified time frame then tough regulatory action will be taken to ensure that it does.[241]

221. While lowering the fat content of foods would seem a sensible aim, Professor Andrew Prentice pointed out to us that this would not achieve the objective of reducing obesity if, as he believed was already happening, food manufacturers substituted fat with other highly energy-dense foods, such as refined carbohydrates and sugars, in order to keep selling the products to people who had acquired a taste for energy-dense foods.[242] Professor Prentice argued compellingly that it was energy density that needed to be targeted rather than just fat.

222. We note the Government has made efforts to date to reduce salt levels in foods, but we feel that urgent attention should also be given towards tackling obesity. We recommend that, rather than targeting sugar and fat separately, the Government should focus on reducing the overall energy density of foods, and should work with the Food Standards Agency to develop stringent targets for reformulation of foods to reduce energy density within a short time frame. While we expect that reformulation could be achieved through voluntary arrangements with industry, and while we believe that the introduction of legislation in respect of labelling will encourage industry to make the entire product range healthier, the Government must be prepared, in the last resort, to underpin this with tougher measures in the near future if voluntary measures fail.

Food pricing

223. Research has shown price to be a key factor in people's food choices, and our evidence suggests that particularly for lower income families economic concerns may override any health information.[243] Changing food prices to influence people's decision-making in favour of healthier foods could be achieved in two ways—either by increasing the prices of unhealthy foods to act as a disincentive for consumers to purchase them, or by introducing measures to lower the prices of healthy foods, making them affordable to all. In evidence to us, the Department was reluctant to discuss these issues, arguing that "obviously, it is not for government to tell industry how much they charge for a particular food." However, they did state that the forthcoming Food and Health Action plan would be considering food production, supply and availability, and within that equality of access to food.[244]

224. Opinions vary widely on the issue of introducing fiscal measures to raise the prices of high energy density or fatty foods. According to media reports, a paper prepared by the Downing Street Strategy Unit argued that the extension of VAT for some dairy produce, fast food and sweet foods would act as "a signal to producers as well as consumers and serve more broadly as a signal to society that nutritional content in food is important."[245] A report in the British Medical Journal also claimed that a fat tax could prevent 1,000 premature deaths from heart disease alone every year in the UK.[246]

225. However, critics of the idea contend that, as with any 'vice tax', rather than changing their behaviour people simply divert spending from other necessities. It has been suggested that a fat tax would disproportionately affect lower income families, who already spend a higher proportion of their income on food and drink. The plans have also attracted criticism for ideological reasons: according to Martin Paterson, of the Food and Drink Federation, "Consumers will rightly feel patronised by 'top-down' messages based on the idea that they can't think for themselves and need to be taxed into weight-loss."[247]

226. Value Added Tax is already levied on certain 'treat foods': savoury snacks, ice cream, confectionery and fizzy drinks (including zero calories diet drinks) all incur VAT at 17.5%. PepsiCo pointed out in their written memorandum that this has given rise to an anomalous situation, in that other, similar treat foods are zero rated, such as cakes, cake bars, plain biscuits, Jaffa cakes, cookies, Bourbon biscuits and Ginger Bread Men with chocolate eyes—but the addition of chocolate buttons on to any of these products would result in VAT being levied.[248]

227. The healthcare costs of obesity rehearsed earlier illustrate how the NHS and society have to pay for causes out of their control. The price of cheap, fatty, sugary foods, for instance, does not include the healthcare costs that may follow much later from excess consumption. In formal economic terms, when consumers purchase cheap calories, there may be further indirect costs much later. This raises complex issues which the Wanless Reports have begun to address. The recent World Health Organisation draft strategy on diet and physical activity suggested that member states consider taxes and other fiscal measures to send more health-enhancing price signals to consumers.[249]

228. The notion of taxing unhealthy foods is fraught with ideological and economic complexities, and at this stage we have not seen evidence that taking such a significant and difficult step would necessarily have the hoped-for effect of reducing obesity. We recommend, instead, that the Government should keep an open mind on this issue, and monitor closely the effect of fat taxes introduced in other countries. We also recommend that the Government should take steps to address the anomalies in the current arrangements for VAT on unhealthy 'treat' foods as it is clearly ludicrous that VAT is levied on ice cream and fizzy drinks but not on Bourbon biscuits or cakes.

229. The other side of the food pricing equation would be to attempt to lower the prices of healthy foods so that they present a realistic and affordable alternative for everyone, as currently healthy foods, both 'healthy' versions of pre-prepared foods, and naturally healthy fruit and vegetables, can cost significantly more than non-healthy alternatives.

230. We hope that as the Government and food industry work together to reduce the energy density of foods, the need for 'healthy' options will be gradually reduced, with standard versions of foods being healthy as a matter of course. However, as this is likely to be a phased process, we recommend that in the short term the Government must work with the food industry to ensure that 'healthy' versions of foods, with reduced calories and fat, are available at an affordable price.

231. Evidence suggests that there may be considerable scope for trimming the profits attached to fresh fruit and vegetables, as according to Friends of the Earth, fruit and vegetables are significantly cheaper in street markets than in supermarkets.[250] DEFRA put average 'farm gate' prices (what a grower actually takes, after paying the costs necessary to supply the supermarket, including grading, packaging and transport) for Cox apples in October 2002 at £0.33 per kilo, while the average supermarket retail price for the same period was £1.45 per kilo.[251]

232. This inquiry has not probed in depth the complexities of European agricultural policies. However, it is clear that while the potential for the CAP to work in concert with public health policy has been recognised for over 20 years, numerous attempts to reform the CAP to these ends have failed. The UK's Committee on the Medical Aspects of Food Policy recommended that the Government should review the CAP's impact on diet as long ago as 1984, arguing that "consideration should be given to ways and means of removing from the Common Agricultural Policy those elements of it which may discourage individuals and families from implementing the recommendations for dietary change."[252] More recently, in 1999 and in 2002, this has been raised by the World Health Organisation:

Despite a call for public health to be considered in all EU policies in 1999, no review of the CAP objectives has occurred and public health is still not mentioned as a policy determinant in the Agenda 2000 reform or in the recent mid-term review of CAP.[253]

233. According to the Consumers' Association report on the CAP, "nutrition considerations have been given scant concern by agricultural policy makers, even though diet and health are closely linked."[254] The initial reluctance of DEFRA to contribute to our inquiry on obesity could be regarded as further evidence of this continuing lack of linkage between agricultural and health policy, and the fact that the Department of Health was the last government department to respond to the Curry Commission consultation on the future of food and farming could also be seen to indicate a lack of pro-active communication in this area.

234. When a representative of DEFRA, Mr Callton Young, did eventually give evidence to us, he stated that he had not come briefed to talk about the Common Agricultural Policy. However, he confirmed that:

The CAP does have a role to play … in terms of the health and nutrition agenda. The price of food is very clearly linked to what people buy and the extent to which it is subsidised must have a feedback down the chain to the consumer.[255]

235. Mr Young agreed that the promotion of healthier food "has to be a part of the Common Agricultural Policy."[256] However, although he emphasised the need for government departments to "look at these things holistically", when asked why his Department had not mentioned nutrition on its website he argued that that was because "the lead policy responsibilities for nutrition and health reside with the Department of Health."[257] Mr Young said that the issue of the CAP had been raised at cross-governmental steering group meetings for the Food and Health Action Plan, but he feared that what could actually be done about the CAP was "a much more difficult nut to crack".[258]

236. Following on from our oral evidence session, DEFRA submitted written information on the CAP, in which they told us their policy objective was to "move away from a position where the market and demand have been distorted by over-supply of some products and measures to address that over-supply." This meant, in their view, that "to this extent we will be neutralising the CAP as a force which may have contributed to increasing obesity." However, DEFRA ended on a note of pessimism, stressing the need to be realistic about what reform of the CAP could and could not achieve, and arguing that "in reality the CAP is not a particularly important factor in causing obesity."[259] This attempt by DEFRA to distance agricultural policy from health by playing down its impact does not strike us as particularly helpful in achieving joined-up solutions to this problem across government.

237. As a matter of urgency, the Government must redouble its efforts to reform the Common Agricultural Policy as part of the public health agenda, and the future UK presidency from July 2005 will afford an opportunity for this to be done. Obesity is, after all, a growing problem in almost all EU countries. The issue of agricultural policy presents a perfect opportunity for the Government to demonstrate that it is committed to tackling public health issues in a joined-up way, an opportunity which in our view it has to date entirely neglected. However, as noted above, progress on the CAP will be extremely difficult unless public heath is given much greater emphasis in Europe. We therefore call on the Government to use its influence, and its forthcoming presidency, to encourage the Commission to reconsider the Treaty of Rome and put public health on an equal footing with trade and economics.

238. In the interim, the Government, led by the Treasury should emulate the Swedish Government[260] and produce a Health Audit of the CAP, and build a stronger alliance of Health Ministries to combat other interests protecting the status quo in public policy.

239. As well as healthy food being generally more expensive than less healthy alternatives, this inequity is compounded by the now widespread use of price promotions which are heavily biased in favour of unhealthy foods. This is now an accepted part of food marketing, ranging from 'buy one get one free' price promotions in supermarkets, to super-sizing of meals in fast food restaurants and 'meal deals' on take away lunchtime foods.

240. We note that there have been improvements overall in the numbers of supermarkets where there is no confectionery available at the till. We were interested to hear that ASDA, who came out worst in a Food Commission report into this area, were now trialling the sale of fruit and non-food items at the till. We look forward with interest to hearing how this trial has gone.[261]

241. During this inquiry we have heard repeatedly that industry is keen to be 'part of the solution'. If this desire is to be translated into reality, then supermarkets should adopt new pro-active pricing strategies that positively support healthy eating, rather than acquiesce in the view that their duty to their customers goes no further than simply providing the range of foods which they want to buy. As part of their healthy pricing strategies, supermarkets must commit themselves to phasing out price promotions that favour unhealthy foods, and also stop all forms of product placement which give undue emphasis to unhealthy foods, in particular the placement of confectionery and snacks at supermarket checkouts. Alongside this, all sectors of the food industry should collaborate in the phasing out of super-sized food portions. We expect that the food industry will be keen to capitalise on the significant commercial opportunity that introducing these policies will present, and indeed much good work has already been done in this area. Several supermarkets have already committed themselves to banning the placement of confectionery at checkouts, and Kraft and McDonalds have begun to limit the availability of super-size portions. We commend fast-food outlets for offering fruit and salad options, though we request that these should be promoted more effectively than at present. Those companies who do not comply with Government guidance on healthy pricing, including product placement and super-sizing, should be publicly named and shamed.

Food in schools

242. Throughout our inquiry, the diet of children and young people has been a recurring theme. A survey conducted by the Consumers' Association in March 2003 asked 246 children to compile a food diary which revealed that, despite the fact that children seemed to know what foods were healthy and to understand the health implications of poor diet, children in Year 6 and the girls in Year 10 ate just two portions of fruit and vegetables per day with boys in Year 10 eating just 1.5 portions. Most children ate at least one bag of crisps a day, and many had sweets or chocolate every day.[262]

243. We have already discussed in detail the promotion of unhealthy foods to children in schools, through a wide variety of schemes embraced for the commercial benefit they bring to schools without consideration of their wider health implications. In our view these should be stopped immediately. We have also made recommendations to improve the teaching of cookery in schools to teach children to choose and prepare healthy meals. However, to support improvements in both of these areas, a good example needs to be set in the school meals provided by schools themselves, something that does not seem, at present, to be happening. Again, we cannot accept that this is a matter purely for local determination by schools. Children's nutritional requirements do not vary according to where they happen to go to school.

