Memorandum by the Department of Health
The Government welcomes the opportunity of this
enquiry to set out its policy on the prevention and management
Obesity is an international problem, which no
country has successfully tackled. There are inequalities in the
prevalence of obesity, particularly among women. It is a complex
multi-factorial condition which has genetic, social, cultural
and behavioural causes.
The Government is concerned at the impact that
obesity has on health and disease and is committed to reversing
the current trend of increasing overweight and obesity in both
children and adults.
The prevention and management of obesity are
at the heart of many of the Government's priority areas, as set
out in the NHS Plan, Cross-Cutting Review on health inequalities,
Cancer Plan, and National Service Frameworks, particularly those
outlining action on coronary heart disease, diabetes and older
The best long-term approach is prevention. To
do so we need to address the main risk factors of diet and physical
inactivity. An integrated, cross-governmental strategy is in place
to tackle obesity, by improving diet and by increasing physical
activity levels. Key to this is the development of the Food and
Health Action Plan and the Sport and Physical Activity Board.
reduces life expectancy on average
by nine years;
is responsible for 9,000 premature
deaths each year; and
increases the risk of a wide range
of diseases and illnesses, including heart disease, type 2 diabetes
and some cancers.
What are the health outcomes of obesity in society?
Obesity is associated with increased risk of:
Heart disease and stroke
Some cancers, including postmenopausal
breast cancer and colon cancer
Complications in pregnancy
Increased risk in surgery
Psychosocial and social problems,
including reduced self-esteem and increased risk of depression
and social isolation
2. Body fatness is most commonly assessed
by body mass index (BMI)weight (kg) divided by height (m)
squared (ie kg/m2). A BMI 25-30 is considered "overweight"
and greater than 30, "obese". Mortality rates begin
to increase at BMIs greater than 25 and increase rapidly over
30. "Central obesity"most commonly identified
by a high waist circumference or waist hip ratio (WHR)is
also associated with increased morbidity and mortality.
3. Risk among some populations, such as
Asians, appears to increase at a lower BMI (21-23 kg/m2). The
World Health Report (WHO, 2002) showed that, globally, around
58% of type 2 diabetes, 21% of heart disease and between 8% and
42% of certain cancers were attributable to BMI greater than 21
4. In England, the National Audit Office
(NAO, 2001) found that obesity is responsible for more than 9,000
premature deaths each year (6% of all deaths) and reduces life
expectancy on average by nine years. As well as reducing mortality
it is well established that obesity is also associated with increased
risk of many serious diseases: 36% of hypertension, 47% of type
2 diabetes, 15% of angina and 18% of myocardial infarction cases
are attributable to obesity.
5. 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
livepeople do not have equal opportunities to make healthy
What are the economic and social costs?
6. The economic costs are estimated
over £500 million a year
to the NHS; and
over £2 billion a year to
the wider economy.
The social costs are primarily an increased
prevalence of disease.
7. The NAO estimated in 2001 that the direct
cost of obesity to the NHS is more than £ ½ billion
a year. Estimated costs to the wider economy is more than £2
billion per year. The "big three" cost drivers are hypertension,
coronary heart disease (CHD) and type 2 diabetes.
8. The NAO report was published before the
release of guidance on the prescribing of the anti-obesity drugs
Orlistat (March 2001) and Sibutramine (October 2001)
by the National Institute for Clinical Excellence (NICE). The
latest data from the Prescriptions Pricing Authority indicate
that there was a three fold increase in the number of prescription
items dispensed in the community between publication of the guidance
and September 2002 (with associated net ingredient coststhe
basic cost of the drugsincreasing to £31 million for
the 12 months from October 2001 to September 2002).
9. The NAO report predicted that if trends
continue at the present rate until 2010, the prevalence of obesity
will have increased by around 47% between 1998 and 2010 and the
annual cost to the economy would increase by £1 billion,
or over a third, to around £3.6 billion, by that year.
What efforts is the Government making to evaluate
10. The social and economic costs of
obesity, and trends in overweight and obesity, are carefully and
11. Trends in overweight and obesity, physical
activity levels and their relationship to other cardiovascular
risk factors are monitored each year through the Health Survey
for England (HSE). The Survey is commissioned by DH to provide
reliable information about various aspects of people's health
and to monitor selected health targets. The Survey includes physical
measurements and the analysis of blood samples. Each year's survey
also has a particular focus on a diseases condition or population
12. Information on smoking, alcohol consumption,
health and use of services is also monitored on a yearly basis
through the General Household Survey (GHS), carried out by the
Social Survey Division of the Office for National Statistics (ONS).
13. The White Paper, Saving Lives: Our
Healthier Nation (1999) signalled the establishment of the
Health Development Agency (HDA) to build the evidence base in
public health, with a special focus on reducing inequalities in
health. The DH Research and Development Strategy (2001) identified
the task for HDA as "maintaining an up-to-date map of the
evidence base of public health and health improvement, advising
on the setting of standards in the light of evidence, for public
health and health promotion practice, and effective and authoritative
dissemination of evidence to practitioners". One of the nineteen
topics being undertaken by the HDA is weight management.
14. Further to the NAO report, the forthcoming
Health Technology Assessment Systematic review of the long
term outcomes of the treatments for obesity and implications for
health improvement and the economic consequences for the health
service will provide an assessment of the cost effectiveness
of obesity treatments.
15. The Chief Medical Officer is expected
to publish in the autumn a report describing the evidence for
a relationship between physical activity and health.
16. The Scientific Advisory Committee on
Nutrition (SACN) may consider obesity, particularly the metabolic
consequences, within their programme of work. This issue is to
be discussed at SACN's horizon scanning meeting in September 2003.
Trends in obesity
17. Obesity is rising:
the percentage of obese adults
has almost trebled in 20 years;
the majority of adults are overweight
recent studies show that obesity
is also increasing in children.
What are the trends in obesity (including trends
among particular groups, by social class, age, gender, ethnicity
18. The percentage of obese adults has
almost trebled in England since the beginning of the 1980s21%
of men and 23.5% of women are now obese, and around 56% of all
adult women and 68% of all adult men are either overweight or
obesealmost 24 million adults. The latest figures from
the HSE (2001) are shown in the table below.
|BMI (kg/m2)||1980 *
19. The percentage of adults considered to be "centrally
obese"as measured by a high WHR (>0.95 for males
and >0.85 for females)has also increased. Between 1994
and 1998, the prevalence of high WHR increased from 23.5% to 27.5%
for males and 18.2% to 19.9% for females.
20. In both men and women, mean BMI and the prevalence
of overweight and obesity increases with age, reaching a peak
in 55-64 year olds. In 2001, 26.5% of men and 30.7% of women aged
55 to 64 were obese compared to 9.5% men and 11.9% women aged
16-24 and 16.0% of men and 19.3% of women aged 25-34.
21. The HSE 2001 demonstrated a higher prevalence of
obesity in manual compared to non-manual groups for both men and
women and that these inequalities have been maintained since 1994
||% obese |
||14 ||21 |
||20 ||28 |
Similar trends are observed by social class group, particularly
for women. In 2001 14% women and 14% of men classified as social
class I were obese compared to 28% of women and 19% of men classified
as social class V.
Differences between ethnic groups
22. With the exception of the Irish, obesity is less
common in men from all other minority ethnic backgrounds than
the general population (HSE 1999). The prevalence of obesity in
men is lowest amongst those with an Asian ethnic background.
