Oral evidence: Childhood Obesity Strategy, HC 465Tuesday 20 October 2015

Oral evidence, 20 October 2015.

Witnesses

Professor Simon Capewell, Vice President, Faculty of Public Health, Dr Colin Michie, Chair of Nutrition Committee, Royal College of Paediatrics and Child Health, and Dr Jeanelle de Gruchy, Vice-President, Association of Directors of Public Health, gave evidence.

Chair

Thank you very much for your patience and for coming this morning. As with the first panel, could I start by asking you to introduce yourselves and also to declare whether you have any relevant interests, either personally or for your organisation, perhaps starting with Dr de Gruchy?

Jeanelle de Gruchy

Hi; I am Dr Jeanelle de Gruchy. I am director of public health for the London Borough of Haringey and vice‑president of the Association of Directors of Public Health. I do not have any interests to declare.

Professor Capewell

Good morning. I am Professor Simon Capewell. I am vice‑president for policy for the UK Faculty of Public Health and a professor of clinical epidemiology at the University of Liverpool. I am a trustee for the UK Health Forum for Heart of Mersey and I am a founder member of Action on Sugar, with Graham MacGregor having presented their case last week.

Dr Michie

Good morning. I am Colin Michie. I am a paediatrician from Ealing Hospital. I also chair the nutrition committee for the Royal College of Paediatrics and Child Health. I have no conflicts to declare.

Chair

Thank you. Could I start by asking you each to respond to what you heard from Dr Tedstone at the end of the last session—were you all here listening to that session—particularly the point that having the sugary drinks tax proposal is not in the top three, and what you feel about that list that we heard her talking about? Perhaps Dr de Gruchy can start.

Jeanelle de Gruchy

I can start. Clearly, I am speaking from more of a local government perspective; certainly we need a lot of national work to take place to support us at local level. The Association of Directors of Public Health supports the sugar tax proposal, but we would absolutely see the importance of all the other elements that she was suggesting are key. We would want action to be taken on those other elements—the promotion, advertising and reformulation. We would see those as key as well in terms of the food environment.

Chair

She specifically refers to local authorities’ action as well.

Jeanelle de Gruchy

Yes, and I can talk more to that point if you would like me to.

Chair

Yes, if you want to quickly refer to that point—what you would like to see from what she recommends for local authorities.

Jeanelle de Gruchy

Yes. I do not know, obviously, what is in the report in terms of local authorities, but, certainly from our point of view, local authorities now have a responsibility for public health and play a key role at a local level in terms of leading in the system: that is both place shaping, so the nature of the place in which people live, as well as people and people’s behaviour who live in those places. The first session focused a lot on food and the food environment, and absolutely local authorities would have responsibilities around things like planning and licensing. I can talk more about perhaps the hot food takeaways planning work that we are trying to do. There are also the things that local government does in terms of increasing walking, cycling and people’s physical activity. I know you focused on that previously, but it is all of that together; it is the place shaping and influencing the way that people behave within those places.

Chair

Thank you. Professor Capewell?

Professor Capewell

Yes. From the Faculty of Public Health perspective, we have been pushing for some time for the sugary drinks tax. We have been pushing for some time for a ban on advertising of junk food and sugary drinks to children, at least until the 9 o’clock watershed, and also, to promote physical activity, a 20 mph speed limit. Like you, we are desperate to see the evidence on which these recommendations are made. The idea of ranking them on the basis of benefit to the population is clearly very attractive. We would certainly like to work through the arithmetic. We absolutely endorse the statements made last week and this week that it is an obesogenic environment. The structure of our society is making children fat and therefore the response has to be a comprehensive strategy. There is much to be learned from the success with tobacco and alcohol control, and thinking about the frameworks used: the 3As—the A for affordability, the A for acceptability and the A for availability. When you consider that four out of five men were smoking during the second world war and now it is less than one in five men and women, that does not represent any single magic bullet. It represents equal contributions from getting the price up, controlling advertising, making smoking unacceptable and limiting the availability to a fewer and fewer number of retailers, with no shiny promotions and no single cigarettes being sold to children. We think that the 3As framework might usefully be applied here.

Chair

Thank you.