244. In the course of our inquiry we examined the standards for school lunches that have been adopted in England and Scotland. Technically, both Scotland's standards and England's guidance include the nutrient recommendations for school meals developed by Caroline Walker Trust Nutritional Guidelines for School Meals.[263] However, the placement of the nutrient guidelines within Scotland's standards and England's guidance is telling. The nutrient requirements are located in the first section of Scotland's standards which emphasise that their achievement is "essential."[264] Moreover the overall tone is that compliance is required, or at least expected; the standards speak in terms of "should," "required," and "achievement," as well as stating maximums and minimums. To this end, the Scottish Executive has commissioned the development of nutritional analysis software to assist schools in self-evaluating the compliance with these standards.[265] Caterers will be able to utilise the software to analyse the nutritional content of recipes.

245. In contrast, we were disappointed to learn that England's guidance specifically and conspicuously states that only the regulations, which do not require any specific nutrient content, are compulsory and that the guidance on good practice is "not required by law."[266] The nutrient recommendations are placed in the back of the guidelines as an annex, where it is suggested, but not required, that an approximate nutritional analysis could be accomplished by the caterer, the school food committee using a computer software package, or by an independent expert such as a community dietician.[267] The overall effect of placing the nutrient recommendations at the end, pointing out that the guidance is not compulsory, and using terms such as "aim" and "try," is that the specific nutrient content of school meals is marginal.

246. We also learned that in Scotland, standards bar the provision of fizzy drinks as a part of a school meal in primary schools, and bar the encouragement of the provision of such drinks in secondary schools.[268] Crisps, as a part of a combination meal option/meal deal or packed lunch may only be offered twice per week.[269] Neither England's regulations nor guidelines bar, limit, or discourage the provision of crisps or fizzy drinks.

247. We were please to learn from the Minister for Children that the DfES has asked the FSA and Ofsted to conduct a review of the implementation of the nutritional standards for school lunches introduced in July 2000.[270] However, we were disappointed to learn that the scope of the review did not extend to include school breakfasts.[271]

248. We recommend that the Department for Education and Skills extend the scope of the FSA review of the implementation of nutritional standards, with a view to developing appropriate nutrient based standards for school breakfasts.

249. Furthermore, we recommend that the Department for Education and Skills takes steps to ensure that all children eat a healthy school meal at lunchtime, both through improving the provision of attractive and palatable 'healthy' options, and through restricting the availability of unhealthy foods. The Government should shift from the current 'food-based' standards towards the 'nutrition-based' standards being introduced in Scotland. The quality of school meals should also be taken into account by Ofsted inspections.

Causes of obesity relating to physical inactivity: solutions

250. Making society as a whole more active is an extremely difficult task. As we have seen, the forces promoting sedentary behaviour have grown substantially over the last few decades. There are few grounds for optimism that there will be a reversal in these trends. More and more labour-saving devices are being created, car ownership continues to grow, traffic volumes continue to increase, local shops are being replaced with out-of-town stores, and fear of crime keeps people increasingly indoors. It will require a remarkable cultural shift if society is to become more active across all social classes; a trickle of pilot projects and local schemes will not be adequate.

251. The costs to the NHS of low levels of physical activity are high. Yet as Barry Gardiner MP pointed out to us, spending on treatment dwarfs spending on promotion of physical activity, which, if adequately tackled, could offset some of those considerable health costs:

We spend £886 per head of population per year in providing what amounts to a national sickness service and we spend £1 per person per year on sports and physical activity which could actually prevent a lot of that sickness.[272]

252. As we have noted, the current Government target for physical activity for adults is 30 minutes of moderate activity 5 times per week. Yet currently only 32% of adults achieve this, less than a third of the population, compared to 70% in Finland. The lead department on physical activity is the Department for Culture, Media and Sport. In its document Game Plan, jointly produced with the Prime Minister's Strategy Unit in December 2002, DCMS set a very ambitious target that 70% of people in England should attain the current activity goal by 2020. As Sport England commented, "This presents the Government—and key partners—with an exacting challenge. To put it bluntly, 100,000 inactive people will have to be converted to physical activity every single month for the next 17 years if the Government's targets are to be met."[273]

253. In this section of our report we want to examine what is being done to boost activity levels. In doing this it is important to distinguish between two separate ways in which activity is achieved:

  • organised and recreational activity, in the form of sports and other activities either in schools or in the community; and
  • activity within daily life, which embraces areas such as active travel and activity within the workplace.

254. These areas are not, however, entirely discrete. For example, children walking or cycling to school are likely to be fitter than those who journey by car; they are more likely to enjoy and benefit from sport; and the sporting habits they develop at school are then more likely to feed into an active lifestyle when they attain adulthood.

Organised and recreational activity

255. It is by no means clear that countries with high levels of active recreation and sport will necessarily be less obese—Australia has some of the fastest growing levels of childhood obesity. It may be that boosting the facilities for active recreation will in fact exaggerate health inequalities since the middle classes are much better at accessing these. The Chief Medical Officer's recent report on activity and health emphasises that physical inactivity is not merely a critical factor in obesity but also is implicated in 20 other diseases and conditions and in particular hugely increases the risk of cardio-vascular disease, diabetes and cancer.[274] In the treatment of obesity, disease reduction is just as important as weight loss and the Chief Medical Officer also supported the notion that activity significantly reduces disease in the obese.

256. The impact of school-based activities is also complex. While there is no doubt that active children tend to be less overweight and indeed to achieve more academically, organised school sport seems to alienate many children, and there is ample evidence to suggest that much bullying begins in the changing room. But while school sport occupies only a tiny fraction of the child's waking hours—around 1% a year—it perhaps is most useful in fostering habits of activity which can last a life time.

257. Game Plan records that levels of participation in sport have not increased much in England in recent years. Only 46% of the population take part in sport more than 12 times a year compared to 80% in Finland.[275] Following a recommendation contained in Game Plan, Sport England, the body charged with the strategic lead for sport, working with relevant stakeholders, is developing a national database which will provide a comprehensive audit of community sports facilities. This database will provide guidance to Government Departments, Lottery Distributors and local authorities on needs-based strategic investment priorities. The database will also provide information for the public on what facilities exist and where they are located.

258. Sport England has been modernised following Game Plan's publication so that its objectives now explicitly acknowledge the significance of the health agenda and its responsibility to help promote active and healthy lifestyles.

259. Many different initiatives support sport in the community but in the longer term the uptake of sport will, we believe, be driven more by what is achieved with younger people than with adults. Most of our evidence on sport and PE has focused on young people. As Sue Campbell, for the Youth Sport Trust, remarked:

There is no question now that young people are far more sedentary by nature almost and we are creating young people who are very computer-literate, who are very engaged with other forms of learning and have almost forgotten how to learn physically.[276]

260. In 1999, the then Secretary of State for Education, the Rt Hon David Blunkett MP, announced his intention to address declining physical activity in schools. The National Healthy Schools Standard encouraged schools to provide pupils with a minimum of two hours of physical activity within and outside the national curriculum. However, there is no method of compelling schools to meet this standard and obese children often continue to opt out of activities outside the main curriculum. The Child Growth Foundation was moved to describe "the continued absence of any National Curriculum amendment to provide every child with the two hours per week of enjoyable structured physical activity to which they are entitled" as a prime illustration of Whitehall's inability to tackle obesity. [277]

261. In October 2002, the Prime Minister announced an investment of £459 million to deliver "a national strategy for PE, school sport and club links."[278] Both the Department for Culture, Media and Sport and the Department for Education and Skills now have a PSA target that 75% of school children should undertake two hours of high quality PE and school sport each week by 2006, and a number of programmes have been put in place to support this. The Qualification and Curriculum Authority is also exploring ways of improving PE and sport in schools.

262. To help achieve the two hours weekly target, the Government is developing School Sport Partnerships.[279] These are families of schools that come together to enhance sports opportunities for all. The partnerships comprise: a specialist sports college, eight secondary schools and 45 primary or special schools clustered around the secondaries and the College. Each partnership receives a grant of up to £270,000 each year. This funds: a full time Partnership Development Manager, the release of one teacher from each secondary school for two days a week to allow them to take on the role of School Sport Coordinator, the release of one teacher from each primary or special school for 12 days a year to allow them to become Link Teachers; and Specialist Link Teachers who fill the gaps created by teacher release.

263. Six strategic objectives have been set for partnerships:

  • Strategic planning—to develop and implement a PE/sport strategy.
  • Primary liaison—to develop links, particularly between Key Stages 2 and 3.
  • Out of school hours—to provide enhanced opportunities for all pupils.
  • School to community—to increase participation in community sport.
  • Coaching and leadership—to provide opportunities in leadership, coaching and officiating for senior pupils, teachers and other adults.
  • Raising standards—to raise standards of pupils' achievement.

264. By 2006, there will be 400 partnerships including 75% of schools in England. A recent survey conducted for DCMS indicated considerable success for the scheme:

68% of pupils in schools that have been in a partnership for three years, are spending at least two hours each week on high quality PE and school sport in and after school, rising to 90% at Key Stage 3. This compares to 52% for schools new to the programme.[280]

265. The Government has checked the trend established in the 1980s of local authorities selling off school playing fields to raise capital. Active protection (through legislation introduced in 1998) and strict planning regulations has resulted in an average of only three applications a month being approved, and almost half of these are at schools which are closed or closing. In all cases, any proceeds are being ploughed back into improving sports or educational facilities—the proceeds are not being spent on school books or teachers' salaries.

266. Some £581 million is being invested in England by the New Opportunities Fund with the aim of improving and increasing sports facilities at schools. This funding will be used to support projects designed to bring about a step-change in the provision of sporting facilities for young people and for the wider community, through the modernisation and development of existing and new facilities for school and community use (including outdoor adventure facilities), and the provision of initial revenue funding in support of these developments.

267. An investment of £130 million is being allocated to 65 Local Education Authorities through the Space for Sport and the Arts programme to develop new sports and arts facilities on primary school sites. As well as benefiting schools themselves, these premises will also be available for community use, with the emphasis on inclusion of currently under-represented groups.

268. We commend the wide range of measures and substantial funding being directed by the Government towards physical activity, particularly in schools. While we have reservations about the effectiveness of measures taken to date, we wish to pay tribute to the efforts that have been made in the last two years and to acknowledge the substantial funding that has been provided.

269. As we noted above, the majority of children still fail to achieve two hours per week of structured activity. In many cases, schools do not have the resources to provide the suggested amounts. A House of Commons Committee of Public Accounts report found that "achievement of children's entitlement of two hours of physical exercise a week requires an adequate and equitable distribution of facilities. There is, however, a considerable disparity in the opportunities for sport currently being offered to children by different schools."[281]

270. A large amount of anecdotal evidence—including accounts given to the Committee at the 'Watch It' clinic in Leeds—suggests that obese children are often bullied, a problem that may become more acute when children are involved in traditionally competitive school sports. Many children opt out of school sports as they find competitive team sports unattractive. The National Curriculum for Key Stage 2 states that PE should be taught through dance activities, games activities, gymnastic activities and two activity areas from swimming, athletics and outdoor and adventurous activities, although there are no specifications within these areas, and no guidelines about how vigorous these activities should be. Guidance from the DfES also stresses that provision should encourage children to enjoy PE and be keen to get involved. It is clear then that schools need to offer a range of activities in order to attract all pupils. This, however, can be difficult when resources are stretched and facilities are inadequate.

271. Barry Gardiner MP, who gave evidence to us, has proposed a more radical plan which will be piloted in four schools in Brent North from September 2004, starting with pupils in Year 7. Here, the school day will be extended to run from 8:30am-6pm, which will allow the possibility of two guaranteed hours of sport in each school day. Mr Gardiner argued that as well as improving the health of school children, the scheme would provide a number of other indirect benefits such as a reduction in youth crime, improved scholastic achievement and increased social cohesion.

272. If playing sport is not possible for some children, Mr Gardiner proposes that music, art or drama could be taught instead, which would also help relieve pressure on teaching staff. To avoid children being put off sport for life they should instead be offered "a smorgasbord, a whole range of physical activities." This might range from "ethnic dance right through to boxercise."[282] Teachers for the PE session could be assisted by volunteers and School Sports Co-ordinators (a scheme organised by Sport England).