23. Among women, the prevalence of obesity among Black
Caribbean and Pakistani women is substantially higher than the
general population (approximately 50% and 25% higher, respectively).
The prevalence of obesity is lowest among women of Bangladeshi
and Chinese ethnic backgrounds.
24. The HSE (1999) found that the prevalence of raised
WHR was highest among Indian and Irish sub-groups and lowest among
the Chinese groups. Men in all South Asian groups were half again
as likely as the general population to be centrally obese. Among
women, the prevalence of raised WHR was higher among all minority
ethnic groups than the general population.
25. Differences between ethnic groups will again be considered
by the HSE in 2004, when ethnic minority groups will be over sampled
to allow full assessment.
26. There is on-going debate on the definition of overweight
and obesity in childhood. Proposed international "cut off"
points (Cole et al 2000) have been found to underestimate the
prevalence of childhood obesity in the UK. An alternative methodusing
BMI above the 95th percentile to represent obese and BMI above
the 85th percentile to represent overweighthas therefore
been used to assess the HSE data. However, all recent studies,
no matter which definition is used, have shown that the prevalence
of overweight and obesity is increasing in children in England.
27. 8.5% of six year olds and 15% of 15 year olds are
obese (HSE 2001). Between 1996 and 2001 the proportion of overweight
children (aged 6-15) increased by 7.0% and the prevalence of obesity
increased by 3.5%.
28. Children's weight tends to "track" from
childhood to adulthood and children who are overweight or obese
are at high risk of being obese in adulthood. Obesity in childhood
is an important risk factor for adult obesity, but of course the
majority of obese adults were not obese children. This suggests
that factors throughout the lifecourse have an impact on the development
of obesity (Parsons et al, 1999).
29. There is some evidence that the prevalence of overweight
and obesity in British children may increase with increasing social
deprivation (Kinra et al, 2000), but this has not been shown consistently
30. The impact of lifestyle on obesity is discussed under
the section What are the causes of the rise in obesity in recent
decades (see paragraphs 39 to 55).
What is the relationship between obesity and other health inequalities?
31. There is a strong correlation between obesity
and health inequalities.
32. Inequalities in obesity tend to be reflected in the
prevalence of the chronic diseases with which obesity is associated.
For example, less affluent people also have a higher than average
risk of type 2 diabetes and, among women, levels of high blood
pressure increase as income decreases. Disadvantage is also associated
lower consumption of healthier food options;
poor access to sports facilities;
higher rates of inactivity in some groups; and
less physical activity outside work and less participation
in sportfor example 31% of men and 24% of women with the
lowest incomes participate in sports compared to 55% of men and
45% of women with the highest incomes (HSE 1998).
33. Risk factors for disease tend to cluster. Government
action to tackle chronic conditions such as obesity therefore
take a broad, lifecourse approach with a focus on tackling inequalities
34. The Acheson Independent Inquiry into Inequalities
in Health (1998) noted that "Improvements in the diet of
girls and women are likely to bring improvements not only in their
own health, but in the health of their children. Avoidance of
obesity similarly benefits both the mother and child. The effects
of mother's nutrition on their children's health will take more
than one generation to alter. An approach which starts with both
mothers and children is likely to bring the most rapid benefits".
What are the international comparisons? (EU, OECD, USA)?
35. Obesity is an international problemvirtually
all population surveys have shown an increase over the last two
36. In 2001, the OECD reported that obesity levels have
risen sharply in recent years in many countries, for example:
Australia7.1% in 1980 to 18.7% in 1995.
England7% in 1980 to 20% in 1999.
US23% in late 1980s/early 1990s to 31%
in 2002 (Flegal et al, 2002).
37. Obesity is more common among women than among men
in two-thirds of OECD countries, and such problems also tend to
be more common in lower socio-economic groups (OECD, 2001).
38. It has been suggested that the prevalence of obesity
in England (and the rest of the UK) is rising faster than in other
European countries. However, as the table below shows, while the
UK has the highest rate of self-reported obesity in the EU, measurement-based
sources show the prevalence of obesity in the UK to be below the
EU average. Many countries rely on self-reported values,
which will underestimate the true prevalence. Monitoring of trends
in overweight and obesity is particularly good in Englandmeasured
yearly through the HSE.
PREVALENCE OF OVERWEIGHT AND OBESITY IN THE EUROPEAN UNION,
BY TWO DATA SOURCES
|European Union||BMI 25-29.9
||BMI >30||BMI 25-29.9
||BMI >30||BMI 25-29.9
1 Self-reported data from a European Union survey by the Institute
of European Food Studies, Trinity College, Dublin, 1999.
2 Measured data from MONICA CINDI and other studies as compiled
by Bergstrom et al (2001).
Source: European journal of Clinical Nutrition page 202.
What are the causes of the rise in obesity in recent decades?
39. Without periods of increased energy intake and
/ or decreased physical activity, individuals will not gain weight,
no matter what their genetic make up.
40. International trends in obesity have been too fast
to be due to genetic factors alone. However, there may be an interaction
between individual genetic make up and environment.
41. Changes in lifestyle observed in many developed countries
are likely to have contributed to trends in obesity. Factors associated
with the development of obesity are discussed in paragraphs 42
What has been the role of changes in diet?
42. The National Food Survey (NFS, 2001) shows that average
energy (calorie) intakes have been falling since the 1950s (graph
below). However, the graph below also shows that total fat intakes
have remained relatively constant, and have not fallen in line
with energy intake. Foods which are high in fat are less "satiating"
than lower fat foods, and so a diet high in fat can lead to "passive"
43. While providing valuable information on trends, the
ability of the NFS / EFS to track trends in average caloric intake
is to some extent limited. The Survey does not fully account for
foods eaten outside the home. Furthermore, as the prevalence of
obesity has increased, so the extent of under reporting of food
intake may have increased. People who are overweight or obese
are more likely to selectively mis-report what they eat.
44. The WHO report on Diet, Nutrition and the Prevention
of Chronic Disease (2003) suggests that, unless individuals are
very active, fat intakes above 30% of calories could increase
the risk of obesity (WHO 2003). A high fat diet may undermine
the normal mechanisms regulating energy balance in humans and
predispose to weight gain (Prentice and Jebb 1995). Most countries
which have experienced increases in obesity, such as those observed
in the UK, have fat intakes above 30-35% of calories. The National
Food Survey (NFS, 2000) and preliminary data from the Expenditure
and Food Survey (EFS, 2001/2) (DEFRA 2003) suggest that average
fat intakes are around 37% of total calories. The forthcoming
National Diet and Nutrition Survey (NDNS) on adults will provide
more detailed information on macronutrient intakes in adults in
England (expected June 2003).
45. There is evidence to suggest that:
People are snacking more (borne out by
industry surveys showing continued rise in sales) and drinking
more carbonated drinks. (In the UK, the recent National Diet and
Nutrition Survey (2002) showed that consumption of carbonated
drinks by adults age 19-64 years has almost doubled during the
past decade, with young adults consuming, on average, six cans
per week. Most of the increased consumption in carbonated drinks
for adults overall is attributable to an increase in the consumption
of diet drinks. However, for young adults half the increase is
attributable to non diet drinks containing sugar. This style of
eating is an international phenomenon.
There has been an increase in the number of meals
people eat out (see graph below). Meals and snacks eaten outside
of the home tend to be higher in fat (NFS 2001) and may also be
higher in calories and sugars than foods eaten at home.