Dr Michie

I thought it was really very interesting and full of positive findings. Just to emphasise two of them, the idea of staying with the five-a-day programme is very important, sticking with our educational messages that we know have worked so far—and that is a rather important one, although whether it is five portions a day or more is another point—and the eatwell plate does merit a comment. An eatwell plate has been very helpful to schools and preschools. It is a very useful framework from which to work with healthy children’s diets. The problem is that it does not have any fluids on it; the eatwell plate does not come with a drink. That has been one of the big gaps in the use of it throughout our educational system. So I would add that caveat, but certainly I thought there were some very positive messages. As was emphasised, the College is very concerned about marketing and promotions that involve children. We have good evidence to show for many years that this has a powerful influence on what happens within families and it is a complex thing, because it is not just the children that are being influenced—they influence their parents and the parents then purchase the foods too. There is a complexity there. But, clearly, marketing is crucial to any intervention that is taken centrally and nationally. From the point of view of the tax position, the College thinks that it would be of great advantage to tax sugary drinks. A big problem that we have is that we face large numbers of patients in clinics, and Susan Jebb touched on it at the end. The problem is not in trying to prevent something that is coming at us; it is in our clinics already. We have a problem with treatments and we cannot see a way out of treatments without doing something fairly immediate. I am sorry but we are doctors and we want to do something now, and we cannot see any of these interventions which are slightly more nationally directed and perhaps slower in timeframe. We would like to do something fairly urgent and that is why we are a little bit biased toward the idea that a Pigovian tax would be the way to sort this out fairly swiftly for children.

Chair

Thank you. I note that Dr de Gruchy wanted to come back in.

Jeanelle de Gruchy

Yes. Could I come back on two things that were spoken about earlier? The first was around sponsorship. Absolutely, we see that playing out at local level. One of the sugary soft drinks companies is sponsoring park activities for children. You see that happening and that has been taken up by lots of councils, so it is going into local areas to do that. The concern we might have is that, as councils’ budgets are reduced, they will be looking at other ways in which we can improve health and you get into this quite conflicting area again of the sponsorship with the branding of particular drinks or food companies linked to kids being physically active. I absolutely echo the concerns that were raised about that in the earlier panel. Likewise we are doing work with local businesses; they were mentioned. As well as the big national chains there are a lot of local businesses, and certainly there will be a lot of small businesses. When you talk about the big national reformulation and the voluntary schemes, we are doing that at local level. We have things like a healthier catering commitment and are working with a lot of the independently owned fast‑food takeaways to improve their offer. But again that is very labour‑intensive work; it takes up a lot of time and capacity at a local level to do that. It is reducing—

Chair

We are probably going to explore in greater detail local action in a minute, so thank you. Professor Capewell, you have already indicated that you would like to see the report. Would other panellists also like to see the report?

Dr Michie

Most certainly, thank you.

Jeanelle de Gruchy

Yes.

Chair

Thank you very much. Can I focus on one area to start with—the reformulation aspect? We heard some differences of opinion on whether it should be voluntary or regulatory. Do any of the panel want to expand on whether they feel it should be voluntary?

Professor Capewell

Yes. The lessons from tobacco control are very clear. Over 10 years ago Mike Daube wrote a paper entitled “Voluntary agreements” with industry: “designed to fail”. When the structure of the responsibility deal for food was laid out five years ago, The BMJ had a cartoon with fat representatives of the different companies sitting around the table and there were analogies with Dracula being put in charge of the blood bank. Voluntary deals do not work. The Department of Health itself commissioned extensive evaluation of the responsibility deals—alcohol, physical activity, workplace and food. They were consistent in demonstrating lack of effect. As Susan said in the earlier session, the industry vetoed the effective interventions. So price was off the table and advertising was not discussed. The formulation was discussed but nothing actually happened. Most of the much-vaunted pledges from the industry were already happening or due to happen. The evaluation and the reporting was patchy and the quality was poor. There really was no evidence of health gain. There were similar conclusions from the evaluation of the alcohol, physical activity and workplace RDs. In contrast, mandatory regulations have been demonstrated to work around the world for tobacco, alcohol and food. As Susan and Alison were explaining, the major successes with salt reformulation happened before the responsibility deal started, and they happened because the industry reps were dragged into the office of the Minister and the Minister made it quite clear that either they could do it the easy way or they would do it the hard way with regulation. This was, effectively, soft regulation. The reductions in salt were dramatic—more than a gram and a half per person per day by 2011—but, when the responsibility deal came in, that reduction slowed. Graham MacGregor published a paper in The BMJ less than a year ago suggesting that the slowing had resulted in 6,000 additional deaths because the previous reductions had not been pursued. So the Faculty, and indeed I think the vast majority of the public health community, would argue strongly for mandatory approaches. My group and other research groups have looked at the potential benefits from voluntary versus mandatory. Mandatory are consistently more powerful by a factor of five, 10 or 20‑fold, and also they are more equitable, so they work particularly well in the disadvantaged groups that have the bigger burdens of disease. I hope that is helpful.

Chair

From the earlier panel we heard the comment that you could achieve greater reductions with voluntary arrangements; also the point made earlier was that you would give an impression that that is acceptable at that level and it does not encourage people to go further. How would you respond to those points?

Professor Capewell

They were fine statements. I am sure they were well intentioned. I would love to see the evidence because the evidence from the UK, and indeed across the world, is very much in the other direction. Mandatory is far more powerful. It is just a very simple matter of thinking about the companies who did not come to the table for the responsibility deal. Of those that came, the pledges they pursued were mostly activities they were going to do in the first place. They are companies and their single statutory obligation is to maximise profit for shareholders. The one thing they are not going to do is pursue any activity that reduces sales and reduces profits. The public partnership approach is such a naive concept. Mandatory is far more powerful.