273. Mr Gardiner's scheme also recognises the need for healthy food in schools. His proposal provides children with healthy balanced meals—an optional breakfast club in the mornings, a nutritionally balanced lunch at 1pm followed by the two hours of sport from 2pm-4pm. There would follow another break which would incorporate a carbohydrate-based snack to keep the pupils going for the rest of the day. [283]

274. A project co-ordinator will supervise the Brent scheme and £150,000 is being devoted to evaluate it. According to Mr Gardiner, initial reaction from both teachers and parents has been enthusiastic.[284] However, the response from the Government so far had, in Mr Gardiner's words, been limited to "a great many kind words".[285]

275. We regard it as lamentable that the majority of the nation's youth are still not receiving two hours of sport and physical activity per week. While we very much welcome the DCMS/DfES target to have 75% of school children thus active by 2006 we do not believe that this goes far enough. We have reservations about the quality of much of the activity undertaken, since little work has been done to establish what the two hours involves, and whether it includes, for example, time taken in travelling to and from facilities. Moreover, even the two hour target puts England below the EU average in terms of physical activity in school, despite the fact that childhood obesity is accelerating more quickly here than elsewhere.

276. We recommend that, given the threat of obesity to the current generation of children and taking account of the proven contribution of physical activity to academic achievement, the aspiration should be for school children to participate in three hours per week of physical activity, as recommended by the European Heart Network.

277. Relentless pressure on the curriculum has served to squeeze out school sport and PE. However, there is ample evidence that being physically active benefits children's academic performance, and many schools in the independent sector offer four or more hours of exercise per week. We know that the Government is monitoring closely the Brent project but that it has been less than forthcoming with supportive funding. We believe that this is a fascinating pilot project and would like to see it rigorously evaluated. Given its potential importance as a model, we also think it would be helpful if the Department's favourable initial appraisal of the scheme were supported by funding.

278. We recommend that the Curriculum Authority should address ways of diversifying organised and recreational activity in schools to embrace areas such as dance or aerobics to broaden the appeal of PE and to counteract the elitism, embarrassment and bullying that the changing room sometimes creates.

279. We do not think it appropriate that the activity of a school in delivering the physical activity agenda should be extrinsic to any evaluation of its overall performance. Physical activity is not—or should not be—a second order consideration. Not only is it crucial to children's health but it also directly benefits academic performance. So we recommend that the Ofsted inspection criteria should be extended to include a school's performance in encouraging and sustaining physical activity.

280. The psychosocial aspects of obesity, which are often ignored in the drive to improve physical health, are particularly important in children. Obese children are frequently bullied and school sport can prove a humiliating experience. We recommend that the Department for Education and Skills, as part of its wider work to improve self-esteem and self-confidence amongst school children, should ensure that each school, as part of its policy against bullying, remains alert to the particular issue of bullying of children who are overweight or obese. Teachers should receive training in children's diet, physical activity levels, and how to help obese children combat bullying, without further stigmatising them.

Active lifestyles

281. When physical activity is mentioned, what springs to mind most readily is probably what Susan Jebb termed "programmed, planned exercise", such as joining a local sports team, going to an aerobics class, or using an exercise bike. However, as Living Streets argued, "for many people, joining a gym or taking part in a team sport are not realistic options—for economic or time reasons."[286] Our witnesses stressed repeatedly that rather than promoting planned sport or active recreation, which might require life changes that were unsustainable, a far more useful and realistic aim was to increase activity levels within people's daily lives. Of these lifestyle changes, perhaps the single most important concerns transport.

282. In a report published in 1997, the British Medical Association confirmed the links between transport and health.[287] Evidence from the United States and Australia has also indicated that promoting walking can change lifestyles and improve health.[288] Many commentators have argued that a national transport plan could provide a useful tool to promote and facilitate active methods of transport. According to Living Streets, "regular walking as part of a daily routine is a viable option and involves only modest changes to lifestyle."[289]

283. Targets to increase walking and cycling within the fabric of everyday life have been set by successive governments but have totally failed. Levels of each activity have dropped to an extent which we find startling. As we have noted, levels of walking and cycling have fallen dramatically in recent years.

284. Published research from Bristol University and elsewhere using accurate measures of children's movement indicates clearly that most energy expenditure takes place when children walk to school, play out at break times and again after school.[290] Informal play seems to be more important than formal activity at least up until the teen years. Furthermore, this work shows that children are less active at weekends and in school holidays, indicating how important the school and its schedule of activities, not just formal PE and sport are to facilitating children's activity. We believe that providing safe routes to school for walking and cycling, adequate and safe play areas in and out of school is very important in the battle against obesity.

285. The Environment, Transport and Regional Affairs Committee in its report on Walking in Towns made a wide-ranging and cogently argued series of 25 recommendations.[291] These included:

  • The Government should set targets to increase the level of walking.
  • The Government should publish a national walking strategy.
  • Planning procedures should give priority to walking.
  • Conditions for the pedestrian should be improved by ensuring that walking routes are continuous, well-connected to key destinations and well-signed, and that where such routes meet major roads in urban areas, pedestrians have priority.
  • Particular emphasis should be given to creating good routes to important facilities, including schools and rail and bus stations and bus stops.
  • More traffic-calming and traffic restraining measures should be introduced.

286. Our witnesses echoed many of these points. Tom Franklin for Living Streets suggested that there should be a pedestrian pavement run-off at every junction.[292] John Grimshaw, for SUSTRANS, gave the example of Hull to illustrate the dramatic impact of reducing traffic speeds in cities to 20 mph.[293] Hull has implemented over 100 zones with 20 mph speed limits and the total number of road crashes in the zones has been reduced by 56%. Crashes involving child pedestrians have been cut by 70%.[294]

287. The measures proposed by the Environment, Transport and Regional Affairs Committee in its report Walking in Towns 2001 strike us as sensible and persuasive and we are sorry so little action has been taken to implement them.

288. Given the profound impact increased levels of activity would have on the nation's health, quite aside from the obvious environmental benefits, it seems to us entirely unacceptable that successive governments have been so remiss in effectively promoting active travel.

289. The Department for Transport again suggested to us that it was aiming to publish a consultation for a national walking strategy this year. The Department for Transport set out an overarching transport strategy in its 10 Year Transport Plan published in 2000. This put forward no targets to stop the deterioration of footways, which acts as a barrier to walking.

290. Tom Franklin for Living Streets had no doubt that the reluctance to introduce the strategy stemmed from political squeamishness:

The problem is that the Government is almost embarrassed about promoting walking. I have to say that I think that this comes from the John Cleese sketch 25 years ago of the Ministry of Silly Walks. Since 1996 every Transport Minister has promised a national walking strategy and every one has failed to deliver … They have not delivered because each time they get cold feet because they think they are going to be perceived as the Minister for Silly Walks.[295]

291. The Department for Transport representative giving evidence to us was tentative about progress, telling us that a document would be forthcoming imminently, but that rather than a strategy this would be a consultative 'document' containing some proposals.[296] The Department organised a series of seminars, then announced a consultation in the document On the Move by Foot. That paper, which is extremely slight, encloses a separate report prepared by Transport 2000, not by the Department. The consultation closed in September 2003 but as yet no strategy has been put in place.

292. We regard the failure of the Department for Transport to produce a National Walking Strategy over a period of almost ten years as scandalous. This very inactivity clearly demonstrates that the priorities of the Department lie elsewhere. We would be extremely disappointed if concerns about political embarrassment had indeed obstructed such an important policy. One way of defusing any political embarrassment would be to incorporate the walking strategy into a wider anti-obesity strategy.

293. Assessing the precise contribution that walking can make to combating obesity is difficult, but we have been greatly struck by the potential of pedometers to increase awareness of sedentary behaviour and thus promote activity. The Department of Health is working in partnership with the Countryside Agency and the British Heart foundation to part-fund a targeted pilot project which will distribute pedometers to PCTs in areas of high deprivation as a motivational tool to encourage increased walking. This builds on the Countryside Agency's Walking the Way to Health initiative.[297]

294. Pedometers, which are small and inexpensive electronic devices used to count the number of steps a person takes in a day, can be a very useful tool for encouraging people to live more actively. According to Tom Franklin, "people only have to wear them for a week or so before they start to get a pattern of their exercise and they start to consider, if they did that slightly differently, what the effect would be."[298] The promotion of walking plays a key part in America's strategy to combat obesity, the America on the Move initiative being piloted in the Colorado on the Move scheme.

295. Launched in October 2002, Colorado on the Move is a state-wide initiative aimed at combating obesity.[299] It has programmes to increase physical activity in schools, worksites and communities. Pedometers are distributed to help participants monitor and increase physical activity. The aim is for participants to increase their daily walking by 2,000 steps per day. It is interesting to note that, so relentless has been the rise in obesity in the USA, the goal of Colorado on the Move is not to reduce the weight of the population but rather merely to stop the weight gain. The programme is now being modified to include dietary advice.

296. So far, over 75,000 people have participated in the scheme, ranging from public sector employees, to private companies, churches and native American Indian tribes. In two pilot projects based in communities with high-risk populations in Colorado, average increases of 2,000 steps have been achieved. Within schools, children are being encouraged to make use of the pedometer data within other lessons, for example by marking the total steps taken on a map and seeing how far they have travelled.

297. In America we ourselves were given Coca-Cola pedometers, and Colorado on the Move has sponsorship from a variety of commercial sources including Pepsi. We were told that Kellogg's was considering issuing pedometers.[300] McDonalds has also very recently announced a plan to distribute pedometers with Happy Meals in 2004 in England.[301] We believe that there is great potential for pedometers in making people more aware of their general activity levels and giving them an incentive to increase these. However, the mere issue of pedometers is unlikely to do much to address the problem. People need to be told how to use them, know what targets are desirable, and learn to make increased activity a life-time habit rather than a temporary goal. We believe it would be helpful if commercial firms issuing pedometers also issued guidance agreed with Sport England and the FSA, on the recommended activity levels per day and on the correlation between steps taken and calories consumed.

298. If bought in bulk, simple pedometers are very inexpensive and we can envisage a range of possible providers. These could include:

  • Schools, who could keep sets of pedometers for use with different classes at different times. As in Colorado, pedometer data could be incorporated into other areas of the curriculum besides PE.
  • Employers, who could issue pedometers to their staff, possibly even offering incentives for their use.
  • GP practices, who could offer targeted advice to individuals, and use pedometers to help address the causes rather than the consequences of obesity which is what they largely treat now.

299. We welcome the funding the Department of Health has provided to a pilot project on the use of pedometers. We recommend that the Department co-ordinates inter-departmental activity with a view to achieving wide-spread use of pedometers in schools, the workplace and the wider community.

300. A number of witnesses pointed to the contribution they believed that cycling could make in combating obesity. The English Regions Cycling Development Team argued that there was a suppressed demand for cycling as there are more than 20 million bicycles in the UK, many of which were rarely used.[302] Sustrans suggested that countries which were broadly socio-economically similar to the UK but with much higher cycling rates had lower levels of obesity, as this graphic demonstrates:

301. They contended that obesity was a symptom of the way the physical environment was planned and argued that changes should be made to encourage and facilitate active forms of travel, such as higher parking charges and improved cycling routes. In a survey of users of their National Cycle Network, 70% stated that the existence of the route had helped to increase their level of physical activity. Many of the proposals put forward by Sustrans could also link with attempts to improve healthy routes to school.[303] The Office of the Deputy Prime Minister therefore has a role to play in encouraging or demanding that town planning guidance includes measures to encourage physical activity.

302. The Department for Transport published a National Cycling Strategy in July 1996 with the target of increasing the number of cycle journeys four-fold by 2012. As part of the strategy a leaflet was published offering guidance to employers on ways to encourage their employees to cycle to work. It also referred to the co-ordination role that local authorities could play in stimulating changes to make cycling an attractive means of travel to work for more people.