Evidence from the US (Nielson et al 2002) suggests
that portion sizes are significantly larger now than they
were in the 1970s, especially for high calorie snacks and fast
foods. The "supersizing" of fast foods and snacks has
also occurred in the UK and may make it easier for people to inadvertently
To what extent have changes in lifestyle, particularly moves
to a more sedentary lifestyle, been influential? How much is lack
of physical activity contributing to the problem?
46. Physical activity levels in developed countries appear
to have fallen due to a combination of factors. For children and
adults in developed countries, factors contributing to lower activity
levels compared to previous generations include (Epstein et al
greater use of cars for short journeys;
lower sports participation;
parental reluctance to allow children to play
increased pressures on time available for school
sport and physical education; and
greater access to television and computers and
other sedentary activitiesreduced TV viewing has been shown
to result in decreased adiposity and percent overweight in children.
47. The present UK physical activity recommendations
(HEA 1995) are as follows:
Adults: 30 minutes of moderate intensity physical
activity, at least five days a week.
Young People: participate in physical activity
of at least moderate intensity for one hour per day.
48. In England, six out of 10 men and seven out of 10
women are not active at recommended levels (HSE 1998) and four
out of 10 boys and six out of 10 girls are not meeting the recommended
hour a day physical activity for children (NDNS 2000).
49. The chart below shows that between 1994 and 1998
the percentage of men who were achieving physical activity recommendations
remained unchanged (HSE 1998). For women there was an increase
in the percentage who were "active for health" from
22 to 25%. The increase in the numbers of men and women classified
as sedentary are likely to be due to changes in the HSE questionnairehousework
or manual work/DIY of less than 20 min duration was classified
as a "medium" activity in 1994 but a "low"
activity in 1998.
50. In England, the National Travel Survey (2000) demonstrated
that both walking and cycling have declined since 1975/6. Total
miles travelled per year on foot was reduced by 27% and the miles
travelled by bicycle by 25% (DETR 1999). However, data from the
GHS (ONS 1998) reports that adults are more like to walk over
two miles and go swimming and cycling for leisure. Taken together
these surveys present an increase in the proportion of people
taking occasional physical activity but a decrease in physical
activity in daily life.
Other possible lifestyle factors contributing to trends in
51. Alcohol consumption has increased in women
and young men in England over the last ten year (ONS 2001, table
below). Alcohol provides almost as many calories as fat. Although
epidemiological research on the association between alcohol and
obesity is equivocal (BNF 1999), Wannamethee and Shaper (2003)
recently reported that, among a prospective cohort of middle age
men, heavy alcohol intake contributed directly to weight gain
PERCENTAGE OF ADULTS WITH HIGH ALCOHOL INTAKES
|Men > 21 units per week||
|18-24 year olds||32 ||39
|Women > 14 units per week||
|18-24 year olds||17 ||31
52. Breastfeeding ratesThere is some evidence
that long term breastfeeding may help mothers lose the excess
weight they gain during pregnancy, and children who are breastfed
may be at lower risk of becoming obese later in childhood. Breastfeeding
rates remain low in many developed countries, particularly among
lower social groups. For example, in the UK 43% of women in higher
social groups and 17% in lower social groups breastfed for at
least four months (IFS 2000). The prevalence of women who breastfed
in England at four months increased from 28% to 29% between 1995
and 2000 (IFS 2000).
53. Smoking cessation is associated with a mean
gain of 3-4.5kg (a range of 0-20kg has been observed) and people
who stop smoking are at high risk of becoming overweight or obese.
In 1998, 31% males and 21% of females in England were ex regular
smokers, compared to 24% males and 11% females in 1974 (ONS 2001).
54. Inappropriate dieting strategies"Yo-yo"
dieting and inappropriate dieting strategies may make it harder
to maintain a healthy weight in the long term. Concern about body
image is common in developed countries, particularly among young
women. In England, around half of all 20-24 year old females (and
22% of males) claim they are trying to lose weight (HSE 95-7),
yet less than 11% of 16-24 year olds are obese (HSE 2001).
55. A wide range of other factors have been hypothesised
as contributing to international trends in BMI and fat distribution,
including such diverse factors as increased levels of stress (which
may be associated with poorer dietary habits or other behaviours
which predispose to weight gain or adverse fat distribution);
an increase in the incidence of infants with high birthweight;
holiday weight gain and divorce.
56. It is recognised that a wide range of environmental
factors need to be addressed in order to tackle trends in obesityincluding
access to sport and leisure, family life, access to healthier
diets and education/information.
57. To make an impact on obesity and halt the upward
trend action needs to follow two general strategies:
Prevent future generations of people becoming
obesethrough action to tackle inequalities and improve
diet and increase physical activity, particularly among children
and young people.
Management of overweight and obesitya
number of themes are emerging on what strategies are most effective
for treating obesity (HDA 2002). These include:
diet, physical activity and behavioural strategies
for adults in combination where possible;
reduce sedentary behaviour in obese children and
maintenance strategies eg continued therapist
surgery for morbidly obese.
A gradual, incremental stepwise approach in weight
reduction seems to have the most beneficial long-term effect.
58. For obese individuals, even a modest weight loss
can have substantial benefits. A 10kg loss is associated with
a 20% fall in total mortality and a 10% reduction in total cholesterol
What is the range of levers and drivers (food industry, marketing,
education, family life, genetics, drugs, surgery)?
These are addressed separately as follows:
What is the range of levers and drivers food industry?
Within that range what role can the food industry play?
59. 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.
60. The food industryproducers, manufacturers,
retailers and caterersprovide all the food we eat and therefore
play a crucial role in the determination of dietary intakes.
61. Preference, price, availability and convenience are
major factors in consumer decisions about what to buy and cook.
It is ultimately up to consumers to choose a diet that will improve
their chances of better health. However, industry has a key role
in ensuring that healthy choices don't require extra effort, time
or expense, and that consumers have the information they need
to make sound choices.
62. Changes in lifestyle in England have resulted in
the food industry having an increasing impact on dietary intakes:
There is increasing consumer demand for convenience
food, snacking and eating on the move, and eating alone. Between
1990 and 2000 alone, purchases of convenience foods rose by 24%
There is less demand for formal meals, and for
cooking from scratch. For example, industry research by Geest
indicates that the average time taken to prepare the evening meal
has fallen from 90 minutes in the 1980s, to around 20 minutes.
Eating outside the home is more common25%
of respondents to the Consumer Attitudes Survey (FSA 2002) said
that they regularly used some form of fast food or takeaway outlet.
What is the range of levers and driversmarketing? Within
that range, what role can marketing and advertising play? What
are the responsibilities of the food industry in respect of marketing?
63. The Food Standards Agency (FSA) is currently funding
a systematic review of research into advertising and the promotion
of food to children (expected July 2003). This will review and
critically appraise the available evidence on the effect of a
range of promotional activities on the eating behaviour of children
and seek to draw conclusions on their effect relative to other
influences on eating behaviour.
64. The key issues are that:
Independent research on the link between food
promotion and eating behaviour is currently lacking.
Industry surveys show that advertising spend on
food products is reflected in increased sales, but the impact
on food category as opposed to brand sales is unclear.
Food products such as confectionery, drinks and
snacks are among those most commonly advertised, particularly
Advertising to children includes TV and print
advertising, as well as indirect forms of advertising such as
food promotions to schools.
Advertising to children is banned in Sweden, but
the impact is difficult to assess. This is because the ban relates
only to terrestrial TV, while non-terrestrial viewing figures
65. The Broadcasting Act 1990 requires the ITC to publish
a Code governing standards and practice in television advertising.