Dr Michie

If I could join in on that particular bandwagon, paediatricians have many years of experience in dealing with the milk formula companies, and trying to agree with them on any voluntary arrangement is a very frustrating business. There is a great history to this, the consequence of which is that this country now has the lowest exclusive breastfeeding rate in Europe. We have shelves full of unnecessary products in every supermarket and there is a continual business in trying to fight the advertising from these companies to promote their products very surreptitiously or very obviously in every possible part of the media. Paediatricians would never buy a voluntary arrangement with a large company for precisely the reasons that Simon has just outlined. They are in this as a business, they are extremely good at doing what they are doing and the voluntary arrangement is only ever a very temporary one. The consequence of this infant feeding has been a disaster and history will write it down as such because of this problem that we have with trying to defend breastfeeding in the face of this barrage from companies, from industry.

Chair

Are you concerned about things such as, for example, proxy advertising of infant formula with follow‑on formulas and things like that?

Dr Michie

Precisely. Follow‑on formulas are not necessary for human beings, but it would not seem so if you watch television. They problem is we are all very convinced by the stories. There are other issues that have parallels for what was said earlier in that the milk companies sponsor education, training, events and an awful lot of professional activities, which again does exactly, to our minds, what we heard it does to infants’ minds: when we see brand names, we equate certain things with them. It is an insidious business that we know enough of to be very wary of. For this reason, we would be extremely worried about any voluntary arrangements with big companies.

Chair

Thank you. My final question is this. How strong do you feel the evidence is that you have seen around the other measures we have talked about—a sugary drinks tax—but also marketing and advertising? Would you like to talk about what you feel should be the priorities there?

Professor Capewell

In terms of the evidence, the issue before us, and indeed before Ministers shortly, is whether the evidence is sufficient to move from the status quo. The status quo, I think we recognise, is appalling, with one fifth of children arriving in reception already being overweight or obese and a third of them when they move up to high school. If we were waiting for absolutely perfect evidence, we would still be waiting for the randomised controlled trial to prove that smoking causes lung cancer. This is clearly absurd, although the industry would love to prevaricate, and we saw some prevarication last week. We think that the evidence is very strong for a sugary drinks tax. There are empirical data from a number of countries now showing a rapid benefit—a substantial benefit. The evidence for reformulation is very strong for salt and we have heard no opposition from the industry saying it would not work. We have heard that it will reduce the bulk, which might be a good thing, and we need to try. We have also heard from industry very clearly last week that they want a level playing field. I did not mention this with the mandatory versus the voluntary, but, as discussed earlier in this session, the industry are rather weary of pioneers being picked off by doing pro‑health interventions and their competitors making money out of philanthropic mistakes by the pioneers. A level playing field is very important and would be welcomed by the industry. It would certainly be welcomed by the public. There is big public support for sugary drinks taxes and for reformulation. The parents, in particular, want something to be done.

Chair

Thank you. Do you have anything to add?

Dr Michie

I have a brief comment on the business of advergaming. There is a great—although not as vast as we have been hearing this morning—research interest in gaming to treat children with neurological problems and we have discovered that gaming has profound effects on the human brain, especially when you are three, four and five. Certainly very large groups like Wellcome and the MRC are recruiting gamers to try and get gaming introduced for little three, four and five‑year‑olds to help them when they have a neurological problem. The only difficulty is that the foods industry—and the baby milk industry—are ahead of us in this; they have already developed these gaming techniques. They are very important. We can use them as treatments and these folks are using them for advertising purposes. Just to add one specific observation about that, it is a sinister thing for our children and we need to try and control this.

Chair

Thank you. Now we come on to James.

Dr Davies

Physical exercise is the topic of my question. Clearly no one would deny the general health benefits that physical exercise brings, but how important would you say that it is in terms of tackling childhood obesity?

Professor Capewell

The UK Faculty of Public Health would like to see more physical activity in schools—at least another two hours per week. As emphasised before the break, physical activity brings many benefits. We would therefore promote active travel and think it would be of particular benefit to children as well as adults. Clearly you need the national policies, supporting structures and the local implementations. Maybe Jeanelle would like to comment.

Jeanelle de Gruchy

We see both physical activity and food as equally important in a very complex way. Physical activity is never going to balance out the high calorie intake of children; it is just never going to do it. As to any of those messages coming out from industry such as, “If we can be a bit more physically active, that will counterbalance it and it will be fine,” we do not think that is the case at all. Certainly we are very keen locally to increase active travel—active travel to schools. That is where the Department of Transport is important in terms of roads, road safety, cycling routes for children, 20 mph speed limits—and quite a number of councils are now putting those in place—and play areas. Are we ensuring that children have places to play, that the car is not supreme in terms of car parking spaces rather than playgrounds in new estates and so on? It is amazing how children’s play and physical activity has been planned out of the way we live—out of a lot of our public and home spaces—nowadays. We are very keen to look at ways to do that, obviously through local government influences, but you need the national Government legislation to support that. School is another key area. There are things like healthy schools. We have a very strong programme in London, but it is variable across the country. Many schools are looking at how they can encourage children to be active, not just in formal sports but certainly specifically during lunch hours, after-school activities and things like that. Absolutely, being physically active is so important, both for your healthy weight but also your emotional health and well-being.

