Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 360-371)

17 JULY 2003


  Q360  Dr Naysmith: You are right, there could be a number of other explanations for that.

  Dr Lobstein: There are and it is well worth looking at.

  Q361  Dr Naysmith: There are general health benefits so it is a good thing anyway.

  Dr Lobstein: Put that on your list of things to consider.

  Professor Prentice: I would like to make some very specific points, first to endorse the need to attack both sides of the energy balance equation. We were invited here to look at gluttony versus sloth. The answer is very clearly that it has to be both so please let us keep sight of that. I would like to see us turning this in a positive direction and develop a strategy on healthy weight maintenance. Stop beating obese people and stop beating all of ourselves about the problem of obesity. Turn it positive. For instance, Dr Jebb as Chairman of the ASO, has got an initiative at the moment called Leaner Fitter Future. We can do things together, we can bring people on board by saying, "These are the problems, we have all been ambushed by changes in the environment, let's try and get out of this together and see positive things to do." The other advantage of that is it removes stigmatisation and concentrates our minds on the fact that this is a nationwide issue. It is not just fat people we are worried about because the health effects kick in very early. Having said that we should be very positive—

  Q362  John Austin: Can I just interrupt you on that. I accept the general premise you are putting forward, that it is a problem across the whole community, but if you look at children you can identify very clearly that the young child who is grossly overweight is probably associated with low self-esteem, over eating, not exercising, whose self-esteem in punished even further by the physical activity within the school because there is nothing worse than being overweight and being humiliated in front of your class mates in the PE gym or whatever. Quite clearly young people at risk stand out so how do we tackle that?

  Professor Prentice: We do indeed but the way you phrased your questions exactly brings out this stigmatisation of a particular sub-group. The point I am trying to make is it is all of us, we are all in this together, no child becomes fat without first of all being a little overweight and the same goes for adults, so we need to tackle it earlier. Also what we need to get across is that the health risks associated with excess weight kick in at a very small incremental weight. If you look at the risks for diabetes—and this was not clearly brought out by the evidence last week—with people with a BMI that does not classify them as clinically obese (a BMI of around 28 in women) the increased risk of diabetes is 18-fold. That is a huge risk relationship in even moderately overweight people. In terms of doing the numbers game of where you get the impact that is very important. Coming back to my other points we have got to be brave and apply a bit of the "Occam's razor" and say a lot of the things we need to do are very clear and let's get going on those and apply the precautionary principle. I see the CMO is arguing this very strongly already that we should start to get going. I get very worried by accusations of the nanny state. We are prepared to go to war against Iraq against the population's better judgment and wishes, we are prepared to wear our seat belts and stick to speed limits, by and large, because we know they are good for us, and I think there is something that could be done. My final point is we have got to work with the food industry to tackle the rogue elements because they are creating as much of a problem within the food industry as they are to us. There is a lot of the food industry who are very keen to sort this out with us and we need to separate out those who are not and move forward with those that are. The analogies with tobacco are quite strong. McDonald's never intended to create a product that would harm children or make us all fat but the fact is the evidence is pretty strong that it does and they now have a moral responsibility to join us in doing something about it. Similarly with Coca Cola and soft drinks, we need to name and shame them in order to get them on board and get them to start to listen to a dialogue.

  Dr Wareham: I would like to suggest that the biggest thing government can do at the minute is to engage in a public debate about individual and collective prevention versus the further medicalisation of society. I do not think most people are aware of the rather insidious way in which the boundary between normality and abnormality for many obesity-related disorders is being shifted so that we are all being defined as being diseased. The specific example I want to give is of diabetes where maybe 4% of people in Britain have diabetes but maybe 20% have a precursor condition pre-diabetes, and there is a move to have that proportion of society medicalised and given drugs and the drug companies are queuing up to make drugs that will benefit those individuals. We have a stark choice because all these individuals will be overweight and that proportion of people in that sector is going to increase with time. The stark choice is do we move that boundary of normality and abnormality further down to medicalise people and to treat our way out of this problem, which we may not be able to afford, or do we tackle the problem at the root by individual and collective proactive action, and I think we need that debate.

  Q363  Mr Burstow: One picks on the point about joined-upness in terms of government policy and approach and the reference which was made to the Cadbury's Eat Chocolate Get Fit campaign which did cause some concerns earlier on. What I want to try and get is an idea of where you all might suggest that the lead responsibility ought to be placed for taking forward strategies within government and also at a local level. Where is the lead, which is the organisation, who is the person within government who ought to co-ordinate this? Is it the Department of Health or somewhere else? We now have a Minister for Children who in terms of children's obesity might well be the person to take this lead role. I would be interested to hear who should have the lead in government, both locally and nationally.