Compliance with the Code is a condition of television broadcasters'
licences. The ITC Code of Advertising Standards and Practice contains
guidance on the content of individual television adverts, in the
case of food advertising guidance exists to prevent harm, notably
from that which misleads, makes unsubstantiated health claims
or disparages good dietary practice. For example, the Code states
"advertising should not undermine progress towards national
dietary improvement by misleading or confusing consumers or by
setting bad examples, particularly to children." The code
also states that advertisements must not "encourage or condone
excessive consumption of any food" or "disparage good
dietary practice". Non-broadcast advertising must comply
with regulations against misleading claims.
66. Qualitative research carried out by COI Communications
on behalf of the Food Standards Agency (FSA, October 2001) indicated
that parents' main concerns were around mis-leading information,
for example being led to assume that fruit "drinks"
were pure fruit juice. Misleading labelling is being addressed
by the FSA through its labelling action plan.
What is the range of levers and driverseducation? Within
that range, what role can schooling play?
67. Action in schoolscombining dietary advice
and exercisehas been shown to be effective in preventing
obesity (Story 1999). Integrating regular activity into the daily
life of children has also shown to be effective (and maintained
at two year follow up) and more so than structured aerobic exercise
68. The NHS Centre for Reviews and Dissemination Effective
Healthcare Bulletin on the prevention and treatment of childhood
obesity (2002) states that "Currently there are a number
of government initiatives specifically targeting schools and there
is some evidence that school-based programmes that promote physical
activity, the modification of dietary intake and the targeting
of sedentary behaviours may reduce obesity in children, particularly
69. The Health Development Agency evidence base on obesity
highlights that while there is a the lack of high quality evidence
on the treatment and prevention of obesity within school settings,
findings from less rigorous research are encouraging.
70. See paragraphs 145 to 154 for more information on
the role that schools can play.
What is the impact of family life, genetics, drugs and surgery
71. A wide variety of factors within families may have
an indirect impact on obesity rates, including:
changes in family eating patterns and leisure
reduction in opportunities for active outdoor
changes in the way children and their parents
travel to and from school and work;
pressures on parental time, including the increase
in female employment and single parent families; and
increase in access to labour saving equipment.
72. Many parents, especially those who are overweight
themselves, may not recognise overweight and obesity in their
73. The NHS Centre for Reviews and Dissemination Effective
Healthcare Bulletin on the prevention and treatment of childhood
obesity (2002) stated that "Family based programmes that
involve parents, increase physical activity, provide dietary education
and target reductions in sedentary behaviour may help reduce childhood
obesity." The HDA evidence base on obesity is in agreement
with this conclusion.
74. For more information on the role of family life,
see paragraphs 120 to 123.
75. See paragraph 40.
76. Appropriate use of obesity drugs results in greater
weight loss than placebo. Furthermore, patients who lose weight
using obesity drugs are more likely to maintain the loss when
the drug use is extended than those who rely on diet and exercise
alone. For more information on the use of obesity drugs, see paragraph
77. Surgery is usually reserved for the extremely obese
patient with life threatening disease. It has been shown to be
effective (Glenny 1997) and NICE has concluded that surgery is
the recommended treatment for morbidly obese people (BMI >
40 kg/m2), providing certain criteria are fulfilledfor
example, that all appropriate and available non surgical measures
have been adequately tried but have failed to maintain weight
loss. More information on surgery is in paragraph 119.
What is the range of levers and driverstransport? Within
that range, what role can transport play?
78. There has been a reduction in active transport
in many developed countries.
79. The British Medical Association (1997) have confirmed
the links between transport and healthincluding inactivity
80. In the UK, 59% of 5 to 16 year old school children
walked to school in 1985-86 compared to 48% in 1997-99. Children
transported to school by car over the same period increased from
16% to 30%. Virtually no primary school children cycle to school,
and among secondary school children, the figure has fallen from
6% in 1985-86 to 2% in 1997-99 (DfT 2000).
81. The Social Exclusion Unit's report Making the
Connections: Final Report on Transport and Social Exclusion
(2003) examines the links between social exclusion, transport
and the location of services. The report highlighted that people
living in disadvantaged communities may have limited access to
shops offering healthy and affordable food and suffer disproportionately
from the effects of road traffic, through pollution and pedestrian
accidents, particularly among children.
82. More information on transport is in paragraphs 124
How influential is the media?
83. The impact of the media on issues related to
overweight and obesity can be positive or negative.
84. The media can be a source of conflicting information
and inappropriate advice on weight management. It has also been
blamed for increasing concerns about body image. A British Heart
Foundation Survey (2002) found that most adults who diet do so
for cosmetic reasons. Furthermore, most adults view "dieting"
as a short term activity despite the fact that successful weight
loss is accomplished by making positive sustainable changes to
long term eating habits and physical activity patterns (BDA 2002).
85. In the UK, the mediaTV, newspapers, radioare
the most commonly cited sources of information on food and food
safety (FSA 2002). The same is likely to be true for issues around
weight management and obesity.
86. The US Surgeon General's Call to Action to Prevent
and Decrease Overweight and Obesity (2001) states that "The
media can provide essential functions in overweight and obesity
prevention efforts. From a public education and social marketing
standpoint, the media can disseminate health messages and display
healthy behaviours aimed at changing dietary habits and exercise
patterns. In addition, the media can provide a powerful forum
for community members who are addressing the social and environmental
influences on dietary and physical activity patterns."
How can the amount of physical activity being undertaken be
87. Details of how physical activity can be increased
are addressed in paragraph 106 to 117.
To what extent can and should Government, at central and local
level, influence lifestyle choices?
88. The role of Government is to ensure that all
people can make informed choices and that they have proper access
to healthier options. Government also has an important role in
developing the evidence base and monitoring.
89. A range of government departmentsincluding
those with responsibility for health, transport, food and sporthave
an important role in preventing and managing obesity.
90. Government can influence choice by:
working with a wide range of stakeholdersat
national and local levelincluding industry, health professionals
and NGOs, in particular, to address issues around access to healthier
providing guidance and implementing legislation,
providing clear, consistent information to aid
working with a broad range of partners to ensure
consistency in all relevant policy areas, including health, transport,
food, education, sport; and
ensuring that the interventions are evidence based,
regularly monitored and evaluated.
How coherent is national and local strategy?
(also see paragraphs 98 to 119)
91. DH is working with other Government Departments (OGD)
to ensure co-ordinated action to tackle health inequalities, to
address healthy eating at every stage of life and to increase
mass participation in physical activity and is driving local action
through the NHS. Regional Government Offices (RGO), Primary Care
Trusts (PCTs), Strategic Health Authorities (SHA), Public Health
Networks (PHN) and Local Strategic Partnerships (LSP) provide
the mechanisms for effective co-ordination of local policies and
92. There are three main strands to DH's programme of
developing the evidence basefor example:
the HDA maintains the evidence base for a number
of public health topics including obesity, physical activity and
research and development activity related to diet,
nutrition and obesity.
implementation of service provision and national
DH has set out standards for the NHS through a
series of National Service Frameworks (NSFs).
Regional Directors of Public Health and their
teams are uniquely positioned to work with OGDs in the regions
to build a strong health component into regional programmes in
areas such as transport, environment and urban regeneration.
monitoring and evaluation:
see What efforts is the Government making to
evaluate these?, paragraphs 10 to 16, and What is the role
of the Department of Health?, paragraphs 98 to 118.