Dr Michie

My colleagues have covered the nuts and bolts here but, just to give an example, we heard this morning that certain sportsmen were advertising foods as part of their day‑to‑day work, as it were, and a normal part of their activities. To put the opposite spin on that, there is a chap in Canada called Pierre Lavoie, who was a Canadian Ironman. After two of his children died of a metabolic problem, he set himself a challenge to cycle a certain distance. He now has virtually the whole of French‑speaking Canada cycling on what he calls “Le Grand défi”—the great challenge—as part of exercise. Although there are no figures, the obesity figures in Quebec have fallen pretty steadily, and a lot of folk there attribute this to the activity of the great challenge and getting everyone of all ages to get out and cycle. They collect little cubes of energy which they save from their schools and communities, and they get prizes and sponsorship for local developments based on this activity. Exercise can change communities, and it can change the whole health of a community and, as a consequence, one will then see obesity resolved.

Dr Davies

We have already touched on the role that schools can play, but do the panel feel that schools are, in general, involved sufficiently in this agenda, and what more might they do?

Jeanelle de Gruchy

There is always more we can do. It is a real shame that the healthy schools programme went, leaving the much more variable ad hoc way that schools have approached a whole‑school environment in terms of healthy weight and food and physical activity. We would like to see a healthy weight environment in schools coming into the Ofsted framework so that when schools are inspected that is something they absolutely want to know about. How is this school promoting healthy living for the children? I know Alison said there have been changes. I would probably be a little bit less positive about that. It is extremely variable across the country and there is a huge amount more we can do, but I do agree with her point that it is before children get to school, both in terms of their age but also in the mornings on the way, eating fast food on the way to school and so on, and then after school when they come back eating fast food or sugary drinks or whatever, and then coming home to the meals at home.

Professor Capewell

I would echo all of those statements and point out that, at the moment, guidance on healthy food—lunches, for instance—only applies to state schools. It does not apply to academies. Why on earth not? This is putting on a huge pressure, making a big assumption about parental responsibility, and surely parental responsibility should be reinforced and supported for the children who go to academies as well as to other schools.

Dr Michie

Alongside that, there is not a requirement for everyone in all schools, particularly academy schools, to have a PHSE session for their children, and that is crucial in order to teach people about their health and healthy eating in secondary school. Although the obesity rate goes up a lot in primary schools, it is also increasing in secondary schools; so we need to be able to have some national recommendation on PHSE in all schools.

Dr Davies

Is it felt that the school food standards, where they apply, have been successful or are sufficiently stringent?

Jeanelle de Gruchy

I am not sure I can comment on that.

Professor Capewell

They were recently relaxed. I think most people in the public health community regret that they were relaxed.

Dr Davies

Okay.

Chair

Can I follow on from that with a point that Jamie Oliver made yesterday about the fact that school foods standards do not apply to lunch boxes? Therefore, it is very difficult for teachers to say, “That is inappropriate to have.” Do you feel, in addition to saying that it should apply to academies, that it should cover the other foods that are supplied to the children?

Professor Capewell

Absolutely. Clearly, there are ways of doing this. It is a learning opportunity. It could be integrated into lessons. There could be discussions in class. Rather than a Draconian “This school does not accept cheese burgers coming through the gates” that gets into the tabloids, it could be turned into a very positive development for the children as part of a broader and deeper education in health and nutrition.

Jeanelle de Gruchy

I totally agree with that. We have seen in London, where we have a very good healthy schools London programme—we have about 1,600 of the schools signed up to that—that the school takes responsibility for its food policy, and that will include the lunch‑box policies, what kind of break‑time snacks the children have and so on. Also, if the school sees that healthy eating and being physically active improves not only the emotional well-being of the child but also the educational attainment, which it does, then they have a vested interest in it. Putting time into, say, the midday supervisors and training them so that they get children more physically active would also help in terms of what they are bringing into school in their packed lunches.

Chair

When you say “help”, do you mean they have an ability to send a note back home to say, “Please don’t supply this in your child’s lunch box”? How does that operate?

Jeanelle de Gruchy

It is probably quite variable in how it is implemented, depending on the schools, but some do, although certainly not all of them.

Chair

Thank you.

Dr Michie

It is a really important issue, but the only problem is that sometimes it causes quite a lot of friction and it comes down to the observation that has been made today that overweight and obese children very often have overweight and obese parents who do not necessarily know what to put in the lunch boxes. One has to do it sensitively, as Simon has said, but it is not always easy.