303. The leaflet suggests a number of measures that employees could take to encourage cycling to work, including the provision of safe, secure and covered cycle parking, lockers, changing/drying facilities and showers and the offer of interest-free loans to purchase bicycles. The Department for Transport also pointed out the benefits to employers of this policy. By having a fitter, healthier workforce, employees will take fewer sick days and will have improved levels of concentration.[304]

304. The 10 Year Transport Plan was published in 2000. This included an ambitious target to treble the number of cycling trips between 2000 and 2010. It provided additional funding to make conditions easier and safer for pedestrians and cyclists. The Plan requires authorities to prove, through Local Transport Plan (LTP) Annual Progress Reports, that they are developing and implementing strategies to secure significant increases in cycling and walking. Over the five-year period of the first LTPs, local authorities estimate they will deliver over 5,500 km of new or improved cycle tracks and cycle lanes. Around 1,200 km of cycle tracks and lanes were laid by local authorities in 2001-02 an increase of 43% on the previous year. In the same five-year period LTPs estimate that they will deliver over 1,000 km of new or improved footways and pedestrianisation schemes.

305. In 2002 two initiatives were launched by the Department for Transport to help deliver increased levels of cycling. A National Cycling Strategy Board was set up to co-ordinate and monitor implementation of the National Cycling Strategy, supported by a network of regional advisers to promote good practice and provide support to local authorities. Additionally, a Cycling Projects Fund, with £2 million funding was launched in March 2002 to support projects that can achieve a significant increase in cycling locally, or raise public awareness of the increase in cycling opportunities.

306. However, in the progress report on the ten-year plan, Delivering Better Transport (December 2002), only two of the 150 pages are devoted to progress in encouraging cycling and walking. This report also admits that latest available data from the National Travel Survey suggest that, as of 2001, the long-term decline in cycling and walking had not been reversed.

307. In 2002, the then Transport, Local Government and the Regions Committee expressed "little confidence" that the target for cycling increases would be met, detecting few signs of any growth in cycling in the first two years of the period.[305]

308. CTC, the National Cyclists Association, suggested some additional policies that would be useful to increase the number of cyclists, such as integrating cycling with public transport by creating cycle carriages on trains and buses, providing cycle hire facilities and doing more to tackle the growth of traffic and reduce the need to travel.[306]

309. Countries such as the Netherlands and those in Scandinavia have seen a much slower increase in obesity rates in the last 20 years and this is generally attributed to those countries' inhabitants having a much more active lifestyle, and in particular greater opportunities for active transport. In countries where there have been steady increases in cycling, such as in Denmark, there has been a reduction in casualty rates per mile. This has been achieved by "adopting comprehensive measures to create better conditions for cycling and because the more cyclists that there are, the more motorists are aware of cyclists and consequently the better they are at dealing with them."[307]

310. Again, a Health Committee report is not the appropriate forum to discuss the detailed measures required to increase cycle use on a massive scale. We can, however, record some of the key points that our witnesses made. John Grimshaw for Sustrans suggested that "Mostly any cycle lane stops exactly where you want it, at the junction." He urged that pedestrianised city centres should be permeable to cyclists. He also suggested that greater priority should be accorded to cyclists, for example by making one way streets two way for cyclists, as was common on the Continent.[308] Employers could play their part by ensuring that there were adequate cycle parking facilities and showers and changing rooms available.

311. Denmark is a country with some of the highest cycling rates in Europe, and cyclists are given much more priority in transport planning. We visited Odense, Denmark's third largest city, which has a population of 200,000. The Danish Department for Transport has nominated Odense as Denmark's "national cycling city." Cycle use rates are extremely high. In Odense we met local urban planners to see what made the city so appealing for cyclists.

312. It was immediately obvious that cyclists were granted a far higher status in this city than in any in England. Dedicated cycle paths, screened from cars and pedestrians, allowed cyclists access to all of the city centre. A covered cycle parking space with room for 400 cycles had replaced a car park which had accommodated eight cars. It was even possible, for a small fee, for people to lock a cycle and any valuables away in a secure automated garage facility. As in all Denmark, there is a presumption that liability for an accident involving a motorist and a cyclist lies with the motorist. This is not the case in English law.

313. The sophisticated and comprehensive cycle network we witnessed had not been designed into Odense—this is an historic city, with a cluttered centre made up of eighteenth- and nineteenth-century buildings. It has had to be integrated within an existing city, as would be the case with major towns and cities in England. We were told that the current configuration for cycling was actually the third phase of planning. For almost 20 years Odense has been working to develop cycling. We were particularly impressed to see how children were involved in the planning process. Each year, children in schools are asked to use a computer program to map their journey to school. On this, they mark any hot-spots where they feel in danger. This information is then collated and planning authorities give priority to improving conditions at these danger spots. We also commend the approach we saw in Odense, where funding support for school transport was based on the degree of danger in covering the route from home to school by other means. This provides a financial incentive on the authorities to create safer walking and cycling routes.

314. We are pleased to note that the Department of Health has recently been involved in active travel plans. According to one of our witnesses, it was essential that the Department should have an input into transport policy; for this witness at least, that had not always been the case:

The Department for Transport has this target of increasing cycling four-fold to eight per cent of all journeys, which would more or less be in common with what was achieved in Sweden. I am sure that the Department of Health have not put their weight behind that; they probably do not even know it exists. Yet a four-fold increase in cycling would probably be more valuable for their aspirations than for the Department for Transport which is actually only interested in reducing congestion.[309]

315. The Department for Transport has recently announced that it will provide funding for "sustainable travel towns". It has set aside £10 million to help develop plans for sustainable transportation in three towns in England. These towns will "incorporate all aspects of best practice to encourage walking, cycling and other public transport use and act as showcases for other towns wishing to promote greater travel choice." Darlington, Peterborough and Worcester were selected from applications by 51 local authorities who submitted expressions of interest. They were selected on the basis of fully worked-up plans to deliver a sustainable transport scheme aiming to produce innovative school, work and personal travel plans; cycle lanes and improved cycle parking; better conditions for walking; and improved bus services.[310]

316. It would not be appropriate for us to spell out the individual measures required to achieve the Government's ambitious cycling targets, although we were particularly impressed by the segregation of cyclists from road traffic we witnessed in Odense. If the Government were to achieve its target of trebling cycling in the period 2000-2010 (and there are very few signs that it will) that might achieve more in the fight against obesity than any individual measure we recommend within this report. So we would like the Department of Health to have a strategic input into transport policy and we believe it would be an important symbolic gesture of the move from a sickness to a health service if the Department of Health offered funding to support the Department for Transport's sustainable transport town pilots.

317. As the submissions from Living Streets and SUSTRANS made clear, what is needed is a wholesale cultural change to a country where people are more active. Town planning needs to prioritise pedestrians and cyclists rather than road vehicles; a strip of white line at the side of a busy trunk road does not constitute a safe cycle route.

318. Sustrans, in partnership with the Children's Play Council and Transport 2000, has supported Home Zones schemes, where groups of streets are designed and laid out so that car users do not have priority over other users, with cars travelling at little more than walking pace. The design enables people to use the streets as a social space, meaning that children can play outside, neighbours can socialise and the local communities can take control of their own environments.[311]

319. There are other impediments to active travel in addition to the transport network and services. Services located in out-of-town sites where access is only easy by car promote a sedentary lifestyle and "help 'lock-in' car dependence."[312] The Social Exclusion Unit's report into transport and social exclusion indicated that from the mid 1970s to the late 1980s, total distance travelled for food shopping increased by 60%.[313] Whilst transport policies are necessary and important, the wider planning of communities also needs to change. There seem to be no regulations in place requiring active travel and recreation opportunities for all new housing developments; these are still being built with no consideration of the need for safe walking and cycling routes to school.

320. Many commentators argue that a national transport plan would be useful to promote and facilitate active methods of transport. Sustrans contended that obesity was a symptom of the way the physical environment had been planned and that therefore they would like to see changes that encouraged active forms of travel, such as higher parking charges and improved cycling routes. Sustrans, the National Heart Forum, the International Obesity Taskforce and others argued that a health impact assessment should be made on all transport project proposals and policies before implementation.

321. There will be profound economic as well as health costs to be paid if the current obesity epidemic continues unchecked. Major planning proposals and transport projects are already subject to environmental impact assessment; we believe that it would be appropriate if a health impact assessment were also a statutory requirement. This would enable health to be integrated into the planning procedure and help bring about the sort of creative, joined-up solution which is required. This may seem a cumbersome and drastic step but we believe that only such strong measures will help reverse the dramatic decline in everyday activity that has occurred in recent decades.

The workplace

322. Employers also have a role to play in encouraging activity. We were surprised not to receive a single memorandum from any industry not directly involved in obesity, or any umbrella organization representing the interests of industry, in the course of our inquiry. The problems of overweight and obesity are already having a substantial impact on business. For example, back pain is the largest single cause of days lost from work; obesity is a known contributor to back pain, as is a general lack of fitness.

323. Our predecessor Committee, in the course of its public health inquiry, visited Cuba, a country with remarkably good health outcomes given its relatively tiny health expenditure as compared with the UK.[314] One of the features of public health in Cuba is the extent to which workplaces encourage employees to take part in physical activity. It is true that there are isolated examples of similar practice within England, but they are the exception rather than the rule.

324. Sport England suggested that tax incentives could be provided to employers that provided gym membership to their staff.[315] We believe that this is an area that could be explored but we also recognise that there are many simple measures that could be taken to raise the energy output of employees at work. The NAO report Tackling Obesity in England noted the example of research by Glasgow University and Glasgow Health Board which aimed to test "whether incidental activity could be incorporated into the daily routines of members of the public." Simply by putting signs on the escalators encouraging stair use to maintain fitness, stair use increased by 15-17%.[316]

325. The settings for heating and air conditioning in offices affect the amount of energy the body uses. Commercial canteens, like schools, can provide healthy or unhealthy food; simply offering better information on, for example, the calorie content of different meals might offer a start. As we have already seen, employers can make cycling, walking or running easier for their employees by offering appropriate facilities.

326. Little seems to have been done to address the problems of sedentary behaviour in the workplace. Yet, as the working patterns of modern society have drastically altered, and as manual labour has dwindled, the office-bound workplace, with its desk, chair and computer terminal has become the norm for millions of people.

327. In the USA, one major company, Sprint Telecoms, has recently opened a 200 acre headquarters building designed to make its employees lose weight by forcing them to walk everywhere. The car parks have been built ten minutes walk away from the offices; staircases are airy and inviting; the lifts are slow and small. Sprint argues that reducing obesity will reduce absenteeism and improve the performance of its employees.[317]

328. We recommend that the Department of Health, in conjunction with the Department for Work and Pensions and the Department of Trade and Industry first organises a major conference to promote awareness of obesity in the work-place and then engages in an ongoing process of consultation to see how measures can be taken to address sedentary behaviour. We recommend that these Departments consult with the Treasury to see what fiscal incentives can be provided to promote active travel.

329. We also recommend that the public sector looks to set an example in finding creative ways of encouraging activity in everyday life, and that this is built into a PSA target for each Department.

Strategic direction

330. Some memoranda queried whether adequate structures existed to promote and implement measures to facilitate healthy lifestyles. Len Almond from the BHF National Centre for Physical Activity and Health called for a much-needed strategic platform to promote physical activity which would involve an alliance of interested organisations to plan the direction and lead on strategy.[318] He suggested: "at present there is no organisation that represents the interests of mass participation in health promoting physical activity in England. Consequently, there are no national strategic plans to promote physical activity for health."[319] It is clear however that in order to increase levels of physical activity, policies must make it easier for people to be more active as part of their daily routine—primarily through promoting active transport—and must encourage people to be more active in their recreation time.

