Official Report (Hansard)
Date: 05 March 2009
COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Inquiry into Obesity - Action Cancer Evidence
5 March 2009
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey
Dr Caroline Hughes )
Ms Geraldine Kerr ) Action Cancer
Ms Treasa Rice )
The Deputy Chairperson:
The next evidence session is with representatives of Action Cancer. I welcome Geraldine Kerr, acting chief executive of Action Cancer; Caroline Hughes, research and evaluation officer; and Treasa Rice, health promotion manager. Members have a copy of the written submission.
You are welcome to this afternoon’s Committee meeting. Geraldine Kerr will make a short presentation, and that will be followed by members’ questions.
Ms Geraldine Kerr (Action Cancer):
Thank you for inviting us — we have not presented to a body such as this before. I will provide a brief overview of the document that we have presented to you. Details on statistics, for instance, will emerge in the discussions afterwards.
Obesity is a complex issue, and there are various facets involved. We examine the issue in two strands: society and the individual. Previous concentration was on societal issues such as food labelling, cycle lanes, etc, and the need to work cross-departmentally, from the top down.
I want to focus on the individual and what our work can do to inform the inquiry. I will explain the reasons for our work, our aims, the programmes that we use, how they can help and contribute to the approaches — particularly in respect of obesity — and how they could be applied within a strategy.
It is important to remember that the health consequences associated with obesity are a primary concern. Obesity cannot be viewed in isolation. A number of factors contribute to weight gain. It is not solely about the food that we eat, the amount of alcohol that we consume or our lack of energy output. A lot of it relates to one’s lifestyle. Our lifestyle programmes are focused on cancer. Two thirds of cancer can be prevented through lifestyle changes, such as more exercise and a change in eating habits. We concentrate on lifestyle changes. There is some relevant learning as a result of some of our programmes.
It is important to remember that nobody chooses to be overweight. People choose certain behaviours that have poor health consequences. We have to provide more knowledge about those behaviours and why people make those choices.
Treasa Rice is our health promotion manager, and she can provide more detail. We are a regional service; we go to primary and secondary schools, community groups and workplaces to provide different levels of programmes. Our programmes include education on cancer awareness, cooking and eating, and physical activity — with “boxercise” and “dancercise”. That exercise input is aimed at active measuring and addressing some of the issues.
I do not know whether members are aware of our Big Bus initiative; I know that Carmel knows about it. It is a regional mobile unit that provides a breast-screening service. Other important services that it provides are the health checks for men and women. Those checks provide an overview of body mass index (BMI), cholesterol and blood pressure. An evaluation has been completed on that service, and we can provide more detail on that. It is interesting to know that 45% of the people who came to the Big Bus would not have had their health check if it had not been for the bus. The health checks have also provided cancer awareness and an awareness about self-checking, diet and lifestyles.
Caroline will provide more detail on the evaluations, but there have been increased awareness and lifestyle changes as a result of that.
Certain schemes that work well are the school programmes and the health checks. We feel that it is important, as has been identified in other people’s input, that an overall strategy be adopted, which is connected from the ground to the top in a completely co-ordinated way. Everything that we do in our programmes aligns with various strategies — for example, the Investing for Health strategy.
It is good to be able to go into schools, because young people provide a nice, set audience. Informing people from a young age is easier because we are able to target our work to that audience and there is less need to change behaviour. If we get the message across to people early enough, we can inform behaviour that will carry into adult life.
Our regionally based service is provided on a consistent basis, and that work will be important in informing some of our insights and recommendations about how things need to be taken forward. Our evaluations show that people’s knowledge about the need for a healthy diet — eating fruit and vegetables, for example — is very high, but they also show that we need to develop our programmes to examine attitudes and motivational issues, and move from having that knowledge base to actually applying that knowledge. We are doing that, and we can give you more details on that as we go through this session.
As I said, 45% of the people who we are reaching through the Big Bus mobile service would not have had their checks were it not for that service. That is very significant and highlights the importance of the statutory and voluntary sectors adopting a community approach, because the Big Bus brings services into socially deprived areas where such services may not normally be available. That service involves working with local trusts and other agencies in a connected way to allow that provision to go into communities, and it is that partnership that gets the Big Bus into communities and increases the uptake of services.