Chair

You would support it being a voluntary—

Dr Michie

Yes, I think it is a voluntary thing, but it is an important educational step for a family and it really takes someone like Jamie Oliver to do that in a way that would not get everyone frightfully embarrassed and fighting with the teachers, which is not what we want to start.

Chair

But he was very clear that he felt it was an impediment that there were not standards. Would you agree with him?

Dr Michie

There are not and there should be.

Professor Capewell

Yes, we would agree, particularly because it takes the onus off the teachers. Teachers are busy people and they want to build relationships with parents. They do not want to be pointing the finger in a Victorian fashion. If there are national guidelines and there is strong messaging coming out from Public Health England and other respectable sources saying, “This is what a healthy lunch box looks like; this is what an unhealthy lunch box looks like, and it is promoting a risk of obesity and future ill health in a child. Would you like to think again?”, that will save an awful lot of teachers’ time and stress, and of course it will be a much more powerful comprehensive strategy.

Chair

So an eatwell plate and an eatwell lunch box—

Dr Michie

Absolutely. One of the charities that does eatwell plates has tried to do a lunch box but they could never float it; it did not get funding to support it. But there is an eatwell lunch box plan already drawn up.

Chair

Thank you. I am now going to come on to the child measurement programme.

Dr Whitford

If I could start with Dr Michie, what do you think the impact has been of the national child measurement programme?

Dr Michie

It has been critical because it has outlined the size of the problem we face. It is very limited—it is two time points—but it has shown that there is a big problem with children when they are coming into reception at school. Twice as many as one expected are obese. By the time they have got to the end of their primary school the problem has got worse, and, over time, this has not really changed except to get mildly worse. We do have a big problem. It indicates, crucially, how big a problem we have in front of us and what we need to do to sort it out. There are problems with it in that it only starts off at the beginning of primary school. Crucially, you would like to know what two or three‑year‑olds are doing because a lot of infant feeding probably contributes to this. Indeed, a mother’s health during pregnancy probably contributes a lot in many cases to the development of obesity, but we do not really have good national data on that. Whereas we have wonderful data for what is happening in primary school, we could do exactly the same if it were extended. The IT is here, the GP link‑ups are there, and we could do this and extend it a little bit. We could do more measurements later on to look at secondary school likewise, but it is a crucial instrument and it is very high‑quality data. This has a very high take‑up rate and is terribly useful.

Dr Whitford

I was going to come on to how you think it needs to be improved and you have already touched on that. Obviously babies are measured right at the start, so is it around two or three? How would you go about it—linking it with one of their vaccinations?

Dr Michie

Yes; at two or three is quite an opportune point at which to check on development and measurement. I gather my colleagues in the Royal College of General Practitioners are quite interested in that. We do have an issue—and there is another reason for giving that age—in that we do not have BMI charts for anybody under two—BMI starts at two—partly because body composition is changing quite significantly and quickly. Because of the population scatter, it might not be a good idea to do BMI any younger than that, but certainly starting at two we do have good population data that would allow you to make some reasonable conclusions on their nutritional state at that point.

Dr Whitford

I do not know whether you would want to add anything.

Professor Capewell

The programme is absolutely essential. We are talking about all sorts of fundamental interventions here. We need to gauge the effect. We need to gauge the effect quickly. The advantage of focusing on children is that we will see benefits very rapidly, particularly if, as Colin says, we are measuring at three. We heard before coffee about the life course analysis—pre‑pregnancy, pregnancy, early life and the first 1,000 days. Effective interventions will reduce obesity in children over a couple of years very quickly. The programme is absolutely essential, both to measure the scale of the burden and to assess and evaluate those interventions rapidly.

Jeanelle de Gruchy

Yes, it has been critical and certainly I am sure has supported this work today in terms of what is happening in those two groups, who represent, in a way, a population of children. It absolutely needs to continue, it is mandated and we at local authority level fund it and make sure it happens, is done properly and has that quality and high uptake by the schools. I would be quite hesitant, though, about extending that. I do not know if that is what you were asking.

Dr Whitford

I am just asking how you think because your suggestion was extending it—

Jeanelle de Gruchy

Just as a survey, it provides us with the information with which to look at policy both nationally and locally. Certainly we absolutely use it locally with local politicians. It is really important in galvanising action and support locally. Whether adding another year here or there will make any material difference in that task, I am not sure. I would have to—

Dr Whitford

Do you not think, if you are trying in the coming decades to see what works, that you need a little bit of linear information rather than just a time point? If we are intervening in primary school but actually we do not know what is happening to the children when they are 15, we do not know whether what we did worked. I would have thought that you do need a little bit of linear extension at both ends.

Jeanelle de Gruchy

Obviously there are different cohorts going through, so you will start to see the cohort that is measured at reception year coming through to year 6. So you do have some trend with the different cohorts that come through. You will see over time the different cohorts. I suppose it is just that, when we are looking at our budgets locally, does the benefit of knowing that bit extra justify the money that we would have to put in, which we would have to take from somewhere else? We need to be assured of that.

