Official Report (Hansard)
Date: 14 May 2009
COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Inquiry into Obesity
14 May 2009
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mrs Claire McGill
Ms Sue Ramsey
Ms Gerry Bleakney )
Dr Carolyn Harper ) Public Health Agency
Dr Eddie Rooney )
The Deputy Chairperson (Mrs O’Neill):
We now move to the inquiry into obesity. Today’s witnesses are from the new Public Health Agency: Dr Eddie Rooney is the chief executive, Dr Carolyn Harper is the director of public health, and Ms Gerry Bleakney is a health promotion commissioner.
Dr Eddie Rooney (Public Health Agency):
I will give some context of where we are as an agency, because it may have a bearing on how much we can tell the Committee. The Public Health Agency has been in existence for six weeks. The agency has inherited many strands, but it is still putting its own stamp on priorities and how those will sit in its business plan. That work has become a little more difficult over the past couple of weeks because we did not quite expect that element of health protection — swine flu — to take such a high profile so early. Nevertheless, we are trying to move on as quickly as we can to establish the agency’s priorities. We will hold our second board meeting next week to try to progress that as quickly as we can.
There is no doubt that tackling obesity will be one of those high priorities because it is a priority for the Department and the Executive, and we know that it is a vital health issue, particularly in our area of health, which assesses prevention and wider public health. It is not an easy issue to tackle because it is so embedded in our lifestyles. It has taken many years to reach our current position.
My colleagues Carolyn and Gerry will very briefly take us through the presentation. One issue that they will address is how far we have moved towards becoming a sedentary population over the past 50 years. We will not be able to turn the tide quickly. However, much has been learned. We know that we must plan, and we must demonstrate to the Committee that we are on top of the task and the level of attention that we are giving to it.
At the outset, it is clear to us is that the issue will not be solved by the Public Health Agency or the health sector. It is at the core of cross-departmental and inter-sectoral working. That will inform how we approach partnerships with other organisations and bodies. That will not happen through strategies. For too many years, we have been involved in different aspects of nutrition and physical activity. I chaired the Fit Futures steering group, and I emphasised its cross-sectoral nature.
We must link strategic words with community action. One advantage of having an agency such as the Public Health Agency is that we can straddle that link. The agency is an implementation body, and we realise that we must work at ground level to have an impact. That will guide our approach as we start to develop our own planning system and our actions in relation to obesity.
We will take members through some key parts of the strategy. We are very happy to take as many questions as members can come up with. Our responses will be on the basis of it being very early days for us. We do not have a blueprint that demonstrates our solution, but formulating that is a priority.
Dr Carolyn Harper (Public Health Agency):
Members have received much information from other presentations, so I do not want to spend too long on that. I will then highlight some programmes and interventions in Northern Ireland and indicate the direction in which we think our own actions and those of others need to go.
It struck us that, when daily activity levels of the current population are compared with those of the population 50 years ago, it equates to running one marathon each week. That is a lot of activity and a lot of calories being burnt.
The key facts are: 60% of adults and one in five primary 1 children — four- and five-year olds — is overweight or obese. There is increasing evidence that the impact of obesity is similar to that of smoking more than 10 cigarettes a day. Therefore, it is not simply an aesthetic issue; it is a genuine health issue, and there are some health conditions for which the risk is increased among those who are overweight or obese.
There is also a significant impact on our health services. I need to draw your attention to a correction to one figure in paragraph 3 of our paper. The paper states that the current cost to the Health Service of anti-obesity drugs is £0·5 million a year; the cost is, in fact, £0·5 million a quarter, with a total figure of £2 million a year. Overall costs to the economy have been estimated at some £500 million a year, much of which relates to lost working days.
Action is focused on different settings and target groups. The Health Promoting Homes initiative is intended to get the entire family involved in changing behaviour and understanding the need to do that. The Healthy Steps for Life programme tries to embed some of those good habits in children at an early age. Eddie mentioned the need for community involvement, real engagement and ownership. There are schemes that are targeted at communities to own and take a lead on the issue. The workplace is another key setting.