A very interesting finding from our men’s health checks is that there are discrepancies between individuals’ actual diet and their perceived diet. People feel that their diet is healthy when, in fact, it is not. We can provide the Committee with some information on that, if that would be helpful.
We believe that there is a need for improvement in the strategies aimed at changing lifestyles, because we think that that is key when dealing with obesity. Obesity cannot be looked at in isolation; it is a lifestyle issue, and changing those lifestyles will be very important. Some of our programmes have elements that could, perhaps, be included in such a strategy.
There is no central source of information on what programmes are available across Northern Ireland and what other groups are working on health promotion and other related areas. It is important to have some sort of audit to understand what services exist. We have a regional base and operate in schools; therefore, we have a good basis from which to develop those areas, just as other agencies have. We should be trying to secure a more consistent approach and join up services, rather than having a situation in which everyone is working individually.
Not all programmes use a robust evaluation system. I note from previous input into this inquiry that groups have talked about the need for co-ordinated research, and that is something that we endorse. However, it is the level of evaluation that takes place, and the fact that that is done in a consistent way, that is important. That will give people a wider information base and will inform what needs to go into a strategy and how that needs to develop.
We have found that the outcomes of academic research are not always passed to community organisations quickly enough. Funding may be going into academic streams to inform research, but there can be a delay in getting the findings to community groups and those who are offering provision. Therefore, the impact can either be delayed or missed. It is important that, right from the start, there is a connection with the workers on the ground, so that problems can be addressed.
As previously identified with regard to schools, education strategies and interdepartmental working are vital. Obesity cannot be considered in isolation. Some of our ideas for addressing obesity through lifestyle change must be supported by education strategies: they need time and funding to be effective. The connection or interfacing with education is important to the success of the strategy. I can offer an example: to effect a real change in lifestyle, we may need to find classroom time. However, short of that, support from the education strategy and willingness among everyone to work in a connected way must suffice.
Funding must be made available, but it should be targeted and co-ordinated to improve knowledge as to what strategies on obesity and other health issues are effective. There must be a link from research, through evaluation, to effective practice. Funding may be on offer, but people may not be made aware of what is available. That starts with the audit. Practices that are already in place and known to be effective must be used. Evaluation and research will provide knowledge about what is effective. We must find ways of measuring the effectiveness of each funding stream, so that research can be widened to find a more coherent way of approaching the problem. In that way, there will be more than just pockets of funding available. I can offer an example: we have applied for funding from the Big Lottery Fund for work with complementary therapies. We drew upon the work of all the charities and hospices, and anyone working in that area, to do that evaluation in the same way, in order to gather more information within the same timescale. In that way, we must carry out an audit in order to find out what should be our key measurements and targets.
It is important that we have a steering group to co-ordinate that work, and it should have clear timelines and targets. Although strategic targets will be set, it is also important that smaller, measurable targets should be set alongside those. Some of the aspects we have thought about are leisure centre use, food purchase, activity levels and knowledge base. We can provide some information on how that knowledge base can be measured and how behaviours have changed as a result. Another way of measuring progress is through the uptake rates of programmes.
That is all that I have to say at present, but I can offer more information in answering your questions.
The Deputy Chairperson:
Thank you very much for that, Geraldine. It was most informative. I must ask about the surveys you compiled on the Big Bus project, which show the difference between what people perceive to be healthy and what is really healthy. Have you any ideas as to how that can be tackled?
Dr Caroline Hughes (Action Cancer):
One part of the health check is a form that participants fill in. They are asked: do you think that your diet is healthy? About 75% of respondents think that it is. However, the next question is: do you eat five portions of fruit and vegetables each day? To that, only 50% of respondents give a positive answer. That range of yes/no questions highlights that, although people might think that they are being healthy, their behaviour belies that.
A masters student is to carry out a small piece of research for us to find out what is going on — why people come for health checks, why people think that they are healthy when their behaviours are not, and so on. That research is the first step of the process.
The Deputy Chairperson:
That is very important. People are often on fad diets that they chop and change all the time. It is obviously unhealthy to be on a WeightWatchers diet one week, a Unislim diet the following week, and something else the next week.
Yes, and people receive a lot of mixed messages. Many people pick up their knowledge from adverts and hear phrases such as “no added sugar” and “fat free”. Those people think that they are being quite healthy, but that is often shown not to be the case when their diets are broken down.