Dr Whitford

Particularly for girls, often their weight starts to change in their teenage years. That is why I was talking about trying to link it to something else. If you are vaccinating the child, is it a big deal to weigh them, whereas when you are doing it as an individual thing I realise that is quite a big commitment?

Professor Capewell

It is worth mentioning that the Health Survey for England does do young people, but it starts with adult life. These are random surveys that are representative of the wider population. One of the potential criticisms of the existing programme is that it is 100%. Does it need to be? No. So long as it is representative, you will probably still get value for money. The other thing that Jeanelle and I discussed was the precarious nature of the programme in some local authorities because it is supported by school nurses. Local authorities are being exposed to extreme cuts—40% last year. The Chancellor has proposed that another £200 million is taken away from local authority public health budgets this year. That is clearly a false economy. It is going to cause all sorts of additional burdens for the national health service and, in addition, if school nurses are taken away from some local authorities that will just demolish the measurement programme at a stroke.

Dr Whitford

I totally take the point that if you are looking at it epidemiologically you do not need to get all the children, but if you are trying to do it as an intervention on those children then you do, and that brings us to the next question as to what you do with it. You touched on speaking to parents, but if you are identifying in reception that you have a child who is overweight or on the way to obesity what do you currently do with that?

Professor Capewell

If you do a national programme, then a representative national survey will show you whether those interventions are working. You do not have to measure all the children.

Dr Whitford

From an epidemiological point of view, I am talking about the individual child, spotting that wee Johnnie is way above the line and are we speaking to wee Johnnie’s parents?

Dr Michie

That is the elephant in the room, if we can shine a light on him, and, as Susan Jebb said this morning, the whole problem is that there are no treatments coupled or linked to the NCMP. Basically, we find out about children, but quite often the parents do not get the measurements or the interpretation of them back, and, if they do, in the vast majority of cases there is no treatment or treatment plan, or even advice to provide, that goes with that. It is a stand‑alone system that is very helpful epidemiologically, but from a clinical perspective it is not very helpful at all. What you have just alluded to is exactly what we would like to have so that a GP or a parent who has a little Johnnie whose BMI is too high at three, four, five or 10 knows what to do and can refer them in to do something appropriate. Right now there is a disjunction, mostly because of cuts in funding as there are not many local services for obese and overweight children that link with the measurement programme.

Dr Whitford

It was always envisaged more as a survey rather than a tool for individuals.

Dr Michie

Yes.

Dr Whitford

It is also a difficult conversation. You were talking about the lunch boxes, but equally that conversation with parents, who, as you say, may be overweight themselves, is not an easy conversation either.

Professor Capewell

One point worth emphasising from before the coffee break is that we are stuck with treatments. Treatments are not very effective. Very few obese children will turn into adults of normal weight, and that is with the best will in the world and the best clinical care—and it is expensive. The idea of prevention, of structural change that creates the healthy environment so that children never get overweight in the first place, is immensely more attractive and it is cost saving—substantially cost saving. That is an important point to make. This is very much first aid; it is accident and emergency services dealing with a disaster that should not really have happened in the first place.

Dr Whitford

That is to try and change things for the future, but it still leaves us with 70 years-worth of people who have finished primary school, so we maybe cannot afford to wait all that length of time.

Professor Capewell

That is true, but Susan Jebb’s systematic reviews have demonstrated that, even in adults, the weight loss programmes are frustratingly weak in effect, that the adults in the best RCTs will lose 4 kg or 5 kg, but, after the intervention stops, if you follow them later—as most people in this room will know if they have tried dieting—it creeps back. We really have to put more emphasis on prevention and take the scales from our eyes in terms of weight-loss management. It is really a weight-loss industry.

Dr Whitford

The Prime Minister has focused on the BMI within the primary school years and we have touched on whether we should be looking at younger and older. Do you think that that is something that would be helpful? Your comment was more just to stick with primary school.

Jeanelle de Gruchy

Are you talking about the NCMP?

Dr Whitford

No. He has said that, generally, we have to change the BMI of primary school children. In the previous panel we were talking about 10% of kids actually arriving at school with a problem, and then, as I commented, often it would evolve later.

Jeanelle de Gruchy

We have to take a comprehensive approach. Focusing on children is absolutely right because we need to protect children and their health. The way in which we do that is by looking across the life course. Overweight or obesity in pregnant women, which is becoming an increasingly big problem, means their infant is more likely to be overweight themselves. Breastfeeding is absolutely critical in terms of a healthy weight later and then it starts from there. However, I have already mentioned the mother. It is already the parents; it is the family and the family context. I suppose when Alison and Susan were talking they were talking about the family, the family home, the family food, who does the shopping, who does the cooking or whether they all go out together. That is an important concept. Certainly children at the younger age are very dependent on parents and family. The problem we have with young people is, of course, that off they go and can access fast foods quite easily without any parental guidance. As they get older, the issue becomes how those children can access extra cheap calories elsewhere.