FRESH is a weight-management programme for 11- and 12-year-olds. For children in their early years, there are programmes that are targeted at playschools, nursery groups, childminders and those who interact daily with young children. Nutritional standards have been introduced for school meals, and we are trying to address where children spend their days, both in school and at home.
Our approach is to prioritise obesity prevention and to own it at both central Government and local government level. It is a genuine issue that needs to be tackled with co-ordinated action across all Departments and with central Government action reflected at local government and within local communities and neighbourhoods. Obesity prevention needs to be brought down to neighbourhood level. A key task over the next few months will be to strengthen our existing relationships with local government, councils and other partners in education, transport, planning, and so on, and to translate that central direction into action on the ground.
On the matter of working with communities, I have highlighted the approach in France with the Ensemble, Prévenons l’Obésité des Enfants (EPODE) programme, of which you may have heard. It is concerned with planning the environment to promote walking and cycling. Parks, leisure facilities, and so on, have their part to play in tackling obesity. That emphasises the importance of cross-Government working.
Families are a priority. Parents influence what their children eat, and children influence their parents. Our approach is to give practical skills and knowledge of what a normal diet is and to address the shift towards fast food and larger portion sizes, which, subtly and latently, have become normal behaviours and patterns. It is about reframing and helping people to understand what a healthy, normal diet is.
Although some interventions are in place, it is essential that we are able to extend their scale and sustainability. Evidence has shown that 3,000 four- to five-year-olds and 4,500 11- to 12-year-olds already require interventions because their habits and behaviours are creating weight problems for them.
We cannot tackle obesity through single, small-scale interventions. Given the limitations of available funding, that approach has had to be taken. However, we want to take a dual approach. First, we want to draw in additional funding, and, secondly, we want to connect the existing services and programmes not only in the health and social care service but in transport and education to get the most of that resource. We want to take a fresh look at how we connect people to all available services.
Another key issue concerns measuring the impact of programmes and knowing what does and does not work. That will require an additional focus and some specific attention. Without that, we will simply continue to hope for the best rather than tackle the issue in a cohesive way.
We need to learn from effective practice elsewhere. Evidence has begun to emerge from some areas about what does work. We need to think that evidence through, accept it at a Northern Ireland, cross-Government level and then make sure that it is implemented at a local level. Finally, it is important that we bring that evidence base to others so that we can inform policies.
Our paper lists some immediate priorities that I will not go through. However, I want to draw out some concluding points. As a society, we cannot treat ourselves out of this situation by prescribing drugs or performing operations; rather, we must focus on prioritising prevention.
A key lesson to be learned from other areas where there has been some success in tackling obesity is that it is about communities and neighbourhoods. People must recognise and accept that they own obesity and that is not done onto them by health and social care professionals. They need to accept that obesity is much more fundamental than an aesthetic issue; it is a health issue of which they have to take ownership for their sake and the sake of their families. Those are the key points.
The Deputy Chairperson:
The Public Health Agency has a key role to play not only in tackling obesity but in addressing many others issues such as prevention and getting that message out early through education.
You referred to the good evaluation of the EPODE programme in France and said that the programme resulted in overweight boys experiencing a 50% decrease in obesity, which is a good statistic. How big is that programme? Was it very costly to implement? Could it be easily adapted for a pilot scheme here?
Ms Gerry Bleakney (Public Health Agency):
That is one programme that is being trialled, and those are preliminary results. Some health professionals from England are in France to evaluate the programme fully. The preliminary results look very promising; however, we will have to wait for the full results.
As regards evaluation, many health improvement initiatives that have been used over the years have not been as good as they should have been. We need a gold-standard-type agreement on the sorts of issues that we should be building into evaluations, and then we can move towards achieving that across the UK. The Institute of Public Health in Ireland, the all-Ireland obesity observatory, the Public Health Agency and others will work together to achieve that for the country.
During the inquiry, I have harped on about a particular point that I will also make to you. The work that the agency does is all well and good, but it is really designed only to try to keep a lid on matters.
No matter what we come up with in the inquiry, the situation can be resolved only by getting everyone to exercise and, more importantly, to force the food industry to limit the fats, sugars and salts in their produce. Until we do that, other measures will only keep a lid on the problem. I know that you cannot force the food industry to act, but what action are you advising the Department to take? Can we force the food industry to put the right ingredients in their foods, because that is the way to tackle obesity?