The Deputy Chairperson:
It all comes back to informing people through an education programme. You said that research shows that a lot of people do not realise that obesity is the second biggest risk factor for some cancers. That is a very strong message that people would take on board, one that you are always trying to get across, and it comes down to education and promotion.
Yes, and that is one of the messages in our health action programme.
Ms Treasa Rice (Action Cancer):
The health action programme covers a range of lifestyle-choice topics such as smoking, alcohol, cancer awareness, healthy eating and exercise. We are sending out a number of messages about healthy eating and exercise, for example, so that young people and children in schools become aware that obesity is a big cause of cancer.
Thank you for coming along today and making your very useful presentation. The paper that you provided for the Committee outlines what is working well. It states that the health action programme is reaching large numbers of young people right across Northern Ireland and that the key messages are, therefore, being highlighted on a Province-wide basis. Will you elaborate on that and tell us why you think those programmes are working well? I do not doubt that the programme is reaching people right across Northern Ireland, but I would like to hear more about it.
The Deputy Chairperson talked about the differences between what is perceived to be a healthy diet and what is actually a healthy diet. You mentioned that a lot of people say that they do not eat a certain amount of fruit each day. Has your research and study given any indication that there are some fruits that people should not eat? Are there foods on sale that are not good for one’s health, particularly in their impact on weight increase? That is an important point that may inform the Committee’s report on obesity.
The health action programme is about changing knowledge levels. For that reason, we have before-and-after evaluations of the programme. We measure people’s knowledge levels before they start the programme and after they finish, and then we make comparisons between the figures. The evaluation indicates that the programme increases knowledge levels on issues such as smoking, body awareness and cancer awareness.
We have been doing that for about 18 months, and data collection will continue until the end of the current school year. By then, we should have about 350 before-and-after questionnaires that have been completed by young people from across Northern Ireland. Our health promotion officers use the evaluation figures, which definitely show that the programme improves knowledge levels.
One finding that emerged from the evaluation is that knowledge levels are reasonably high, so there is an awareness that smoking is bad for them and that they should be eating five portions of fruit and vegetables a day. Therefore, young people already know something about healthy living before we go into the schools, which makes sense, given all the media attention and advertising about the issue. The message is starting to get through to people.
However, we have begun to identify that the work now needs to focus more on attitudes, because knowledge does not change behaviour. Just think of how many people know that smoking is not good for them, yet still choose to smoke. We can put everything in place, but it all comes down to an individual choosing healthy behaviour rather than unhealthy behaviour. We want our programme to develop to address that issue. Because we have carried out the evaluation, we can see that people’s knowledge is changing. We still need to run knowledge programmes, but we perhaps need to start targeting people’s attitudes, by carrying out more intensive work with smaller groups.
As an organisation, we obviously need to have the necessary resources in place to carry out that work, whether that involves funding or personnel. The schools will need resources to allow them to let children out of class for one hour a week for six weeks so that we can engage them in slightly more intensive work. Treasa will be able to go into detail about food choices.
Through the health action programme, we promote the balance of good health, which shows the healthy plate, the five main food groups, portion sizes, and the foods that we should be eating each day. Fruit and vegetables and carbohydrates should make up the largest portions, as they are the two main food groups. We explain to the children and young people that, unfortunately, we should be eating the least amount from the saturated-fat food group, as those are the foods that are bad for us.
Children become aware of the choices. We tell them how much exercise they need to do to work off a whole pizza — around three hours of exercise. We talk about various snacks and show the equivalent number of sugar cubes in each one. It will surprise you all to know that a relatively small portion of jelly babies contains the equivalent of 60 sugar cubes. We always get a strong reaction when we tell people that — people do not realise that they contain so much sugar. Thus, the message that certain foods are bad for them is getting through to children and young people. We can see them hiding their wee cans of Coke and packets of crisps.
The Deputy Chairperson:
Perhaps the Health Committee needs to hear that advice, too. [Laughter.] We were shocked there.
Another aspect worth mentioning is that Centra supports our health action work. We talked about connections with the food industry, and that has fed into the Committee’s inquiry. Centra is a key supporter of our programme, and that is an example of the food industry following up on our work. We talked about a motivational approach, and we give bikes and iPods to children as part of that work.