Dr Michie

There are many interventions that are coming up to deal with pregnancy and the first few years of life—the first 1,000 days. There is a lovely one at King’s called UPBEAT, for their pregnant mums. They have developed a programme to help them lose weight. It is effective. It works very well at that point and, in terms of life span, might really influence things. If we had an earlier measuring point at two or three years, we would be able to measure those interventions and their effects, but right now we are a little in the dark and reliant on individual studies because of that.

Professor Capewell

We also have to recognise that, in responding to your question, there is the issue of scientific evidence about what works and there is the issue about practical politics. Jamie Oliver emphasised yesterday that we have a duty of care to our children and this is the message that we think Mr Hunt and Mr Cameron will be able to sell to colleagues in Parliament and the wider country. There will be a push back about the nanny state, but let’s get real. The nanny state means that drinking water is safe and that we are sitting in a room that is not full of cigarette smoke. I could go on and on. We are alive today and our families are healthy because of the nanny state, so let’s do the appropriate thing to the proportionate scale, as Malcolm Clark was emphasising.

Dr Whitford

Thank you very much.

Chair

Before we move on to our final group of questions, can we follow on from Philippa’s to draw on the health inequality aspects that have been identified by the child measurement programme with the very large differences between the lowest 10% and highest 10% in advantage terms? Would you like to see greater focus within the child measurement programme in high‑risk areas? Given that it cannot be afforded everywhere, would you like to see—

Jeanelle de Gruchy

The child measurement programme is everywhere.

Chair

What I mean is this. You were saying that it is difficult to fund an increase in the number of measurements taken. If you know you have, for example, a school that has a higher prevalence of obesity, do you think you could argue that you could do more measurements within certain communities that are going to be at a higher risk or not?

Jeanelle de Gruchy

No. We would probably go for an all‑school approach. In some of our schools 60% of the children are overweight and obese in the two bands that we measure. So I suppose you make the assumption—

Chair

No, I am not suggesting that you would target certain individuals within a school, because clearly that might feel stigmatising, but if you know within a local authority area that you have some schools that have a higher prevalence overall, do you think there would be a case for saying that you can look more intensively at some communities if resources are short?

Jeanelle de Gruchy

Yes. We have the data from the child measurement programme and some schools, as I say, have very high levels and others have lower, so the amount of energy and effort you can put into supporting those schools or advocating that they have a healthy whole-school approach, whatever that might be, is variable across the country. It is about looking at the whole environment and working with those schools, but in some of those areas we have very high levels of fast‑food takeaways or a lack of play areas or green spaces. You can target areas and look at the kinds of environment that are creating a lot of the overweight and obesity, and make big changes there. We can target in that way. In areas where there is a lot of regeneration work going on, absolutely we have to get walking and cycling and the place shaping done more in a healthy way.

Chair

In other words, you would see more focus on the response than the amount of monitoring you do. That is my question.

Jeanelle de Gruchy

If I am looking at the limited resources of my team, which it often comes down to, I would rather they were out and doing that than doing another year’s survey.

Chair

Thank you; that was my question.

Maggie Throup

You have touched already in some of your responses on the role of local authorities with the responsibility of public health being transferred to local authorities. I want to explore that a bit further and your views on the role of local authorities in tackling childhood obesity. I want to know—and probably both questions are targeted at yourself, Dr de Gruchy, but I would like the others to input as well—how local authorities are spearheading efforts to tackle childhood obesity at the local level.

Jeanelle de Gruchy

I have spoken a bit about that and my last answer probably covered some of it. They are doing that by influencing the places where people, where children, live, so walking and cycling, planning around fast‑food takeaways, 20 mph speed limits and looking at play areas and green spaces. There is a lot that local authorities do to influence in terms of those. I could speak to each of them, but certainly there would need to be quite a lot of intensive local work, officer time and local councillors’ time, going into each little positive improvement in those things. Take the 20 mph: that takes quite a lot of time, energy and effort to implement in a local area. It is the same with walking and cycling schemes. As to planning, we are having to put a lot of energy and effort into that. There are a lot of steps one has to go through to try and limit the proliferation of hot‑food takeaways in a local area. We have to put things into planning documents. I will not go into all the detail, but it takes a lot of processes and steps and you do have representation. Last week we tried to do that in my borough. We had representations from KFC and McDonald’s, a lot of very legalistic documents that need officer time at a local level to address. As to the evidence base, as we have heard this morning, it is quite tricky to prove if a hot‑food takeaway is directly linked to childhood obesity and so on. If the legislation was done differently at a national level it would make it a lot easier for us at a local level to try and address some of these issues, such as a proliferation of hot‑food takeaways. I am happy to provide more information on that. There are quite a lot of things where national legislation is very helpful, but it is also about how it gets implemented and, looking at some of the challenges that we face locally, how we could make it more effective and make it more effective across the country. So it is this variability.