In many ways, you have hit the nub of the issue. If you think of all the issues that we tackle as mathematical equations, obesity should be one of the easier ones to solve: restrict what and how much people eat and get them to exercise. Those two measures will solve the problem.
However, it is difficult to tackle obesity, because there are so many players and interests, and because we are trying to turn the clock back on 50 years in which we have been going in a very different direction. It is also difficult to tackle the problem because we are dealing with fundamental aspects of our culture and what makes people tick. Even some of the basic aspects of tackling obesity that look simple turn out to be complex. For example, early investigations pointed out the importance of early years and early intervention. In the research that formed part of the Fit Futures initiative, which included kids as young as two and a half years of age, the basic messages were understood, such as the difference between good and bad. The role of enjoyable activity as part of a solution was also well understood, but it is not necessarily matched by the way in which society works. One cannot deal with children if one does not deal with parents and carers at the same time.
We are trying to turn the tide on many historical practices and behaviours at the same time as dealing with the issue at its source, which is not easy. The problem is multifactorial: for example, people’s rights are highly valued, but where they bring people into clear areas of risk, we have to turn the tide. That points to community-based approaches, which is why we are interested in examining some of the evaluation work and international research. There are lights in the tunnel; the holistic approach seems to be showing some benefits in countries such as New Zealand and Finland among others.
Research is a key element of the agency’s work, and we need to sharpen up our research on what measures work here and make sure that we do everything to publicise them. We are dealing with several interests and factors, many of which we do not have direct control over but still have to influence.
We all know the health message, and I am fit at the moment, because I am knocking on doors and canvassing for the European election. However, I am in the habit of eating what is put in front of me; I do not look at food packaging and will probably die 10 years younger as a result. That is why legislation on food packaging is required; I need help to eat the right food, because it is too convenient for me to eat the wrong foods. That is why I encourage you to force the Minister to do something about that.
The Deputy Chairperson:
We must all be very healthy, because we are all out knocking on doors.
As a GP, I want to be able to prescribe exercise regimes for patients where appropriate and play a role in preventative medicine as opposed to drug treatment. That is part of the future and does occur in some areas in the east of Northern Ireland.
The EPODE programme mentions boys, but are there any results for girls? As I have mentioned before, I am a little worried about obesity in girls: two young girls admitted to me in front of their parents that they smoke to suppress their appetites, which is a worrying development. I do not know whether girls get as much exercise or are as proactive as boys. Why does the EPODE programme make specific reference to boys?
An astounding number of people do not eat fruit or say that they do not like fruit. The same people will say that they feel guilty that they are not eating the recommended five portions every day. They are even unsure about what constitutes five portions, so will you quantify exactly what is meant by five portions? Some people think that it means eating five meals, but the five portions could be contained in two meals.
Primary care and secondary care are able to make referrals. Referral schemes have been operational across Northern Ireland; there is a scheme in the eastern area and part-schemes in the southern and northern areas. As a new agency, we need to draw on what has been best practice and what has produced good results. We will try to share that information to ensure that there is an equitable provision of good practice across the region and that as many people as possible are granted access to good practice.
I have been heavily involved with the referral scheme in the east, but the evidence base to support it is questionable. We had already committed to the scheme when the National Institute for Health and Clinical Excellence (NICE) guidance came out, and it was then suggested that it should be run only as part of a well-researched approach. Clients from general practice, primary care and secondary care give good reports about the scheme in the east, and we think that it is working. We will continue to assess the scheme because it is an expensive intervention. It is also a potentially very cost-effective intervention given the health outcomes that it creates.
EPODE is a community intervention that includes boys and girls. Our paper reports the boys’ figure simply because it is the most striking; I could not give you the corresponding figure for girls off the top of my head. EPODE is a holistic project that is taken forward by the mayor of the local town or city. It develops community spirit and engagement around social action for change. EPODE is about physical activity and healthy eating rather than obesity, although its outcomes influence obesity.