What is international best practice?
93. To date, no country has successfully tackled
the problem of obesity.
94. The WHO report Obesity: Preventing and Managing
the Global Epidemic (1999) highlighted that there has not
yet been any well evaluated, properly organised public health
programme aimed at the population management or prevention of
obesity. Furthermore, very few countries have a comprehensive
population wide national policy or strategy to deal specifically
with the problem of overweight and obesity.
95. A number of countries have recently made moves to
implement national policies to tackle obesity, including:
Americain 2002, committed $250 million
in federal spending for programmes including local obesity prevention
and exercise promotion projects, and federal studies into the
effectiveness of weight-reduction programmes for children.
Australiadeveloped a strategy in 1997 with
a broad range of approaches such as safe bicycle paths and healthier
food choices in schools (however a Lancet editorial 2001 stated
that it had still to be implemented).
New Zealand and Denmarkboth launched strategies
To date, no information is available on the impact of these
96. The WHO has identified the features of successful
public health programmes as:
adequate duration and persistency;
slow and staged approachchanges to diet
and physical activity need to be realistic;
legislative action may be useful in some instances;
education required to encourage and support changes
advocacy from respected elements within all sectors
of society has been a key feature of the decrease in smoking rates;
shared responsibility by consumers, communities,
food industry and government.
97. The WHO are in the process of developing a Global
Strategy on Diet, Physical Activity and Health, which is to be
launched in May 2004.
98. An integrated, cross-governmental strategy is
in place to tackle obesity, by improving diet and by increasing
physical activity levels. Key to this is the development of the
Food and Health Action Plan and the Sport and Physical Activity
What is the role of the Department of Health? How coherent
is national and local strategy?
99. The aim of the DH is to improve the health and well-being
of people in England. DH is responsible for driving forward change
and modernisation in the NHS and social care, as well as improving
standards of public health. DH also develops policies, sets national
standards and ensures that these are being met.
100. Addressing the prevention and management of obesity
is key if Government priorities in England are to be met, as highlighted
in the NHS Plan, Cancer Plan and the NSFs, particularly those
outlining action on CHD and diabetes. Action on obesity, diet
and nutrition is included within the DH-led cross-cutting health
inequalities strategy and supports the public service agreement
target to reduce inequalities in health outcomes.
101. In addition to the specific initiatives and programmes
delivered by DH, there are many relevant programmes being run
by Healthy Living Centres and Sure Start local programmes.
Action on Diet
102. There is a need to ensure co-ordination of policy
on diet and nutrition at national and local level and to ensure
clear and consistent messages. Work is in hand to achieve this
through the development of a Food and Health Action Plan.
103. The development of the Action Plan was announced
as part of the Government's Strategy for Sustainable Farming and
Food (December 2002), which builds on Sir Don Curry's Independent
Policy Commission report. The Plan will aim to achieve a healthier
diet for the people of England and will include clear policy objectives
on nutrition, setting out the arrangements for future co-ordination
of nutrition work across Government and other sectors at national,
regional and local level. The Plan will address not only those
policies where nutrition is the key aim, but policies across Government,
particularly other elements of the Sustainable Farming and Food
Strategy, such as regional and local food strategies and public
procurement of food.
104. The Plan's development is being led by DH in collaboration
with FSA, DEFRA and OGDs. However the Plan will not be for Government
alone. It will present a framework for action for bodies outside
Government, including industry, setting out the key responsibilities
105. The Food and Health Action Plan will pull together
all action on diet and nutrition. Current action takes a lifecourse
approach, is predominantly based on commitments outlined in the
NHS Plan (2000), and includes:
Reform of the Welfare Foods Scheme (WFS) to use
the resources more effectively to ensure children in poverty have
access to a healthy diet and increased support for breastfeeding
which is accepted as the best form of nutrition for infants to
ensure a good start in life.
Action to promote breastfeeding, including the
funding and evaluation of 79 "best breastfeeding practice"
projects and support for an annual National Breastfeeding Awareness
Week. The aim is to increase the rates of breastfeeding, both
initiation and duration, particularly among disadvantaged groups.
This is a goal shared by all Sure Start initiatives (see paragraphs
121 and 122).
Action in schools, including the Food in Schools
Programme, the National School Fruit Scheme and the National Healthy
Schools Programmesee paragraphs 143 to 152.
Eating more fruit and vegetables instead of foods
high in fat and/or sugar, can help in the maintenance of a healthy
weight (Biing-Hwan et al 2002). The 5 A DAY programme aims to
increase consumption of fruit and vegetables through work at a
national and local level. The programme has 5 main strands of
National School Fruit Scheme (NSFS) (see paragraph
Local 5 A DAY initiativesnational evaluation
of the 5 A DAY pilot initiatives demonstrated that community initiatives
can produce important changes in people's knowledge, access and
intake of fruit and vegetables. Overall, the intervention was
found to have had a positive effect in people with the lowest
intakesthis is important for addressing inequalities in
health. Those who ate less than 5 a day at baseline increased
their intakes by 1 portion over the course of the study. The New
Opportunities Fund (NOF) has made £10 million available to
support the establishment of 66 new initiatives, led by PCTs.
These will also be fully evaluated. Guidance on delivering evidence-based
interventions has been developed and is informed by lessons from
the pilot initiatives.
A communications programme (see paragraph 137,
Work with the food industry (see paragraphs 133
Work with national and local partners, such as:
cross-government and health, education and consumer organisations.
Evaluation and monitoring underpins the programme.
At a national level consumption, attitudes and awareness of fruit
and vegetables will be monitored annually through the HSE, the
EFS, the FSA Consumer Survey and ad hoc surveys.
Initiatives with the food industry (including
manufacturers and caterers) to improve the overall balance of
diet including salt, fat and sugar in food, working with the FSA
(see paragraph 135).
Action on physical activity
106. The Government's aim is to significantly increase
levels of sport and physical activity, particularly among disadvantaged
groups by 2020. In practical terms the target is for 70% of the
population (currently 32%) to be reasonably active by 2020. In
this context, "reasonably active" means 30 minutes of
moderate exercise five days a week or the equivalent.
107. In December 2002, the Prime Minister's Strategy
Unit and DCMS jointly published Game Plan: a strategy for delivering
the Government's sport and physical activity objectives. The
report recommended the creation of a Sport and Physical Activity
Board (SPAB) to work with a wide range of partners to develop
mass participation policies. The scope within Whitehall for encouraging
greater participation in sport and physical exercise is wide-ranging.
There is also a broad range of organisations outside central governmentin
local government and in the sporting, health, charitable and other
sectorswith important delivery and policy roles.
108. The practical steps that SPAB will take will be
innovate, introducing change where there is supporting
evidence and available fundingthis should give early impetus
to the work;
pull together evidence and present itjointly
with outside sporting and health organisationsas part of
a positive communication strategy, disseminating evidence and
test and evaluate interventions where evidence
is not strong, including other externalities of increased participation,
such as crime reductionwhere the timescale might be longer;
identify sources of funding; and
gather comprehensive data on participation and
109. A progress report on this work will be made in 2004.
The report will identify areas where work is underway and set
out existing evidence. It will also contain proposals for improving
data collection and running pilot schemes to increase long-term
mass participation, as envisaged in Game Plan.
110. DH hosts the National Alliance on Physical Activity
(NAPA) which provides a forum for policy makers, experts and practitioners
to share experiences and learning on strategies, plans and projects
that aim to promote increased participation in physical activity.