There is also a fruit voucher scheme: kids who take part in the health action programme get a free fruit voucher, so they can get a free piece of fruit from their local Centra store, which gives them a wee bit of incentive to eat their five portions of fruit and vegetables every day.
The stores display healthy messages and run promotions and strategies, working alongside us and the schools. That triangle of connections has been very productive, and is an example of the links among the sectors.
Thank you for that information. There seems to be some gain from the link with Centra, but do you think that that type of programme is effective? What else do children and young people buy when they are in a Centra store? Perhaps they go in to buy something else that you would not recommend at all. How can you say that that programme is working well to counter obesity and promote healthy eating?
That is why we are trying to develop another programme that works on people’s attitudes, which would follow on from the knowledge-based programme.
We do not measure behaviour because the ‘Young Persons’ Behaviour and Attitudes Survey’ generally records the behaviours of young people. We hope that those types of surveys will highlight the change in behaviours further down the road. At this stage, the evaluation of our programme measures whether knowledge levels have changed. Because of that evaluation, we have been able to see that we need to move towards dealing with attitudes. We can then look specifically at how behaviour changes before and after that work, because it is the attitudes that matter.
Ladies, I thank you for your presentation, but you have destroyed my enjoyment of pizzas. [Laughter.] I did not realise how much work that your Big Bus creates for poor overstretched GPs. [Laughter.]
Ms S Ramsey:
You are well paid.
As was mentioned during the previous evidence session, communication with the public is important. As a GP, the link between obesity and cancer is a new message. We have long known about other causes of cancer, so how we get that message out is very important. People should know that putting too much of certain foods in their mouths can lead to cancer.
Lifestyle and behaviour were mentioned, and that message should be promoted in the right way. For example, I heard a message on a local radio station this week — I understood the message, but I know that it will cause alarm and make some people anxious. I do not remember the exact words, but the general message was that alcoholic drink could cause breast cancer. The advert then proceeded to talk about safe limits of alcohol consumption. That message could be very alarming for people who drink moderately.
People present in my surgery with mental-health problems due to anxiety — people sometimes even become hypochondriacal. We do not want to make people obsessive about what they do. I do not want to live in a nanny state — I want to live in a country where people make informed choices. We cannot push messages down people’s throats or make them feel guilty about their actions — adults have a choice. Will you do what you can to ensure that your message educates and informs people, instead of alarming and terrifying them?
We make sure that the people realise that the message is about moderation — we can have our pizzas and jelly babies, but it is important to have a healthier balance by eating plenty of fruit and vegetables and less unhealthy food.
Do you see where I am coming from? I can expect people who heard that radio message to come into my surgery on Monday and ask whether they have cancer, because they had a couple of drinks at the weekend. The message must be balanced.
We give counselling and complementary therapy services to cancer patients. One issue that arose in our evaluation of those services was that many patients who are diagnosed with cancer use self-blame as one of their coping strategies. The statistic that 80% of cancers are preventable means that many people automatically think that they could have prevented their cancer.
Just because someone has a certain lifestyle does not mean that they will get cancer — there is a link between the two, but, for example, some people who smoke do not get cancer. People who live certain lifestyles increase their chances of getting cancer.
The danger is labelling people. Some of the research states that obesity is caused by low self-esteem, so our programmes try to tackle that by looking at a wider way of connecting information. Therefore, if you are sending out wider lifestyle messages, which address eating and the dangers associated with obesity, they must tackle people’s motivations, find out their attitudes and inform them on how they can change those attitudes. That is the way to approach obesity —; regarding it as a problem or labelling people will isolate people.
In trials that we mentioned, some children will not change into their PE kit for boxercise classes, because they are overweight. In that instance, we should try to offer the programme in a way that offers an option, rather than making someone more distraught by highlighting them in what they feel is a negative manner.
Promoting self-efficacy is also important — the belief that the people are able to carry out the behaviours needed to make change. Enhancing the independent characteristics of the individual is important.
Good afternoon; you are very welcome. That was a very good presentation; you kept to the point. The message that I took from it was that there was a need for more working together, and for better communication and co-ordination. One group of people may be involved in one piece of work, and it would help them to know about research and evaluations, particularly when it comes to introducing initiatives. Things are all over the place, and we are not working well together.