331. Our predecessor Committee's report into Public Health recommended that the Government should appoint advisers to co-ordinate the work of all departments in delivering the sport and health agenda. The Government rejected this proposal but partly in response to our recommendation, and following findings in Game Plan, an Activity Co-ordination Team (ACT), was created and co-chaired by the Minister for Public Health and the Minister for Sport, with senior representatives from the following Departments: Health; Culture, Media and Sport; Education and Skills; Environment, Food and Rural Affairs; Work and Pensions; Office of the Deputy Prime Minister; Home Office; and Treasury. In addition, there were representatives from No. 10 Downing Street, Sport England, the Local Government Association, the New Opportunities Fund and the Health Development Agency. There was an interval of almost seven months between the recommendation in Game Plan that a board co-ordinating activity should be created, and the first meeting in July 2003 of the ACT. As we write this report it has met on five occasions.[320]

332. The practical steps it is hoped ACT will take will be to:

  • Innovate, introducing change where there is supporting evidence and available funding—this should give early impetus to the work.
  • Pull together evidence and present it—jointly with outside sporting and health organisations—as part of a positive communication strategy, disseminating evidence and best practice.
  • Test and evaluate interventions where evidence is not strong, including external factors relating to increased participation, such as crime reduction—where the timescale might be longer.
  • Identify sources of funding.
  • Gather comprehensive data on participation and fitness regularly.[321]

333. The ACT, we were told, will produce "a three-year delivery plan by Spring 2004" which will seek to drive up mass participation. The ACT will present a progress report of its work later this year. In addition to this, the Department of Health is working to establish nine Local Exercise Pilots based in PCTs, whose aim will be to test different community approaches to increasing levels of and access to physical activity. The Department of Health pointed to a number of initiatives showing fruitful joint working between departments, such as the Healthy Schools initiative (joint Department of Health/Department for Education and Skills) and the Young People's Development Pilot Programme.

334. We welcome the creation of the Activity Co-ordination Team though we regret it took so long for it to begin its work. Anything that co-ordinates Government activity in this complex and challenging field is worthwhile. We await with interest the publication of its first report. We recommend that its reports explicitly link its activity to the Government's specific targets on activity both in schools and in the community.

The role of the NHS

Prevention of obesity

335. Prevention must clearly be the primary focus of any efforts to address the problem of obesity, as we have received compelling evidence suggesting that obesity, once established, is extremely hard to treat.[322] Much of the written evidence we received supported a policy focus centred on prevention, with the National Heart Forum arguing that "on the basis of current evidence and technologies there is very limited scope to reverse or 'cure' obesity in individuals."[323] We hope that the recommendations set out above will enable people to make healthy lifestyle choices, and that in turn these choices will allow trends in overweight and obesity to be stabilised in the short term, and reversed in the long term. However the health service clearly has an important role to play in backing up these environmental measures with explicit support for prevention.

336. PCTs, as well as commissioning health services for their local populations, have an explicit role in improving public health. To this end, we might have expected to receive evidence of a number of community-based initiatives geared to preventing obesity. However, we were struck in this inquiry, as in our inquiry into Sexual Health, by the fact that we received very little evidence on strategic prevention within the NHS. In fact, we received only one memorandum from a PCT public health lead, and none at all from Strategic Health Authorities, despite their responsibility for overseeing the delivery of public health services for the whole of their areas.

337. When we asked Department of Health officials how many PCTs currently had an obesity lead actively working on tackling the problem in their local area, they were not able to answer. The Department agreed that Strategic Health Authorities (SHAs) should have information about local work on obesity at their fingertips, and we recommend that a survey of action on obesity, both at PCT and SHA level, should be undertaken as part of the ongoing work on the forthcoming White Paper on public health.

338. A recent report by the independent health information organisation, Dr Foster, showed that strategic action on obesity seemed at best patchy:

Although most Primary Care Organisations (PCOs)[324] had some form of publicly stated policy with regard to obesity, there was enormous variation between areas with some having highly developed policies, whilst in other areas the issue was given relatively little emphasis.

Most PCO policy on tackling obesity is framed in the context of tackling CHD. The analysis of Local Development Plans showed that 30% of areas had well developed strategies in this area.

In some areas, there was little more than a passing mention of obesity in Local Development Plans. For example, Harrow PCT has no detailed obesity strategy, neither is obesity tackled specifically in its action plan for CHD … Cambridge City PCT also makes no reference to the prevention or treatment of obesity within other identified areas for action, e.g. CHD.[325]

339. Amanda Avery, a community dietician with Greater Derby PCT, told us that within PCTs there was not necessarily the flexibility needed to tackle the problem of obesity. She argued that:

Drug budgets could be considerably reduced if obesity was better addressed. Unfortunately, it is quite difficult to transfer monies from a PCT's prescribing budget to help fund other initiatives to address obesity. All the emphasis is currently on guidance as to how to use drugs but not on guidance as to how to prevent their use in the first instance.[326]

340. Ms Avery also suggested that the structural changes in the NHS in recently years had led to difficulties around partnership working with other organisations:

People who championed the obesity cause perhaps moved on. Within our PCT there are good examples of partnership working, but continuity is required over a number of years to establish good outcomes.[327]

341. The failure of PCTs fully to embrace the public health agenda seems also to be reflected more widely. Melanie Johnson told us of her view that there needed to be "fuller development of public health at the PCT level",[328] and the recent Wanless report also made several remarks in this area. It firstly highlighted the "disruptive impact" of the recent reorganisation of NHS structures on public health, arguing that the size of PCTs, and the capacity and dispersal of the public health workforce, had led in some areas to insufficient "critical mass" to fulfil public health responsibilities.[329] The creation of 303 PCTs from 95 Health Authorities has meant that public health resources within each PCT are now considerably smaller, and an increase in corporate responsibilities for each Director of Public Health has resulted in "a reduction in their ability to undertake and practise public health work."[330] Public health teams are now much smaller than they were previously, and with relatively high vacancy rates, many PCTs now 'share' their Directors of Public Health.

342. Derek Wanless reported "A survey commissioned by the Department of Health in 2002-03 to identify the capacity and development needs of PCT and Strategic Health Authorities found that the Specialist public health workforce was thinly distributed and unequally spread"[331], and some PCTs reported that the support provided for public health by SHAs was "variable"[332]. To counter these problems, he recommended that the Department should "reinforce the role of SHAs in relation to the performance management of the public health function within PCTs", and also that the Healthcare Commission "should develop a robust mechanism for the performance assessment of the public health role of PCTs and SHAs."[333]

343. We feel strongly that Primary Care Trusts should be taking a more active role in preventing obesity, and urge the Government to ensure that PCTs have the capacity, competency and incentive to fulfil their crucial obligation to safeguard the public health of the local communities they serve. We also endorse the recommendation of the Wanless report that the Healthcare Commission should develop a robust mechanism for assessing performance of both PCTs and Strategic Health Authorities with respect to public health.

Treatment of obesity

344. Dr Nick Finer, a consultant in obesity medicine at Addenbrooke's Hospital, Cambridge, stressed to us that "even the most successful prevention policies cannot address the current burden of ill health related to obesity, nor obviate the need now, or in the future, for appropriate medical care for the obese."[334] However, when we asked about the provision of such services, we were informed by the Department that the responsibility for ensuring provision of obesity services rested exclusively with PCTs. Worryingly, it was not only in strategic action to prevent obesity that PCTs, and the NHS more broadly, appeared to be failing. The evidence we received pointed repeatedly to the gross inadequacy of services currently available to tackle obesity within the NHS, as articulated by Dr Ian Campbell, a GP with a special interest in obesity:

Whilst no-one would disagree that it is important to prevent obesity, particularly among children, I just find it inconceivable that we should reach a situation where we are not able to offer treatment to those who are already obese, which is about 10 million people.[335]

345. Sally Hayes, of North West Leeds PCT, described the current situation in even more stark terms, contending that "at present most of the NHS has no systematic approach for the management of obesity at any level of BMI."[336]

346. The problems appear to have originated with a lack of prioritisation within PCTs, and to have filtered through every level of service provision. TOAST argued that the vast majority of PCT teams were unaware of their obese patients and "frankly uninterested and unaware of the aetiology of the problem."[337] This view was supported by Roche, who maintained that there was "little motivation within PCTs to ensure that weight management is offered to patients" since obesity is seen as a "lifestyle" not a medical issue.[338] The Dr Foster research showed that over half of primary care organisations in the UK did not have organised weight-management clinics within their local areas, and even in those areas that did, such clinics were available on average through only a quarter of GP practices. According to Roche, "obesity does not rank very highly as an area of interest to GPs", a view which was re-emphasised by Sally Hayes:

At present, primary care professionals are offering short term support to people who are obese within current resources which may include diet, activity and behavioural strategies. Unfortunately this is often on an ad hoc basis with little structure to these key interactions.[339]

347. Obesity is a complex medical problem, and it is clear that superficial interventions, such as the distribution of a diet sheet to an obese patient, are unlikely to work. Specialist skills and knowledge are needed fully to engage with obesity as a psychological and behavioural as well as a physiological problem. It has been likened by some to alcoholism, and requires similarly holistic treatment programmes.

348. Professor John Baxter, a consultant bariatric surgeon, described his constant amazement at the fact that other doctors referring patients to him for bariatric surgery appeared to know so little about obesity, and evidence from those actually working in primary care supported this view. Louise Mann, a practice nurse at the Gable House Surgery in Wiltshire, told us that "as nurses, we do not get any training at all in weight management in our training. In primary care and with our practice, we did weight management, but very much in an ad hoc way, with no instruction at all."[340]

349. This is perhaps particularly concerning given that many of our witnesses were in agreement that primary care was the best level at which to tackle obesity. The National Obesity Forum argued that the "vast majority of overweight and obese people are encountered within primary care, either seeking help directly for their weight problem, or indirectly because of a related medical condition", and maintained that primary care was the best place to offer intervention and concentrate funds and efforts.[341] And according to Colin Waine, Visiting Professor of Primary Care at the University of Sunderland, "about 75% of the population see their general practitioner in one year and approximately 90% over a five-year period. Thus the opportunities exist to identify opportunistically people at high risk and likely to benefit" from treatment. Dr Waine went on to argue that this was in fact one of the great strengths of the British system of primary care.[342] Research commissioned by Roche suggested that patients were reluctant to discuss their weight pro-actively, and would prefer their health care professional to raise the issue. However, further research found that general practitioners were unlikely to raise the issue of obesity during a health consultation.[343]

350. The Counterweight project, a pilot obesity management study being trialled in 80 general practices, is attempting to evaluate the usefulness of setting up specialised obesity-management clinics within a general practice setting, following specialised training and using tailored protocols. The clinicians, who do not necessarily need to be GPs, follow protocols setting out different evidence-based 'lifestyle approaches' to obesity management. The programme will be fully audited in each practice after two years, and will measure changes in clinician knowledge, attitudes, perceived confidence and willingness to treat obesity, as well as changes in practice approaches to obesity management and weight-screening rates. The primary end point for the patient intervention programme will be the percentage of patients achieving >5% and > 10 % weight loss. While the final conclusions of the programme will not be known for some time, the preliminary results from the intervention programme indicate that clinically beneficial weight loss can be achieved in high-risk obese patients in the primary care setting.[344]

351. However, service providers maintained that resources to provide structured, long-term interventions to tackle obesity in primary care were simply not available. Dr Campbell felt that GPs would be "up in arms" if they were instructed to institute routine measurement of BMI, and stated categorically that there was no point in measuring BMI without sufficient resources to address obesity where it is identified:

To try to put this into context, my own practice is 4,500 patients, and we have identified 483 who are clinically obese. I could not start to treat all of those tomorrow, so just measuring it is one thing. You need therefore the resources to do something about it.[345]

352. The Counterweight Project told us that it deliberately did not give practices extra funding, relying, in the words of a practice nurse, "on the good will of GPs".[346] We also heard how a 15-month project to develop a service for weight management within four GP practices in the Leeds North West area also risked being abandoned as it could not secure ongoing funding.[347]

353. In contradiction of the Public Health Minister's argument that the new GP contract provided sufficient incentives for health promotion, Dr Campbell told us that out of a possible 1,000 quality points GPs could gain, only three could be acquired by measuring body mass index.[348] None related purely to the treatment of obesity. Dr Campbell characterised this failure of the new GP contract to incentivise GPs to treat obesity as a significant mistake.