  Dr Lobstein: I do not know enough about your constitutional structure to be sure that it would work but I would assume if it is going to be cross-departmental you have to start with a Cabinet Office approach or something like that. You are better at judging these things than I am. It has to extend quite far down to things like Ofsted criteria for evaluating schools' pastoral care and whether it includes a nutritional policy, let alone the Minister of Sport's behaviour when he discusses his support for particular companies' products and so on. I can only assume that the Cabinet Office would be the starting point for a cross-departmental policy.

  Q364  Mr Burstow: Does anyone else want to add about the local level or the national level?

  Dr Jebb: I know less about the local level. At the moment there is a real problem with obesity between DH and the Food Standards Agency. I absolutely accept that lots of other departments are involved but it is useful to focus on the DH/FSA responsibilities because they will both tell you very firmly that obesity is a Department of Health responsibility and in terms of treatment I am sure that it is appropriate that they should be taking the lead. I am less convinced in terms of prevention that it is most appropriately there because the Food Standards Agency takes primary responsibility for healthy lifestyles and healthy eating and that is the foundation for prevention of obesity (pulling in all sorts of other people as well). It is possible it seems to me that the prevention side is really falling between the two and I would like to see that issue clarified with some urgency. I support Nick's comments about not wanting to medicalise this further, particularly in relation to children. We need an all children approach to this because most children are not fat but many of them will become fat later, so we need to target all of them in terms of healthy eating/healthy lifestyles, and I do not think that necessarily is best with the Department of Health taking the lead. I think treatment issues are very, very different. We have not touched on those at all today. Clearly seriously obese children need active treatment.

  Q365  Mr Burstow: In your paper that you submitted some time ago now you make reference to the Health of the Nation initiative and the targets that were set then which were meant to be coming to fruition by 2005. What evaluation was ever done to know whether or not those targets were likely to have been hit? Do you have any information you can share with us on that?

  Dr Jebb: From the moment they were set most people in the obesity field realised that they were unachievable because the scale of the increase was so rapid, but they were important because they were targets. They were probably unachievable targets which maybe is not helpful but they were targets, which is useful. What Health of the Nation did do was set up task forces for food and nutrition and physical activity which brought together diverse groups. The trouble is they did not have any teeth, they did not really go anywhere. What we need now is not a task force but something at a much higher level because the scale of the problem is three times bigger than it was and growing every day.

  Q366  Mr Burstow: My final question is about messages. Earlier on there was reference to the point that you cannot turn this into sound bites but in terms of trying to achieve a whole society type change, which is what in a way we have been told has happened—a shift in the population's weight and we now want to achieve a shift in the population's weight the other way—what would be the key messages that would be part of trying to educate and inform and change opinion on this? That is really a question for everybody.

  Professor Prentice: John Garrow has coined a phrase "treat obesity seriously", and I think that is very important. That is a sound bite, although I did not intend to give a sound bite. The mere existence of your Committee is enormously helpful. It is getting onto the agenda now and you need to keep it up on that agenda and move in every direction we possibly can. I congratulate you for the work you have done so far, keep going.

  Q367  Jim Dowd: I do not know if you mentioned it in the few moments before I got here, and if you did I apologise, I will look at the record. I came across an article in the Sunday Telegraph last Sunday about something called opiods for the first time. I think this was some work all of a piece with a BBC programme on Tuesday, which I have not seen yet, work at the University of Wisconsin saying that these make you eat more and they have been deliberately used by food manufacturers to put in their products. I do not know whether that occurs naturally and they know about it and are doing nothing to stop it. I just wanted your view on that work.

  Dr Jebb: Professor Blundell, who unfortunately is not able to be here, I know would want to comment very specifically on that. I would suggest that you ask him for some evidence later. I thought it might come up so I asked him what he was going to say and his message in simple terms was food gives pleasure, many foods give pleasure when eating and there is a physiological mechanism for that which is through the brain. The mechanisms are similar mechanisms to those stimulated by addictive drugs. The fundamental mechanism is through a similar pathway. However, he then went on to say that quantitatively they are dramatically different and you simply cannot compare food with addictive drugs. He was very much against the concept of food addiction whilst acknowledging that there are physiological pathways whereby food stimulates pleasure. What he agreed is that the pleasure and the positive reinforcement, the feedback we get from eating food, can lead to a situation in which food becomes very highly desired and there can be a compulsive element to food consumption which is fostered not only by the taste of food but by the whole aura surrounding food, the marketing, the lifestyle that you buy into, and there can be compulsive elements, but he was strongly against the concept that there was addiction in the sense that we think of addiction to hard drugs.

  Q368  Mr Burstow: Does anyone else have any suggestions around the messages that we should be talking about that would start to have some effect in terms of moving the population?

  Dr Jebb: I would say do not super-size. There is almost nobody in the UK who needs super-size portions, our energy needs are lower than ever.