It includes representatives from DfES, DfT, DCMS, Qualifications
and Curriculum Authority, Sport England, and the LGA, as well
as academics and representatives from the NHS and voluntary organisations.
The work of NAPA will feed into SPAB.
111. DH is working with funding partners Sport England
and the Countryside Agency on the Local Exercise Action Pilots
(LEAP) programme to test different community approaches to increasing
levels of and access to physical activity. The nine pilots will
be led by PCTs and based in neighbourhood renewal areas, both
urban and rural and will also involve Sport Action Zones. LSPs
will contribute to the innovate multi agency approach to increasing
activity in key target groups which will include young people,
older people, black and minority ethnic groups, and those at high
risk of illness such as diabetes and heart disease and people
recovering from illness. The pilots will help to establish the
evidence base on what works contributing to SPAB, and support
the delivery of milestones in the NSFs. The ongoing results will
inform and lead action on physical activity across the NHS and
other relevant sectors.
112. DH meets regularly with OGDs to review progress
and ensure joined up working and avoid duplication of effort.
It contributes to on-going programmes such as the School Travel
Advisory Group and the joint DfES/DCMS PE, School Sport and Club
Links PESSCL strategy. At a local level programmes are at varying
stages of development from comprehensive physical activity strategies
to isolated initiatives. Progress is being made to enable greater
linkages, for example through LSPs, the formation of regional
sports boards and the requirement within the CHD NSF for PCTs
to work in partnership with their Local Authorities.
113. Work is also underway by DH to develop a universally
agreed physical activity communication message for adults and
children for use by all those working to address inactivity. It
is envisaged this will promote a simple and effective message
on physical activity that will be relevant and accessible to the
114. Regular walking can help in the maintenance of a
healthy weight (Morris and Harman 1997) as well as helping to
prevent and manage heart disease (Wannamethee et al 1998, Morris
et al 1990). In its November 2001 response to the Environment
and Transport Committee's report Walking in Towns and Cities,
the Government agreed to publish a national walking strategy.
The DfT aims to publish a consultation paper in Summer 2003, with
publication of the final strategy to encourage more walking scheduled
towards the end of this year.
115. DH 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.
116. The HDA is currently building the evidence base
of effective interventions to increase physical activity, as well
as translating this evidence into practice.
117. Sport England is currently undertaking a modernisation
and restructuring programme and as a result its new business strategy
will have three new main objectives, one of which is "to
increase participation in sport in order to improve the health
of the nation". In addition, a placement from Sport England
is working with DH to assist with policy development on physical
activity as part of Sport England's placement programme.
Research and Development
118. DH carries out research and development activity
related to diet, nutrition, physical activity and obesity, including
the recently completed research initiative on nutrition funded
through the Department's Policy Research Programme (PRP). Key
Maintenance of a healthy weight: risk factors
for childhood obesity, childhood predictors of adult obesity,
interventions to prevent obesity;
Dietary change: interventions to increase fruit
and vegetable consumption and reduce fat consumption, particularly
in low income groups;
Physical activity: its role in obesity and bone
health, and promoting physical activity among children and young
Projects currently funded by DH include: systematic reviews
of barriers and facilitators to the uptake of physical activity
and of healthy eating amongst children and young people; a systematic
review of the evidence on the prevention of adult disease through
interventions in early life; trials assessing action to treat
and prevent obesity in primary care; family based treatment for
obese children; development of and obesity website for patients
and health professionals. DH also provided funding for the development
of advice for professionals in primary care on weight management
in children and adolescents.
What is the role of the NHS, including that of primary care,
hospitals and specialist clinics?
119. Action on obesity requires input from primary care
staff, particularly GPs, health visitors, practice nurses, dietitians
and psychologists. There is also the opportunity to provide support
through the wider public health workforce, for example exercise
specialists, school nurses, health promotion specialists and community
workers, located in PCT areas. In order to address health inequalities,
PCTs have been asked to work with partners through Local Strategic
Partnerships on the wider determinants of health, and joint work
on physical activity and obesity could be included as part of
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 focussing 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
NICE and the HDA are to work collaboratively to
develop guidance on the identification, prevention and management
of obesity and maintenance of weight reduction. This follows the
NAO (2001) recommendations that guidance be developed for the
management of overweight and obese patients in primary care. NAO
reported that 63% of general practitioners and 85% of practice
nurses believe that such guidelines would be "useful"
or "very useful".
NICE has provided guidance on drug treatments
for obesityOrlistat (March 2001) and Sibutramine (October
2001). The guidance emphasises that people who are prescribed
the drugs should also be given appropriate advice and support
on diet, activity and behavioural strategies. The Royal College
of Physicians recently reiterated that while drugs can be useful,
they should only be used as an addition to changes in diet and
behaviour and an increase in regular physical activity (RCP 2003).
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
NOF funds 257 Healthy Living Centres in England.
Communities define their own needs and solutions, and while some
of the projects are PCT led, the majority are run with the PCT
as a partner and are led by voluntary or community organisations.
The centres enhance mainstream services, and diet and nutrition
feature strongly43% provide dietary advice, 40% run food
coops, 32% have community cafes and 46% provide training in cookery
skills and nutrition. The HLCs strong community basis gives them
a headstart in engaging people successfully in improving their
PCTs across England are currently piloting the
Expert Patients Programme, a six-week training course for people
in the self-management of long-term conditions, such as diabetes,
CHD, overweight and obesity (which may also be present as a secondary
problem alongside a range of chronic diseases). The course content
and resource materials provide detailed advice on the importance
of physical activity and a healthy diet as ways to reduce the
risk of developing a range of health problems, including obesity.
People who are obese may experience a range of
difficulties from low self-esteem to mild and moderate depression
and more severe conditions such as binge eating. Conversely, people
with a mental illness appear to be more at risk of physical ill
health, including obesity. The NSF for mental health addresses
eating disorders and DH has commissioned a NICE guideline on eating
There has been a three year programme to support
health visitors and school nurses in targeting health priorities
and inequalities, including CHD. Resource packs which are available
to all practitioners include specific sections on promoting physical
activity and healthier diets.
The Department has published a "National
Quality Assurance Framework for Exercise Referral Systems"
(April 2001), aimed at GPs. Recent reviews have shown extremely
good uptake of this initiative.
Funding through Section 64 grantsfor example,
the Department contributed to the funding of the charity Weight
Concern to develop a "toolkit" on obesity, for health
professionals to use with patients in a group setting. DH has
also funded the British Dietetic Association to develop an obesity
website for consumers.
NICE has provided guidance on obesity surgery
which is the recommended treatment for individuals with BMI >
40 kg/m2. At present around 200 operations are performed annually,
many of which are privately funded (NICE 2002). Currently there
are 10 specialist obesity clinics in England (ASO), NICE guidance
emphasises that services and skills to support surgery for people
with morbid obesity be developed in a planned and co-ordinated
NHS Direct provides general advice on nutrition,
physical activity and the maintenance of a healthy weight, as
well as information on available treatments for obesity. It was
recently announced that the capacity of this service is to double
over the next three years. NHS Direct online is the largest and
most successful e-healthcare provider in the world.
What is the role of families?
120. It is likely that the forthcoming NSF for Children
will highlight the family environment as a key determinant of
children's health and a key setting for the development of healthy
habits. A range of government initiatives are likely to have an
impact on family eating and physical activity habits, including
Sure Start, the WFS, the NSFS, the 5 A DAY programme and Local
Exercise Action Pilots.