354. Our witnesses argued compellingly that improving obesity services within primary care was not an aspiration that was entirely out of reach. Dr Campbell suggested that programmes to train primary care clinicians in obesity management, like the Counterweight project and that being undertaken by Leeds North West PCT, would not need to be extended to all primary care practices, but that targeted training need only be offered to interested GPs. Trained GPs with a specialist interest in obesity could then provide specialist obesity services within their own practices, and other practices could also refer to them, as an intermediary between primary and secondary care.

355. We feel that this country's well developed network of primary care providers, local GPs, provides a unique resource for health promotion and for the identification and management of patients who are overweight or obese. However, managing weight problems sensitively and successfully requires specialist skills, and we are concerned by suggestions that obesity is viewed by many clinicians as a lifestyle issue rather than a serious health problem requiring active management to prevent dire health consequences. We deplore the low priority given to obesity by the new GP contract. We hope that NICE guidance on the prevention, identification, evaluation, treatment and weight maintenance of overweight and obesity, currently expected in Summer 2006, will go some way towards increasing the priority of obesity within general practice, as well as helping primary care practitioners develop and improve the services they provide in this difficult area. The Government should also ensure that within each PCT area there is at least one specialist primary care obesity clinic, probably supported by a range of different health professionals, to which GPs can refer any patients they identify as needing specialist support to address a developing or existing weight problem.

356. Weight management within primary care may not necessarily need to take place in traditional primary care settings such as the GP surgery, or even be carried out by GPs. The majority of practices in the Counterweight project, for example, ran nurse-led clinics under the supervision of a GP. Community dieticians can also play an important part, and organisations representing community pharmacists have submitted evidence stating that they are keen to play an increased role in dealing with obesity; and that they have developed thinking in this area, building on an existing scheme for diabetes testing.[349] In Finland we noted moves to make testing for diabetes available in a much wider range of settings. We recommend that, in establishing primary care obesity clinics, PCTs should fully explore the possibilities of using less traditional models of service delivery, involving clinicians from across the professional spectrum, from nurses to pharmacists to dieticians. The full range of interventions available to treat obesity includes diet, lifestyle, medical treatment and surgical treatment.

357. We also took some interesting evidence from commercial slimming organisations. We recommend that the NHS examines whether their expertise can be brought to bear in devising strategies to combat obesity holistically.

358. Although primary care provides the best starting point for treating people with weight problems, more specialist care is clearly necessary for some patients, particularly those with severe and complex problems relating to their obesity, including, amongst others, patients with metabolic and cardiovascular disease whose treatment will need to involve an holistic approach to their medical needs; those suffering from sleep apnoea syndrome; those requiring peri-operative care where weight loss may be needed to minimise risk and optimise outcome; and those with life-threatening morbid obesity.

359. The evidence we received universally pointed to a dire lack of specialist obesity care provision in the NHS. Sally Hayes, of North West Leeds PCT, stated that currently "the secondary care service for morbid obesity has a closed waiting list."[350] Dr Nick Finer, a consultant obesity physician, argued that "secondary care cannot effectively contribute to the management of obesity since it hardly exists."[351] Interestingly, we heard that there have in fact recently been specific directives aimed at the treatment of obesity in secondary and tertiary care. Services for morbid obesity were defined in the Specialised Services National Definitions Set (2nd Edition) No. 35, released by the Department in December 2002. These identified specialised treatment activity that should be subject to collaborative commissioning arrangements including: "an integral management approach … aimed at weight loss and weight maintenance … drawn up by a multi-disciplinary team to meet the needs and requirements of each individual patient." However, Dr Finer argued that in his own area of Anglia, as well as elsewhere in the UK, "these services remain unimplemented, with no process or individual responsible for their implementation as yet operational."[352]

360. Dr Finer reported that the existence of both of the clinics he ran had always been dependent upon research funding, and that both clinics struggled "to receive explicit funding from Primary Care Trusts."[353] He also described the significant mismatch between demand and capacity. At his Luton clinic, he could see about 250 new patients a year. At Addenbrooke's the capacity was only 80 new patients a year. However, the clinics regularly received five times as many referrals as this, and even this figure did not take account of a vast amount of untapped demand. Dr Finer estimated that the current prevalence of obesity meant that within the catchment area of a typical hospital serving a population of 300,000, about 130,000 adults would be overweight or obese, 53,000 obese (BMI>30), and about 3,500 morbidly obese (BMI>40). This means that even if specialist obesity treatment were only to be offered to all patients with morbid obesity, Dr Finer's clinic would require a 14-fold increase in capacity.[354]

361. Oversubscription to the clinic recently forced Dr Finer to run 'group' consultations, which were not well received by patients, and also, more worryingly, to close his clinics to new patients when waiting lists got too long:

The problem has always been how to meet the demand which is there, with the lack of resources. At Luton … over the last seven or eight years the only way of managing referrals was to shut the clinic to referrals. I have been at Addenbrooke's now full-time for a year, and I run a clinic that is primarily resourced from my appointment as a university appointment. Without my doing a large number of extra clinics to see these new patients, I would have lost Addenbrooke's Hospital its third star probably six months ago.[355]

362. The Department told us that there were only ten obesity clinics in England, and that these were not evenly distributed.[356] According to Dr Finer, all of these clinics had waiting lists of "at least 12 months".[357] To put this in context it is worth noting that the Government aims to achieve a maximum wait of three months for an outpatient appointment in any specialty by 2005, and interim targets for March 2004 were set at no more than four months for an outpatient appointment.[358] However, when discussing with us the number and availability of specialist obesity clinics, Department of Health officials did not seem concerned about the low numbers, and stated that "whether there should be more is a decision that needs to be taken through PCTs in consultation with other local commissioners as to the need."[359]

363. Obesity is a serious medical problem. Although in common with other illnesses, its prevention and some first-line management can be delivered within a primary care setting, patients with more entrenched or complex problems need prompt access to specialist medical care. Childhood obesity is a worrying and increasingly common subset of this illness, and children in particular need specialist care. Yet specialist obesity services seem to be an almost entirely neglected area of the NHS, apparently exempt from Government initiatives to push down waiting times despite their obvious importance in preventing a large range of other debilitating and costly diseases. We therefore recommend that the Government provides funding for the large scale expansion of obesity services in secondary care, underpinned by careful management to ensure that the service provision is matched to need. The Government's maximum waiting time targets must apply to all of these services.

364. The treatment of children with obesity is, if anything, more important than that for adults, as habits set down in childhood are likely to form the pattern for the rest of a person's life. However, Dr Finer told us that specialist services for obese children were "even patchier" than the virtually non-existent provision for adults, a view endorsed by Dr Mary Rudolf, a consultant paediatrician with a specialist interest in obesity:

There is a dire lack of services within the NHS for the management of childhood obesity. Our experience in Leeds is likely to be typical of the rest of the country. There is no specialist service even for the grossly obese. A minority of these children are seen in the Regional Endocrinology Service (and only if they are likely to have medical problems resulting from their obesity). They are seen briefly and only very periodically for a "medical check" but no real intervention. The hospital paediatric dietetic department is so limited that there is a ruling that no child may receive dietetic advice about their obesity even if they are on medication for the problem. [360]

365. In June 2003 the waiting list for the specialist obesity service for children at Bart's and the London Trust stood at 11 months and rising.[361]

366. We were appalled to learn of the desperate inadequacy of treatment and support services for obese children. Steps must be taken to ensure that obese children and young people have prompt access to specialist treatment wherever they live.

367. Recent research carried out by the Peninsula Medical School has suggested that overweight and obesity are now becoming so commonplace amongst children that even parents are failing to notice when their own children become overweight or obese. In a survey of 300 British families, only 25% of parents with overweight children recognised that their children were overweight. No fathers identified their sons as overweight, even when they were, and, perhaps even more disturbingly, 33% of mothers and 57% of fathers described their children as 'normal' when in fact they were obese.[362] As treatment is only possible once a problem has been identified, this represents a worrying trend. We were also told by Professor Jane Wardle, of the Health Behaviour Unit at University College London, that parental concern about children developing eating problems may be overly biased towards eating disorders such as anorexia and bulimia:

I think parents feel exceptionally responsible if their children develop eating disorders. I think probably they feel slightly less responsible if their children develop obesity, even though that may not be the justifiable allocation of responsibility.[363]

368. We feel that the school nursing system offers a valuable opportunity to correct this through a programme of routine measurement of BMI throughout a child's school career. The Children's Minister, Margaret Hodge, expressed reservations about the possibility that such a measure could stigmatise overweight and obese children. We are confident that this could be overcome, through the adoption of a sensitive approach whereby rather than singling out individuals, all school children are weighed and measured once a year, and their BMI results sent in confidence to their parents together with, if appropriate, advice on how to modify diet and exercise patterns. Not only would this system identify children who are already overweight or obese, but it could target those at the top end of the 'normal' range of BMI to prevent further weight gain. As the Public Health Minister reassured us that every school now had access to a school nurse, we are confident that such a scheme could be administered within existing resources.

369. We recommend that throughout their time at school, children should have their Body Mass Index measured annually at school, perhaps by the school nurse, a health visitor, or other appropriate health professional. The results should be sent home in confidence to their parents, together with, where appropriate, advice on lifestyle, follow-up, and referral to more specialised services. Where appropriate, BMI measurement could be carried out alongside other health care interventions which are delivered at school, for example inoculation programmes. Care will need to be taken to avoid stigmatising children who are overweight or obese, but given that research indicates that many parents are no longer even able to identify whether their children are overweight or not, this seems to us a vital step in tackling obesity.

370. The National Institute for Clinical Excellence (NICE) has published guidance supporting the use of the obesity drugs orlistat and sibutramine in certain, limited circumstances.[364] These drugs in no way represent a 'cure' for obesity, their success rate averaging a maximum of 5kg of weight loss per year of treatment, weight loss which is usually regained once treatment has stopped. For this reason, the conditions attached by NICE to use of these treatments stipulate that they must be supported by dietary and lifestyle changes. According to the Department's memorandum, estimated costs since the two products became available on the NHS are now approximately £31 million.[365]

371. Research carried out by Dr Foster concluded that 96% of PCTs were prepared to provide funding for drugs for the treatment of obesity, although 4% were not, despite the NICE guidelines. However, this does not necessarily provide a true picture of whether all patients who could potentially benefit from drug treatment are obtaining it, as this will depend on whether GPs are knowledgeable and confident enough to prescribe it, or whether patients are able to secure a referral to vastly over-subscribed specialist obesity clinics. Equally, although PCTs may have an official policy of funding the drugs, GPs may come under pressure to curtail their prescribing of obesity drugs to stay within cost limits, a situation described to us by Dr Campbell:

Two days ago I received a letter from my own primary care trust saying that as a PCT we were quite high in our use of weight-loss medication, and we were to reconsider our practice policies. I cannot recall, in 15 years in general practice, receiving a letter questioning our prescribing of heart disease medication or diabetic medication; and this really typifies the prevailing attitude at the moment.[366]

372. We were dismayed to hear that a specialist GP who devoted much of his time to trying to tackle obesity in his local population was being put under pressure from his local PCT to reduce his prescribing of drugs to tackle obesity, despite these drugs having received approval from NICE, with the corresponding obligation on PCTs to provide funding for them. We were told by the same doctor that in 15 years of practice he had never received communications questioning his prescribing rates for drugs to treat heart disease or diabetes, two illnesses frequently caused by obesity. This provides a telling exposé of current attitudes towards obesity, whereby it is regarded by NHS decision-makers as a lifestyle problem for which treatment is an optional extra. We recommend that the Government takes urgent steps to tackle this subtle deprioritisation of obesity wherever it occurs in the NHS.