Maggie Throup

Do you have some examples where local authorities are doing it really well and other local authorities could learn from those?

Jeanelle de Gruchy

Yes, absolutely. There are a lot of examples where they are doing well. The important thing in a local authority is its local system leadership. It is championing a lot of partners to try and address obesity in the different ways that I have mentioned such as the design of environments and how developments can happen. Certainly in the east of London, with the growth boroughs around the Olympic bid, there was a lot of work and effort put into those areas so that you have play areas, walking, cycling and those kinds of things. You can also influence where staircases are sited in a building—they are small things, but massively important—and whether people use the staircase or whether there are lifts. Our planners and people working in regeneration will be influencing all of that design. Then there is the food environment. There is system leadership at a local level. We also are working with our schools, with the hospitals, the hospital trusts and the GPs. There is a lot that still happens in a hospital trust environment that you would want to question such as the vending machines and the kinds of foods available. It is just remarkable that you still have those. It is a bit like selling cigarettes in the past. As you go into hospitals, you can buy chocolates and crisps and all of that. With our leisure centres, we are trying again to influence the offer, such as vending machines.

Maggie Throup

Do you think the local authorities are taking all this on board?

Jeanelle de Gruchy

Absolutely, increasingly they are, and certainly now with having the responsibility for public health. I have seen a change in the last few years. It has helped that the childhood obesity agenda has gone up nationally. But at a local level childhood obesity is now much more a priority in the health and wellbeing strategies, certainly in ours. You will find that across the country health and wellbeing boards are providing that local leadership to ask what we are going to do about the rise of childhood obesity in our local populations, because, of course, they have the data from the national child measurement programme for their own populations in schools. The problem we are coming into now is a reduction in funds and funding. We do not have a lot of money in public health, certainly. I have noted that there is money across local government in these other areas, but generally, at a local level, trying to address obesity is led by public health teams with the director of public health sitting in the team. So it is about how we galvanise that money and bring it together.

Maggie Throup

It is more than just a pot for public health.

Jeanelle de Gruchy

If you look at our budgets, there is no big pot that says “obesity” in the way there is for sexual health and drugs. There is not. It is a very small amount of money so it is about influencing and implementing what is done nationally, making sure it happens locally. It is about providing that system leadership, making the join‑up. We need people to do that. The in‑year public health cut of £200 million has impacted badly in terms of that. I would be quite concerned that people are talking about school nurses and weight management programmes going. We do not have that in my borough. Again, that would be variable across the country. There is some great innovative work happening on that front, but that is all in jeopardy now.

Maggie Throup

Do you think there should be a pot labelled “tackling obesity” as there is for sexual health?

Jeanelle de Gruchy

Do you mean new money?

Maggie Throup

I am not saying that—just a pot.

Jeanelle de Gruchy

If it was new money. I think nationally and locally there is money in the system that could be joined up. I mentioned some of the departments that do do work that influences the environment. Could that money be put together? We have mentioned the rise of sponsorship of physical activity by certain companies. They all want their branding on it and actually could, conversely, be fuelling childhood obesity, could they not? If they are concerned about the health of our children, could they be putting that money into a blind pot? Why is there sponsorship attached to that? Are there other ways? What would we do with the money? I think some of it is really about leadership and having the capacity to do that, but if you take even that one example I gave you about planning and the fast food, that is a member of my team having to work with the planning officers. That post is jeopardised, so it really does come down to that at a local level; we are really trying to influence. If there was more ability at a national level to join that up but also locally to have the capacity to do some of this work, that would be great.

Maggie Throup

You talk about building in the systems to stop fast foods being placed near schools. What can be done retrospectively, because there is an awful lot there already?

Jeanelle de Gruchy

Do you mean the fast‑food takeaways?

Maggie Throup

Yes.

Jeanelle de Gruchy

You talked earlier about national reformulation and at a local level we are working with businesses—a lot of them are just family‑run businesses—to make their offer healthier: not healthy but healthier. There is quite a lot that you can do with fast‑food takeaways to make them healthier. It is not without its challenge, but a lot of those local‑level owners are happy to have the conversation to look at ways that they can tweak things to not put so much salt on, to not put a lot of sauces on, to use different chip oils and to use thicker chips rather than thinner ones. There are things that they can do. When you think of how many of our young people or families eat fast food, small changes can make quite a big difference. We are also doing that kind of work with the local businesses—that is quite important—with those that are already there, but there are just too many and too many near our schools.

Chair

Thank you. Finally, would you like to see a change in the legislation so that you can have health as a consideration in planning?

Jeanelle de Gruchy

Yes, we would, very much.

Chair

Thank you. Unfortunately, we have run out of time. We could have carried on a lot longer—I am conscious of that—but thank you very much for your time today. I appreciate you coming to give evidence. Oral evidence: Childhood Obesity Strategy, HC 465 29