  Q369  Chairman: This is a very important point and this struck me when we were talking before the meeting started. I have got teenage children and you cannot get a small coke. Why have we suddenly gone there? When did it happen?

  Dr Jebb: I will tell you why. The answer is manufacturers, particularly in the fast food outlets, discovered that people did not like going to buy a second burger, they felt embarrassed at the idea of having a second one, so the marketeers came up with the idea of offering them a bigger one to start with, and it worked a treat.

  Professor Prentice: Another aspect of this is that the actual cost of the ingredients of food has come down so much because of agricultural improvements. We spend about 11% of our disposable income on food now whereas 30 or 40 years ago we spent 33-35%, so it is now extraordinarily cheap, and it is very easy to use that as a marketing tool, "bigger is better". I am glad we have touched on this because I think it is very important and would be an area where you could perhaps try and get voluntary agreements not to market on the basis of super-sizing, to regulate this. You could try the voluntary agreement. My understanding in speaking to the food industry is that they would be open to quite a lot of things if there were a level playing field and if their competitors were forced to do the same thing; they would not be averse to certain of these moves. The difficulty is that it is very difficult for one of them to break ranks first, such as Kraft have actually done, which indicates the pressures upon them. It is difficult for one of them to break ranks because they will lose their competitive edge if they do it.

  Dr Wareham: I want to go back to one thing Andrew said which was to do with the nature of the association between levels of obesity and future risk of disease. For most of the conditions that one is concerned about, the public health burden lies most with the vast majority of people who have got moderate degrees of overweight and who are, therefore, at moderate degrees of risk rather than in the relatively small group of people who are at very high risk and are very obese. I suppose my message would be that it is about all of us, it is not just about seriously overweight and obese individuals, it is about moderate increases in levels of BMI and obesity in the whole society.

  Q370  Mr Amess: Our Chairman reckoned that he was too embarrassed to ask our final question because we are going to end with sex. Is there a need for body weight or shape to be remodelled as a health issue rather than a social or sexual issue? In other words, we are thinking of the huge pressures for people to look wonderful, and that is the emphasis rather than the fact that being overweight and not taking exercise is not a bright thing to do.

  Dr Jebb: Of course there is. We are a society obsessed with super-thinness and this actually is not about healthy weights at all. I have a BMI which is close to the bottom end of the healthy weight range and yet most people would probably think I was somewhere in the middle, I am not particularly thin. We have got to get people to understand the concept in health terms of what is a healthy weight, which is not the media stereotype of glamour which is associated with BMIs which are ridiculously low and levels which are unachievable for the population and which would require them to constrain their food intake to levels at which they may well compromise their intake of assorted essential vitamins and minerals. We need to get over the message of a healthy weight which is higher than the social stereotype. Also, I think there is a bit of a range. There is not one weight which is perfect for everybody, there is a natural range in which there is very little difference in health risks and it depends on all sorts of other factors like fitness and family history and so forth. Yes, that would be helpful. It illustrates the role of the media, which we have not really touched on. The media are important players as another stakeholder in all of this, both because of their ability to transmit messages and because of the way that they contribute to culture and the culture that we have which drives food habits, exercise habits and notions of beauty.

  Professor Prentice: Can I just add a corollary to that. I agree entirely with everything that Susan has said. The pressures have been a useful brake and without them I dread to think what the body mass index and state of obesity of our countries would be. When that brake is released, as it is starting to be in the United States where everybody now has very fat friends and parents who they love dearly, and there is much greater acceptance of fatness, then that is likely to accelerate obesity. We just need to factor that into our future projections of where the epidemic may go. I am not supporting it in any way but, paradoxically, it has been a useful brake.

  Chairman: Do any of my colleagues have any further questions?

  Q371  Dr Taylor: Professor Blundell in his absolutely excellent paper did slip this in: "The four characteristics of successful weight losers from the American Weight Loss Registry could become the gold standard for personal change". I am not entirely clear what those four characteristics are, could you just list those four?

  Dr Jebb: The National Weight Control Registry is a US register of people who have lost 14 kilos or more and maintained that weight loss for at least a year. When they survey them to find out what they do and compare it with the population at large a number of factors come out. They self-monitor, so most of them weigh very regularly, every day or very regularly. They eat less fat, significantly less fat, than the general population. They are much more physically active. They recognise that they use both a low fat diet and regular physical activity as weight control mechanisms. Offhand, I cannot think what the fourth one is, I always tend to think of three: self-monitoring, activity and diet. We could press John Blundell about what the fourth one is.

  Chairman: If my colleagues have got no further questions, can I thank you all for a most interesting session. It is our last session before our summer recess, and I will not say you have cheered us up but you have certainly given us something to think about. We are very grateful. Can I wish my colleagues a peaceful recess. Thank you very much.

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