373. A more drastic option for treating obesity is through surgery. Obesity surgery, also described as bariatric surgery, can be either 'malabsorptive' or 'restrictive'. Malabsorptive surgery works by shortening the length of the digestive tract (gut) so that the amount of food absorbed by the body is reduced. This type of surgery involves creating a bypass by joining one part of the intestine to another. Restrictive surgery limits the size of the stomach so the person feels full after eating a small amount of food. This type of surgery can involve 'stapling' parts of the stomach together or fitting a tight band to make a small pouch for food to enter.[367] Currently, four types of obesity surgery are available: vertical banded gastroplasty, the Lap-Band system, Roux-en Y gastric bypass, or biliopancreatic diversion with a duodenal switch.

374. NICE have also given their approval for obesity surgery to be funded for NHS patients. Having reviewed 19 clinical trials and other evidence, NICE concluded that:

surgery for people with morbid obesity is associated with significant weight loss that is maintained for at least 8 years, whereas there is little sustained weight loss with conventional treatment in this group of patients. Surgery is also associated with improved quality of life and reduced co-morbidities. There are significant risks attached to surgery, although these are thought to be outweighed by the benefits.[368]

However, Professor John Baxter, a consultant bariatric surgeon, told us that despite this recommendation obesity surgery services in the UK were 'third world' when compared with other developed countries. NICE's guidance suggested that the NHS should aim to build bariatric services up over the next eight years to around 4,000 procedures per year, from the 200-300 procedures performed in the UK at present. Professor Baxter felt this target number to be "manifestly too low".[369]

375. Based on the assumption that in the UK around 0.8% of males and 2% of females are morbidly obese, Professor Baxter argued that there were currently around 228,000 men and 570,000 women potentially suitable for surgery. If this were expanded to include all patients who had a BMI between 35 and 40 who had a co-morbid condition, this would push the target population up to 1.2 million. On top of this, Professor Baxter estimated that a further 5,000-8,000 patients would become morbidly obese each year. Even if only 5% of suitable patients opted for surgery, in his view a very conservative estimate, this would mean a current "backlog" of around 60,000 patients needing surgery immediately. Professor Baxter told us that the Swedish health service worked on the assumption that to maintain a "steady state", 500-1,000 procedures are needed per year per 500,000 population. Extrapolating this using UK data, around 25,000 procedures would be needed per year in this country, over six times the number recommended by NICE.[370]

376. Dr Finer supported Professor Baxter's view about the problems with obesity surgery:

Obesity surgery remains virtually unfunded and unavailable to most eligible patients through the failure of district Health Authorities and now Primary Care Trusts to implement NICE guidance.[371]

377. Professor Baxter described provision of bariatric surgery as a "postcode service" and warned that Strategic Health Authorities were now "starting to panic about how to provide this service."[372] He told us that waiting lists were very long in all centres. For his service, in Swansea, the waiting list was one year for an outpatients appointment, followed by three years' wait for surgery, giving a total wait of four years. Another impediment to access was that many suitable patients were not being referred simply because their GPs were ignorant about bariatric surgery. The huge mismatch between capacity and need was shown by Professor Baxter's estimate that at least 300 obesity surgeons were needed, compared with the 13 or 14 currently practising.

378. In the United States, we met with two bariatric surgeons who explained that bariatric surgery was a rapidly increasing speciality there. Last year there were 103,000 bariatric operations performed in the US and this figure is projected to rise to 126,000 this year. While up until two years ago, these operations were only carried out in large specialist university hospitals, now almost every private hospital, both large and small, performs the operations.

379. Bariatric surgery is in no way a panacea for the current obesity epidemic. Rather it is a high-risk, invasive surgical procedure that represents a last line of defence for people with life-threatening morbid obesity. However as the number of people suffering from morbid obesity in England looks set to increase, it is an option that needs to be made available to all those who need it, and it is unacceptable that in some parts of the UK patients with a life-threatening condition are having to wait as long as four years for bariatric surgery. We hope that the measures we have recommended to improve provision of specialist obesity services in both primary and secondary care will help to address the problem that many patients are not referred for bariatric surgery simply because their local doctors are not aware that it is an option. However, the NHS needs also to ensure that adequate service capacity is in place fully to meet need, which is patently not the case at present. The Government must devote protected resources to ensuring that bariatric surgery is available to all those who need it, and should issue guidelines for the strategic development of services across the country, to eliminate the current postcode provision of obesity surgery.

380. As well as medical and surgical approaches, it is vital that the psychological and behavioural aspects of obesity are addressed. As TOAST pointed out in their written evidence, there are a multitude of reasons why people may overeat, many of them linked to underlying psychological factors:

We have asked a variety of groups why they think obese people overeat. The following list is typical of the answers given:

Boredom      Guilt

Anger        Shame

Stress        Because it's there

Loneliness      Pressure from other people

Happiness      Going to start a diet tomorrow

Revenge        Frustration

Depression      It's Sunday

Addiction      Pleasure

Habit        Unloved

Not appreciated      Unfulfilled

Tired        Unsatisfied

Unhappy      To celebrate

Comfort        Holidays[373]

381. TOAST argued that amongst some groups, obesity was comparable to addictive habits such as smoking or alcohol dependence:

For many types of obese [people] there is a strong link to the problems of those with a drink problem; many talk of sometimes feeling out of control around food … All the alcohol treatment programmes we know of use some form of counselling within their treatment profile. They recognise that the alcohol is often used as a coping mechanism, to drown sorrows, for swallowing anger, blotting out the pain, to be part of the crowd. Many overeaters will recognise these behaviours and reasons for over consuming. Alcohol treatment programmes help people to recognise why they have been over consuming and to find other coping mechanisms, helping clients build belief in them.[374]

382. TOAST and the Royal College of Psychiatrists both argued strongly that multidisciplinary teams to treat obesity must involve a range of professionals properly equipped to address the psychological and behavioural aspects of obesity, including counsellors, psychiatrists, psychotherapists, psychologists and family therapists.[375] We feel it is vital that advances in medical and surgical treatment of obesity should be supported by equivalent development of services to address the psychological and behavioural aspects of obesity. All those receiving treatment for obesity, whether in a primary or in secondary care setting, should have access to psychological support provided by an appropriate professional, whether this is a psychiatrist, psychologist, psychotherapist, counsellor, or family therapist.

Prioritisation within the NHS

383. While we agree that the obesity epidemic has, in contrast to other public health concerns which may come to prominence very rapidly, manifested itself gradually and insidiously over a number of years, we were a little surprised to hear the Public Health Minister, Melanie Johnson, argue that it had "caught us all slightly unawares."[376] While it is clear that the Government and the NHS are at present unprepared to deal with this problem on the scale at which it now presents itself, obesity has been recognised as a serious threat to the nation's public health by experts and governments alike for several decades. In 1976, nearly 30 years ago, a report by a joint Department of Health and Social Security and Medical Research Council group highlighted the problem in unequivocal terms:

We are unanimous in our belief that obesity is a hazard to health and a detriment to well being. It is common enough to constitute one of the most important medical and public health problems of our time, whether we judge importance by shorter expectation of life, increased morbidity, or cost to the community in terms of both money and anxiety.[377]

384. Twelve years ago, the 1992 White Paper The Health of the Nation identified targets for obesity reduction. These targets were not met, and obesity increased rather than decreased during this period. However, there were no obesity targets in the 1999 public health White Paper Saving Lives, an omission regarded by TOAST as deplorable: "With the obesity epidemic raging, obesity had been dropped, with no strategy being pursued to reduce or limit it."[378] When questioned about why this had happened, Department of Health officials responded that the issue of targets was a question for Ministers. In its memorandum, the Department argued that service-based targets within existing NSFs were sufficient:

The Priorities and Planning Framework for 2003-06 includes targets for reducing CHD. One of these targets requires practice-based registers and systematic treatment regimes, including appropriate advice on diet, physical activity and smoking. This also covers the majority of patients at high risk of CHD, particularly those with hypertension, diabetes and a BMI greater than 30. In order to tackle health inequalities, the Priorities and Planning Framework also sets a target to contribute to a national reduction in death rates from CHD focusing on the 20% of areas with the highest rates of CHD, and this should encourage action on obesity in disadvantaged areas. The Priorities and Planning Framework has also set a target to increase breastfeeding initiation rates by 2 percentage points each year, particularly among disadvantaged groups.

Standard One of the NSF for CHD relates to the reduction of coronary risk factors in the population and requires that all NHS bodies will have agreed and be contributing to the delivery of a local programme of effective policies on promoting healthy eating, increasing physical activity and reducing overweight and obesity and have quantified data on the programme by April 2002.[379]

385. Speaking to the Health Service Journal, Melanie Johnson, the Public Health Minister, expressed her view that the current package of measures to tackle obesity,—which she listed as the school fruit scheme, the Five-a-day fruit and vegetable initiative, and the as yet unpublished Food and Health Action Plan—when taken together "amounted to a strategy" to tackle obesity.[380]

386. However, none of these things has any direct connection to NHS services to prevent and treat obesity. And although the Government has often cited a reluctance within the health service for more targets and central directives, we in fact received a substantial body of evidence from those working within the NHS who argued strongly in support of a national service framework specifically addressing obesity. Significantly, this call has come both from clinicians and from those involved in NHS management. Dr Ian Campbell, a GP, told us that:

The impact of a national service framework should not be underestimated within the world of general practice. The National Institute for Clinical Excellence has made many pronouncements on weight management and the use of drugs for surgery, but they are only accepted at a distance by health authorities and not always acted upon; whereas national service frameworks are accepted as being directives that must be done, by which primary care services are judged; so it would have a huge impact on the service that followed.[381]

387. Sally Hayes, the CHD Lead at Leeds North West PCT supported this view, stating that an NSF in obesity "would help greatly" as "the setting of standards and targets does wake us up, as organisations".[382] She described her current means of securing one-off funding for obesity as "a mad scramble to try and bid for this and that", and told us that funding uncertainties prevented her project from being developed further, leading to de-motivation amongst staff involved in tackling obesity.[383]

388. According to the Institute of Human Nutrition at the University of Southampton, a key problem with the UK health system in relation to obesity was that there was "a notable absence of well-structured and validated care pathways" and that furthermore, "there is no formal budgetary responsibility at any level of care—community, primary, secondary or tertiary—for the identification of the overweight and the support and management of those identified as being at special risk."[384]

389. Although the Department argued that the references to obesity within the NSFs for CHD and diabetes were sufficient to address obesity, we were told by the Counterweight Project that, ironically, those NSFs were in fact drawing resources away from the prevention and treatment of obesity, despite the indisputable link between obesity and both CHD and diabetes:

The main barriers to continued provision of a structured approach to obesity management have been competing priorities and a lack of dedicated nurse time. Many practices however claim to be prioritising nurse and GP time to meet the national service frameworks for conditions such as diabetes and coronary heart disease. Ironically, many of these competing disease areas can be directly improved by obesity management.[385]

390. Dr Nick Finer, a consultant obesity physician, argued that the references to obesity within two NSFs were scant and ineffectual:

Although there are odd little lines in the existing NSF to cardiology and diabetes, the fact that they are right down in the sub-sub-sections, means that to all intents and purposes they are ignored.[386]

391. Sally Hayes supported this view:

Obesity is not specified enough within those standards and milestones. There are other things based on medication, on lifestyle. It is not specific enough really, and the targets are not specific enough.[387]

392. Dr Ian Campbell, in his capacity as Chairman of the National Obesity Forum, was one of many to recommend the appointment of a 'Fat Czar' to develop a central government strategy to tackle obesity on all fronts, in addition to the development of an Obesity National Service Framework and obesity targets for the NHS.