I was interested in what you said about people’s perception that they have a good diet. We all like to persuade ourselves of that, despite the pizzas and the Mars bars. It is about attitudes and motivation. When people are tired, they will reach for a quick fix; they do not want an apple. People need to eat an apple when they are not so hungry, because they know that it is good for them. We all try to do that, but we do not do it very well.
Dr Deeny talked about a nanny state; I am not sure what a nanny state is. I think that we have a very dependent state here, in which we depend on other people to keep us healthy. Although it is all about balanced information, all of us must take more responsibility for our health. If I am a bit overweight, or drink too many glasses of wine, I will have to put my hand up to that, but it is up to me to get more exercise and watch what I eat — as long as I am informed. The thing is, we are informed; you said that most young people know about the benefits of the five portions a day. However, the difference between knowing about that and acting on it every day is where we all fall down. It will be difficult to say no to the second chocolate biscuit, and change our attitudes to exercise, diet and self-control. Those are the stumbling blocks that we face.
You said that you had had some successes. Are you able to monitor people for a longer time in order to determine whether they are changing their lifestyle? Can you tell whether people have got into the habit of eating less rubbish and taking exercise every day?
That is the problem. The healthy living programme for adults is a six-week programme, but there is no long-term follow-up. Schools, for example, find it difficult to find the time to cover specific topics, and to get young people out of the classroom again in order to measure their progress. Knowledge does not change behaviour; it is down to a combination of personality, attitudes and individual components, which are more difficult to measure. A more intensive programme is required; that is what we are developing now.
I appreciate that you do not have the staff capacity or the resources, but it would be good, when you begin that programme, to tell people that you will contact them six months later. That would inform your programme.
The attitudes programme that we are developing will have a six-week follow-up, which will be part of the programme that we will ask schools to sign up to. We will take half an hour before the programme starts in order to allow people to fill in the evaluation forms that will measure their behaviours, and again at the end of the programme and a few weeks later, in order to determine whether the messages have been maintained, even for a short while. Then, hopefully, from that pilot, we will be able to develop the programme further and go back a year later. That depends on what the schools can do.
It should be available for all groups that are involved, from the Department down. It is about what is working. That is where we fall down. We have all these initiatives that are, sometimes, not very well evaluated, and we do not have the feedback about what works and what does not.
Now that this data has come to light, we hope to follow up on the heath checks in order to discover whether the programme has made a difference and allow us to gather some valuable information.
Part of the evaluation of the health checks involves asking people whether they learned new information from the session and whether they plan to change anything about their behaviour — diet, exercise, smoking, and so on. A lot of people say that they intend to change, but that is only an intention. Intentions do not change behaviour. We follow up by contacting them and establishing whether they have changed anything.
On Mrs Hanna’s point about adopting a more co-ordinated approach, we came across an example of that the other day while negotiating with the Northern Board about its funding of some of our smoking-cessation programmes. During our discussions and input, we talked about coming to address the Committee, and the subject of obesity arose. The board had not made the connection between obesity, lifestyle and the programmes that we have already put in place.
In a sense, that widened the conversation’s remit to include those connections — men’s health checks as well as children’s. The discussion became about connecting parents with the health checks, and connecting the child to the parent through some sort of managed programme that involved the parent as an audience, and that educated the parent to help the child to change behaviours.
Therefore, funding from one area is received by a trust and is then connected into a particular strategy. However, the obesity strategy connects with all other strategies. I am not saying that a trust should not decide where to channel funding, but it is important that it is aware of those strategy connections and of treatment targets.
I suppose the “Cook it!” programme is relevant, in that it is about cooking healthily on a budget. Young people with whom we work do not always have control over what they eat at home if their parents cook. If young people and their parents are being engaged at the same time, programmes such as “Cook it!” can be run.
“Cook it!” focuses on a different food group each week. It may be fruit and veg one week and proteins the next. Each week, there is a wee bit of theory followed by a practical cookery session; therefore, they actually cook to a recipe each week, and then take home those recipes in order to make the meals for their families in the knowledge of what is healthy.
The Deputy Chairperson:
No other members have indicated that they want to ask any questions. I thank the witnesses for coming along — you have been very informative. Thank you very much.