121. Sure Start programmes work with parents-to-be, parents
and children to promote the physical, intellectual and social
development of young childrenparticularly those who are
disadvantagedso that they can flourish at home, when they
get to school and during later life. The Sure Start Unit has a
PSA target of "a 6 percentage point reduction in the proportion
of mothers who continue to smoke during pregnancy". Babies
whose mothers did not smoke during pregnancy are more likely to
have normal birth weight, experience less respiratory illness,
more likely to be breastfed and to be generally healthier. There
is also an SDA target"Information and guidance on
breastfeeding, nutrition, hygiene and safety available to all
families with young children in Sure Start local programme and
Children's Centre areas".
122. The Sure Start local programmes enable better access
to health services, including ante-natal and baby clinics, with
provision of advice on infant feeding. Local programmes include:
encouragement and guidance on breastfeeding and
advice and information on healthy eating and nutrition
for families on low incomes;
nutrition and cookery, including as part of their
parenting skills programme, and "Get Cooking" groups
for healthy eating on a budget;
local food co-ops where parents can buy fresh
fruit and vegetables at affordable prices and community garden/allotment
encouragement of active play, for example by providing
access to outdoor play facilities to encourage exercise and physical
activity, playgrounds for under-4s and exercise programmes for
123. As part of the HDA's evidence into practice work,
family based approaches will be further investigated by working
with families and practitioners, drawing on their experience of
What is the role of transport?
124. The White Paper Saving Lives: Our Healthier Nation
(1999) describes how local communities can increase active transport
implementing the Integrated Transport PolicyA
new deal for transport: Better for everyone;
providing safe cycling and walking routes;
providing facilities for physical activity and
reliable transport for people to gain access to them;
developing traffic calming and other safer measures
as part of transport plans; and
adopting school travel and green transport plans.
125. To improve access to services that can help prevent
obesityincluding leisure facilities and healthier food
options (eg fruit and vegetables)the Government is implementing
the recommendations of the Social Exclusion Unit's report Making
the Connections: Final Report on Transport and Social Exclusion
126. The DfT is leading on a number of initiatives including:
bursaries to 84 local authorities to fund travel
plan co-ordinators to spend time working with schools and businesses
on the development of local measures to reduce reliance on the
site specific advice to help schools, businesses
and other organisations to develop travel plans;
seminars for staff in local authorities working
on school travel plans;
£3 million investment to create a team of
regional cycling co-ordinators to help reverse the decline in
cycling and deliver the target of fourfold growth on 1996 levels
Cycling Projects Fund, supporting 138 projects,
including safer access and secure cycle parking facilities as
part of school travel or safe route to school projects; improved
cycle parking at bus interchanges and train stations; cycle park
and ride schemes; cycle parking at various NHS Hospital sites;
workplace cycling initiatives and cycle routes;
within the next few months a consultation on a
strategy to encourage and promote walking will be launched.
127. The HDA is producing a review of evidence of effective
transport interventions that improve health or reduce health inequalities.
This will include a section on evidence of effective transport
plans, schemes or initiatives that promote cycling and walking.
A report describing local approaches to improving health through
transport between PCTs and local authorities will also be published
How effective are the structures for health promotion?
128. For health promotion to be effective, a wide range
of barriers and facilitators need to be addressedincluding
income, access, knowledge and skills. This requires input from
a range of health professionals, including GPs, dietitians, nutritionists,
health promotion specialists, health visitors, midwives and practice
nurses. It also requires the PCT, through the Professional Executive
Committee to increase health promotion resources.
129. Shifting the Balance of Power has provided
opportunities for the provision of health promotion on issues
relating to obesity prevention and management. Greater integration
of community based services such as dietetics, health promotion
and health visiting into PCTs should enable the development of
improved multidisciplinary working, more seamless care and improved
allocation of resources.
130. The HDA's future "evidence into practice"
work will draw together practitioners from a broad spectrum of
sectors to enable delivery and implementation of the weight management
evidence-based guidance. The HDA will also have a role in facilitating
and supporting changes in practice for those practitioners/organisations
implementing the guidelines.
131. A voluntary register for specialists in public health
has recently been launched and will provide a way of accrediting
multi-disciplinary public health specialists so that potential
employers and others can be assured of their competence.
132. The joint DfES/DoH project "Skilled for Health"
is designing new health based curriculum materials for the Learning
and Skills Council (LSC) programmes which are aimed at improving
the basic skills of adults. Participants will be able to take
better care of themselves through having a better understanding
of their own health and how the make the best use of the NHS,
as well as improving their basic skills. The project will also
design and generate health related curricular programmes in demonstration
sites focussed on particular aspects of health. These can then
be replicated throughout the LSC programme to suit the particular
needs of adults in different parts of the country.
Can health promotion compete with huge food sector advertising
budgets? To what extent can the food industry be part of a solution?
133. The relative funds for health promotion compared
to advertising spend emphasises the importance of working with
industry and ensuring consistency in the message through all programmes
of work. Industry has a major role in enabling access to a healthy
balanced diet. Manufacturers and caterers can assist consumers
through reviewing recipes in relation to fat, added sugars and
salt content, portion size and labelling in line with Government
advice on healthy eating.
134. The food and farming industries have a vital role
in the Food and Health Action Plan (as discussed in paragraphs
102 to 105).
135. The NHS Plan made commitments to initiatives with
the food industry (including manufacturers and caterers) to improve
the overall balance of diet including salt, fat and sugar in food,
working with the FSA. 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.
136. There is also on-going work with industry (including
producers and retailers) to increase provision and access to fruit
and vegetables as part of the 5 A DAY programme. Indeed the success
of the programme will depend on partnership working with the food
industry, and with health, consumer and education organisationsall
giving the same consistent messages facilitated by the 5 A DAY
137. A communications programme has been developed to
ensure that consumers receive consistent messages and advice about
eating 5 A DAY, supported by the production of information materials
for consumers and guidance on establishing local 5 A DAY programmes
based on evidence. This work will continue through 2003-06.
138. The development of the 5 A DAY logo has been carried
out in close consultation with industry and health, education
and consumer bodies. At present, the logo can only be used on
products without any added sugar, fat or salt. While the message
to eat more fruit and vegetables is an important one, the advice
needs to be considered in the context of general dietary advice
to reduce the consumption of fat, salt and added sugars. Therefore
nutrition criteria for the use of the logo on fruit and vegetable
products with added ingredients are currently being considered
by a small expert group. The logo and associated nutritional criteria
provide an incentive for industry to increase the fruit and vegetable
content of products and consider the levels of added sugar, fat
To what extent is the Food Standards Agency influential?
139. The FSA is an independent non-ministerial government
department set up by an Act of Parliament in 2000 to protect the
public's health and consumer interests in relation to food. Between
2001 and 2006, the FSA's key aims include helping people to eat
more healthily, promoting honest and informative labelling and
promoting best practice with the food industry. DH and the FSA
share responsibility for providing the joint secretariat of SACN,
surveillance of the nutrition status of people, defining the health
education message on nutrition issues, taking account of both
food and wider health issues and policy formulation and advice
to Ministers on these issues.
140. The FSA's role includes obtaining sound evidence
on which to base dietary recommendations. This is achieved by
commissioning research and dietary surveys and by seeking advice
from expert advisory committees. The FSA has a major role to play
in enabling, motivating and informing people about diet and in
identifying what steps people can take to change their eating
habits for the better. The FSA's aim is to find out what information
the general public and specific groups require about healthy eating
and the best means of communicating these key messages.