The five-a-day message has been around for quite some time, but we need to do some more work on public awareness. There has been a difficulty in Ireland in that, although potatoes are still part of many people’s staple diet, they do not count as one of the five a day. The former Health Promotion Agency has used some very good material to raise awareness. How many grapes are in a portion of fruit? We can all visualise apples, oranges and bananas, but what constitutes a portion of kiwi or another more unusual fruit? We need to work on the public awareness of some aspects of the five-a-day message.
Have you briefed families and agencies that take children into their care? What is your role in ensuring that those children, boys and girls, are properly cared for?
We are in the process of developing priorities and identifying target groups in the health and public health agenda. Families with children in care will be one of those groups. We will be able to provide you with more information over the next couple of months as we formulate our strategies. It will be a priority for the agency across the public health area.
Do you think that that will be up and running in a couple of months? Will people be briefed, know what they are expected to do and what information to pass on?
We will certainly do our very best to ensure that that is the case. The agency is an action agency, and we will follow through on all development areas down to community group level. However, it is still early days.
Much work has already been done for looked-after children in residential care or children who are placed with foster carers. Much has been done to make nutrition education and support available to those carers. We have identified the development of clear nutritional standards for residential care and children’s homes as a potential area of work. There are clear nutritional standards for education in schools, but there have been issues about children in residential homes. The main emphasis is on having as few children in residential homes as possible. However, we have a corporate parenting responsibility, and nutrition and physical activity are two key elements of that. Therefore, there is a plan to work on that within the next year.
It is the family home that I am thinking about. When children are placed in care, what follow-up is there? Do you check whether that is being implemented to protect that child from going down the route to obesity?
We will certainly take that issue on board.
I agree with Alex about food labelling. Often, the bargains are the rubbish food with the least food value and the most additives. There is an issue about our fondness for food and how it is used as comfort or reward. When my children were small, the thinking was that, if parents did not give their children anything sweet, they would never like sweet foods. Whether we like it or not, however, children seem to like sweet foods instinctively. It is about the culture. However, as the Public Health Agency, your message has to be about all of us taking ownership and responsibility for our own health, albeit with as much support as possible. You said that this issue covers many Departments and that much of what can be done for children is in the area of prevention, starting, for example, with antenatal classes, parents, preschool, and, if necessary, healthy breakfasts in schools. Much of that is happening. However, a lead person or agency is needed to ensure that it is happening and that its progress is monitored. Everybody is doing bits and pieces, but, unless someone is given absolute responsibility for progress, it will never come together.
Years ago, one of my children was involved in a piece of research. All I can remember is a man named Dr Sean Strain, and that it was carried out by the University of Ulster and Queen’s University. For a week, we had to keep a diary of everything that my daughter ate. We were not to be “good” for that week; we were to be honest. They did cardiovascular tests, and she loved being on the exercise machine. I did not hear about any outcomes, but it was a major piece of research at the time. I wonder if you know anything about it. You said that not enough research is being undertaken. It comes down to having one person in charge with the authority to involve all other areas and to monitor what is happening.
To have effective ownership, people need to know what to do, believe that it is right and know how to do it. We need to provide support on all three issues. We have gained a lot, and, although I would never try to turn the clock back on technology, we have also lost a lot. I have seen, particularly at community level, the loss of some basic skills. Programmes such as Cook It! try to reinstate those lost life skills. It is up to us to take that leadership role. However, it is a collective leadership; it is up to the agency to play its part, and it is up to many other people to play their parts. We have to break down the message and understand it from the perspective of people living in the community, as opposed to the message descending from on high. That will be a challenge for us. It is a thread running through the whole public health agenda. It cannot be done remotely. It must be done in communities and working with them. The agency must be able to demonstrate that it can work in that environment, and we are actively pursuing that.
When that barrier is broken, we have a real chance. There is a need for animation in communities and a real desire to do something. However, people struggle with how it can be achieved, and extra support is needed to make it happen. We must fill that challenging gap.
I agree with you that it is about leadership. Everyone has to give leadership, but if there are no specifically dedicated people who have responsibility, it can be difficult to quantify the progress. That is what it is about. If we could see that we were improving, we could build on that.
The Deputy Chairperson:
As there are no more questions, I thank you very much for your presentation.