393. The evidence we received during the course of this inquiry has convinced us that despite its overwhelming importance, obesity remains a low priority for the majority of service commissioners and providers in the NHS. The National Health Service has a responsibility both to take strategic action to prevent obesity, as part of its public health remit, and to provide adequate treatment for those already suffering from overweight or obesity, as it would for those suffering from any other medical condition. It appears to us to be failing in both of these areas, and this needs to change as a matter of urgency.

394. We are fully aware that obesity is mentioned in existing NSFs, but we believe that these scant mentions are woefully inadequate to provide a strategic framework through which to tackle what has been described as 'the biggest public health threat of the twenty-first century'. We also understand that a public health White Paper will be published in the summer, but again we fear that the extent and seriousness of the obesity problem will be lost by including obesity only as part of a wider umbrella of general public health initiatives.

395. We note the Government's reservations about committing to further National Service Frameworks, which they voiced in response to our report on Sexual Health. However, the current structure of the National Service Framework programme places too great an emphasis on tackling discrete disease areas, focusing on downstream consequences at the expense of the upstream contributors to these diseases, including obesity. Indeed, we heard compelling evidence that many general practices are unable to devote time to tackling obesity because of their obligation to meet targets in the Coronary Heart Disease and Diabetes NSFs, even though, ironically, many of these 'competing' disease areas can be directly improved by tackling obesity. And while it is clear that general public health problems, such as smoking, can be addressed within disease-based NSFs, the lack of obesity targets has led to this area being systematically neglected.

396. It is essential that, as part of the Government's wider strategy to tackle obesity, a dedicated framework document is produced to emphasise to a largely sceptical NHS the full scale and seriousness of this problem. The complexity of the challenge facing the NHS in this area, including the need to develop services and care pathways across all tiers of service delivery in a rapidly changing area of medicine, as well as to take the lead on prevention and health promotion, makes a detailed strategic framework vital. This document should build on existing work in this area, drawing together and emphasising the obesity measures already set out in the National Service Frameworks, and linking in with the ongoing work of NICE. Crucially, it must re-introduce realistic but stretching targets for reducing the prevalence of obesity and overweight over the next ten years, underpinned by more detailed, service-based targets, in particular bringing waiting times for specialist medical and surgical obesity services in line with all other NHS specialties. PCTs should be stringently performance-managed on their delivery of these targets.

182   Health Service Journal, 6 November 2003, pp 26-27 Back

183   Q315 Back

184   Q256 Back

185   Storing up problems, p xii Back

186   Derek Wanless, Securing Good Health for the Population, Final Report, February 2004, p 5 Back

187   Ibid, p 121 Back

188   Ev 109 Back

189   Q14 Back

190   Q357 Back

191   Q294 Back

192   Q1304; Q1306 Back

193  Back

194   Department of Health, press release 2002/0499, 28 November 2002 Back

195   Health Committee, Third Report of Session 2002-03, Sexual Health, HC 69 Back

196   Department of Health, Memorandum OB 8C (not printedBack

197   Move4Health is a co-ordinating body representing interested parties seeking to tackle physical inactivity. More information can be found at Back

198   Appendix 34 (Focus on Food) Back

199   Q1509 Back

200   Ibid Back

201   Department for Education and Skills, Back

202   Ev 81 Back

203   Ev 9 Back

204   For example, "All talk and no action on obesity", The Guardian, 7 May 2004 Back

205   Q1109 Back

206   Q312 Back

207   Q302 Back

208   BBC Radio 4, The Today Programme, 3 March 2004 Back

209   FSA Paper 04/03/02, 11 March 2004, pp 8-9, Back

210   Co-op, Blackmail, p3 Back

211   International Association of Consumer Food Organisations, Broadcasting Bad Health, July 2003, p24 and Back

212   See Back

213   See, for example, Q864. Back

214   See eg Health Committee, Fourth Report of Session 2000-01, The Provision of Information by the Government Relating to the Safety of Breast Implants, HC 308, para 31. Back

215   Q1487; Q1493 Back

216   Food Standards Agency, A feasibility study into healthier drinks vending in schools, Health Education Trust, March 2004, Back

217   'Ban Junk Food from Schools, says poll', The Guardian, 22 October 2003  Back

218   The 'Big 8' are defined as: energy, protein, carbohydrate with declaration of sugars, fat with declaration of saturates, dietary fibre, and sodium. Back

219   Q1166 Back

220   Q1151 Back

221   Q1148 Back

222   Q1143 Back

223   Q1153 Back

224   Q791 Back

225   Q897 (Andrew Coslett) Back

226   Q726, Q738, Q920 Back

227   Q535 Back

228   Q1170 Back

229   Q1386 Back

230   Q1168 Back

231   Q1179 Back

232   Q1168 Back

233   Q1179 Back

234   Swedish National Food Administration,  Back

235   Q1258 Back

236   Q1259 Back

237   Q1273 Back

238   Q1148 Back

239   Q1160 Back

240   Ev 18 Back

241   "From sick care to health care: meeting the challenge of chronic disease", speech to Oxford Vision 2020 Conference, 3 December 2003 Back

242   Q291 Back

243   Q303; FSA Survey, 2001 Back

244   Q127 Back

245   "Government unit urges fat tax", BBC online news, 19 February 2004 Back

246   T Marshall "Exploring a fiscal food policy: the case of diet and ischaemic heart disease", British Medical Journal 320 (2000), pp 301-304 Back

247 Back

248   Ev 230 Back

249   WHO, Global Strategy on diet, physical activity and health A57/9, 17 April 2004 Back

250 Back

251   Ibid Back

252   "Setting aside the CAP - the future for food production", Consumers' Association, 2001, p 13 Back

253   WHO global strategy on diet, physical activity and health: European regional consultation meeting report, p. 11, Copenhagen, Denmark, 2-4 April 2003. Back

254   "Setting aside the CAP", p 48 Back

255   Q1195 Back

256   Q1196 Back

257   Q1201 Back

258   Q1206 Back

259   Appendix 59 Back

260   L S Elinde et al (2003), Public health aspects of the EU Common Agricultural Policy, Stockholm: National Institute of Public Health Back

261   Q977 Back

262   Ev 391 Back

263   Scottish Nutrient Standards, Section 1.2 and Section 1, tables 1 and 2; England Primary School Guidance, Annex Cii; England Secondary School Guidance, Annex Cii Back

264   Scottish Nutrient Standards, Section 1.5  Back

265   Scottish Nutrient Standards, Section 1.4 Back

266   England Guidance, Section 4 Back

267   England Primary and Secondary Guidance, Annex Cii Back

268   Scottish Nutrient Standards, Section 2, "Menu Planning" table, Group 5 Back

269   Scottish Nutrient Standards, Section 2, "Menu Planning" table, Group 5 Back

270   Q1497 Back

271   Q1501 Back

272   Q1028 Back

273   Appendix 19 Back

274   At least five a week, p 9 Back

275   However, a European Commission Survey conducted in December 2002, which relied on self-reported evidence, placed the UK roughly in the middle of EU countries for physical activity. See Back

276   Q492 Back

277   Appendix 24 Back

278   Appendix 44 (DfES) Back

279   See DfES website at Back

280   See DCMS website at Back

281   Committee of Public Accounts, Ninth Report of Session 2001-02, Tackling Obesity in England, HC 421, p 7 Back

282   Q1022 Back

283   Ev 300 Back

284   Q1025 Back

285   Q1033 Back

286   Ev 163 Back

287   BMA Board of Science and Education, Road Transport and Health Back

288   Ev 164 (Living Streets) Back

289   Ev 163 Back

290   A C Cooper, et al, "Commuting to school: Are children who walk more physically active?", American Journal of Preventative Medicine, vol 25,4 (2003), pp 273-76 and K R Fox "Childhood obesity and the role of physical activity", Journal of the Royal Society for the Promotion of Health 124 (2004), pp 34-39. Back

291   Environment, Transport and Regional Affairs Committee, Eleventh Report of Session 2000-2001, Walking in Towns and Cities, HC 167, Summary of Recommendations Back

292   Q499 Back

293   Q499 Back

294 Back

295   Q503; the 'Silly Walks 'sketch was actually broadcast on 15 September 1970. Back

296   Qq144-48 Back

297   Ev 15 Back

298   Q503 Back

299   Information in this section is sourced from Colorado Department of Public Health and Environment, Colorado Physical Activity and Nutrition State Plan 2010Back

300   Q877 Back

301   The Daily Telegraph, 23 April 2004 Back

302   Appendix 60 Back

303   Ev 161 Back

304   Department for Transport, Cycling to Work, 2001 Back

305   Transport, Local Government and Regions Committee, Eight Report of Session 2001-02, 10 Year Plan for Transport, HC 558, para 104 Back

306   Appendix 8 Back

307   Appendix 60 Back

308   Q502; 509 Back

309   Q563 (John Grimshaw) Back

310   Department for Transport News Release 2003/0172 Back

311   Ev 111 Back

312   Ev 111 Back

313   Ev 164 (Living Streets) Back

314   Health Committee, Second Report of Session 2000-01, Public Health, HC 30, para 21 Back

315   Appendix 19 Back

316   Tackling Obesity in England, p 35 Back

317   "Architects join fight against the flab", BBC News website, 27 March 2003. Back

318   Ev 106 Back

319   Ev 103 Back

320   HC Deb, 30 March 2004, col. 131 W Back

321 Back

322   For example, see Appendix 33 (Dr Sheila McKenzie). Back

323   Ev 113 Back

324   Including Primary Care Trusts, Local Health Boards in Wales and Scotland, and Health and Social Services Boards in Northern Ireland. Back

325   Dr Foster, Obesity Management in the UK, available at Back

326   Ev 351 Back

327   Q 1101 Back

328   Q1299 Back

329   Derek Wanless, Securing Good Health for the Whole Population, Final Report, HM Treasury, February 2004 Back

330   Ibid, p 45 Back

331   Ibid, p 45 Back

332   Ibid, p 49 Back

333   Ibid, p 50 Back

334   Ev 329 Back

335   Q1046 Back

336   Ev 354 Back

337   Ev 372 Back

338   Appendix 6 Back

339   Ev 354 Back

340   Q1082 Back

341   Ev 318 Back

342   Q1063 Back

343   Appendices 6 and 7 Back

344   Ev 344-46 Back

345   Q1064 Back

346   Q1077 Back

347   Q1084 Back

348   Q1066 Back

349   Appendix 26 (The Pharmaceutical Services Negotiating Committee); Appendix 31 (Lloydspharmacy) Back

350   Ev 354 Back

351   Ev 329 Back

352   Ev 329 Back

353   Ev 328 Back

354   Ev 329 Back

355   Q1047 Back

356   Q60 Back

357   Q1051 Back

358   Improvement, Expansion and Reform - the next three years - Priorities and Planning Framework 2003-2006, Department of Health Back

359   Q60 Back

360   Ev 329; Appendix 4 Back

361   Appendix 33 Back

362   The Observer, 14 March 2004 Back

363   Q205 Back

364   Nice Guidance No 22, Orlistat for the treatment of obesity in adults, 9 March 2001. Nice Guidance No 31, Sibutramine for the treatment of obesity in adults, 26 October 2001. Back

365   Ev 2 Back

366   Q1036 Back

367   Nice Technology Appraisal Guidance - No 46, Obesity Surgery, p 3, 19, July 2002 Back

368   Ibid Back

369   Ev 332 Back

370   Ibid Back

371   Ev 329 Back

372   Q1058 Back

373   Ev 372 Back

374   Ev 372 Back

375   Appendix 40 Back

376   Q1301 Back

377   Cited in Appendix 18 (Royal College of General Practitioners) Back

378   Ev 369 Back

379   Ev 15-16 Back

380   Health Service Journal, 6 November 2003, pp 26-27 Back

381   Q1041  Back

382   Q1075 Back

383   Q1084 Back

384   Appendix 32 Back

385   Ev 346 Back

386   Q1040 Back

387   Q1075 Back

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