141. The FSA's Nutrition Action Plan identifies a range
of work relating to delivering the Agency's Nutrition Strategic
Framework (March 2001). This includes activity related to securing
the evidence base, identifying and addressing barriers to achieving
a balanced diet, informing the public and monitoring activity.
In carrying this out, the FSA will look at every stage of the
food chain, working with industry and consumers to see how all
stakeholders can contribute to better health, and be involved
in finding solutions.
142. The FSA also has a Food Labelling Action Plan to
improve consumer choice through provision of accurate, meaningful
and honest information. The Action Plan seeks to regulate to protect
consumer interests where most appropriate and provide advice and
guidance where this is likely to be more effective. Nutrition
labelling legislation is supplemented by guidelines to ensure
consumers have the right level of information. The FSA is also
pursuing legislation on health and nutrition claims in Europe
which will seek to limit inappropriate claims for, among other
reasons, particular classes of food.
143. Rules on the provision of the energy and nutrient
content in food labelling are harmonised at European level. These
require that such information be provided on pre-packaged foods
bearing nutrition claims. The FSA, in its guidance to manufacturers
on the nutrition labelling regulations, recommends that this information
be provided on all pre-packaged foods to enable consumers to make
a judgement about its suitability in line with healthy eating
How well is DoH liaising with, and what is the role of, other
central and local government departments and bodies?
144. Examples are provided throughout this document,
particularly in see paragraphs 91, 92 and 98 to 119.
What is the role of schools, including sport in schools?
145. The school is a key setting in which to improve
both health and education.
Our Healthier Nation (1999) and the Independent
Inquiry into Inequalities of Health (1998) recognised the importance
of a sound education in promoting better health and emotional
well-being for children and young people, in particular those
who are disadvantaged.
It is likely that the forthcoming children's NSF
will also identify schools as a key setting for promoting a healthy
diet and physical activity among children, as part of action to
promote the health of children in general.
Personal, Social and Health Education (PSHE) has
an assured place in the curriculum.
146. The National Healthy School Standard is the mainstay
of the Healthy Schools Programme. Introduced in October 1999,
it supports delivery of PSHE and citizenship in schools. All 150
LEAs along with their health partners have now achieved accreditation
under the NHSS. The Standard promotes a whole school approach
to health and healthy eating and physical activity are key areas
for action. Work in this area is taken forward through joint initiatives
involving DfES with DH and FSA. For example, the FSA-led work
to identify the minimum food/nutrition knowledge and skills of
young people in preparation for independent living (anticipated
in late Spring 2003) and for the first time monitoring of the
nutritional guidelines on school lunches.
147. The NSFS will be fully operational by 2004 and will
entitle every child aged four to six in infant schools to a free
piece of fruit each school day, as part of a national campaign
to improve the diet of children. The Scheme is currently being
rolled out through a £42 million NOF grant scheme. Children
in the West Midlands, London and North West regions are currently
in receipt of fruit. From the Summer term 2003, one million four
to six year olds, in 8,000 schools will receive fruit. Further
regions will be brought on stream during subsequent terms.
148. The local 5 A DAY community initiatives will also
deliver effective interventions to increase fruit and vegetables
consumption in schools (see paragraph 105).
149. Providing a consistent message to children on healthy
lifestyles is vital if we are to meet our objectives. The DH /
DfES Food in Schools Programme aims to improve children's health
by encouraging a healthy diet at school and promoting clear and
consistent messages about diet and nutrition within the school
environment. The scope of the Programme is broadinitiatives
include the assessment of the overall impact, feasibility and
sustainability of water provision and the inclusion of healthier
products in vending machines. This programme will support other
on-going action in schoolssuch as nutritional standards
for school lunches, NSFS and the National Healthy Schools Programme.
150. Building on the Government's Plan for Sport (2001),
there is a joint DfES/DCMS 2002 PSA target to enhance the take-up
of sporting opportunities by 5-16 year olds: by increasing the
percentage of school children who spend a minimum of two hours
each week on high quality PE and school sport (within and beyond
the curriculum) from 25% in 2002 to 75% by 2006. The two Departments
are investing £459 million over the three years from April
2003 to deliver this target through a national strategy for PE,
school sport and club links, with the aim of improving the quality
of teaching, coaching and learning in PE and school sport.
151. The Government is committed to the preservation
of playing fields for the benefit of sport and local communities:
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 facilitiesthe proceeds are not being spent
on school books or paying teachers' salaries.
The DfES Sporting Playgrounds programme will enhance
physical/sporting activities and improve behaviour.
Sport England has invested over £220 million
on pitch sports since 1995.
152. £581 million is being invested in England by
NOF 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 providing
initial revenue funding in support of the developments.
153. An investment of £130 million which is being
allocated to 65 LEAs 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
will also be available for community use, with the emphasis on
inclusion of currently under-represented groups.
154. As part of the HDA's "evidence into practice"
work on obesity, school based work will be further investigated
by working with practitioners and drawing on their experience.
Who should own and drive delivery?
155. DH is working with OGDs to establish co-ordinated
action and is driving local action through the NHS. In addition:
DH is leading on the development of a Food and
Health Action Plan.
DCMS and DH are leading on SPAB.
RGOs, PHNs and LSPs provide the mechanisms for
effective co-ordination of local policies.
The DfES/DCMS delivery board oversee the implementation
of the Government's Physical Education, School Sport and Club
Links strategy. The board brings together different Government
departments including the DH and other partners to combine effort
to maximise the impact of the funding and strategy.
Have we the appropriate institutional structures, budgets and
156. As already highlighted, addressing the prevention
and management of obesity is key if Government priorities in England
are to be met, as highlighted in the NHS Plan, Cancer Plan and
NSFs, particularly those outlining action on CHD and diabetes.
The Priorities and Planning Framework for 2003-06
(see paragraph 119).
To meet the increase in demand, the NHS workforce
is expanding. For example the number of dietitians employed in
the NHS has increased by 20% since 1997 and further expansion
is expected. Delivering the NHS Plan includes projections for
35,000 more nurses, midwives and health visitors, 30,000 more
therapists and scientists and 15,000 more GPs and consultants
to be employed in the NHS by 2008 over a 2001 baseline. There
is also the opportunity for additional staff support through initiatives
such as the development of dietetic assistant posts and "skills
The Lifelong Learning budget has allocated £24
million to professional skills development for the spending review
period 2003-042005-06. £3.6 million of this budget
has been allocated over the three years to provide training on
obesity for primary care staffenabling 5,900 existing staff
to develop their skills and boosting the capacity of the NHS in
How can the Government's strategy by improved? What are the
policy options? Can they be better integrated? What are the priorities
157. In conclusion, obesity is an international problem,
which no country has successfully tackled. Prevention is likely
to be the best long term approach, addressing the risk factors
of diet and physical inactivity, however effective management
of overweight and obesity is also being addressed.
158. The prevention and management of obesity are at
the heart of many of the Government's priority areas, as highlighted
in the NHS Plan, Cancer Plan, and NSFs, particularly those outlining
action on coronary heart disease, diabetes and older people.
159. One Government department cannot tackle obesity
on its own. An integrated, evidence based cross-government approach
is underway to tackle obesity, improve diet and increase physical
activity levels, and to tackle inequalities. Key to this is the
development of the Food and Health Action Plan and the Sport and
Physical Activity Board which will help shape policy in this area,
ensure a consistent, effective approach, and is likely to have
a major impact on trends in England.
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