Session 2009/2010
First Report
COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Inquiry into Obesity
Together with the Minutes of Proceedings of the committee,
minutes of evidence and written Evidence relating to the report
Ordered by the Committee for Health, Social Services and Public Safety
to be printed 1 October 2009
Report: 10/09/10R (Committee for Health, Social Services and Public Safety)
This document is available in a range of alternative formats.
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Northern Ireland Assembly, Printed Paper Office,
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Committee Powers and Membership
The Committee for Health, Social Services and Public Safety is a Statutory Departmental Committee established in accordance with paragraphs 8 and 9 of the Belfast Agreement, section 29 of the Northern Ireland Act 1998 and under Standing Order 46.
The Committee has power to:
- Consider and advise on Departmental budgets and annual plans in the context of the overall budget allocation;
- Consider relevant secondary legislation and take the Committee stage of primary legislation;
- Call for persons and papers;
- Initiate inquiries and make reports; and
- Consider and advise on any matters brought to the Committee by the Minister for Health, Social Services and Public Safety
The Committee has 11 members including a Chairperson and Deputy Chairperson and a quorum of 5.
The membership of the Committee is as follows:
Mr Jim Wells4 (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mrs Carmel Hanna Dr Kieran Deeny
Mr Alex Easton Mrs Claire McGill1
Mrs Dolores Kelly3 Ms Sue Ramsey
Mr Sam Gardiner2 Mrs Iris Robinson MP5
Mr John McCallister
1 with effect from 20 May 2008 Mrs Claire McGill replaced Ms Carál Ní Chuilín.
2 with effect from 15 September 2008 Mr Sam Gardiner replaced Rev Dr Robert Coulter.
3 with effect from 29 June 2009 Mrs Dolores Kelly replaced Mr Tommy Gallagher
4 with effect from 4 July 2009 Mr Jim Wells replaced Mrs Iris Robinson
5 with effect from 23 September 2009 Mrs Iris Robinson replaced Mr Thomas Buchanan
Table of Contents
Volume 1
1. Introduction
2. Background
Health Implications
Cost of Obesity
Measuring Obesity (BMI)
Causes of Obesity
3. Trends
A Major Global Health Problem
Obesity Prevalence in the UK and ROI
Obesity Prevalence in Northern Ireland
4. Current Approach
Targets
Funding
Life Course Approach
Leadership
Co-ordinated Approach
Existing Initiatives
5. Weight Management
Primary Care
Secondary Care
Bariatric Services
6. Diet and Exercise
Healthy Eating
Food Labelling
Food Portion Sizes
Mixed Messages
Exercise
7. Role of Other Departments, Bodies and Sectors
Role of Local Authorities
Role of the Media
8. Obesogenic Environment
9. Other Issues
Health Inequalities
Community Approach
Workplace Health
Research
Data Collection
10. Conclusion
Appendix 1:Minutes of Proceedings 49
Appendix 2:Minutes of Evidence 73
Volume 2
Appendix 3:Written Evidence
Appendix 4:Other Evidence considered by the Committee
Appendix 5:Minutes of Evidence Session held on 19th May 2009 699
Appendix 6:List of Witnesses who gave Evidence to the Commitee 797
Executive Summary
Obesity is a major global public health problem. Recent decades have seen a significant rise in levels of overweight and obesity in many countries around the world. In a number of the major developed countries, including the UK and the USA, the rates of obesity have doubled in the last 25 years and this relentless increase is predicted to continue in the decade ahead. The most recent Health and Social Wellbeing Survey in Northern Ireland in 2005 found that 59% of all adults here were either overweight or obese, with 24% of adults obese. Worryingly, data from the Northern Ireland Child Health System in 2004/05 found that 22% of children are either overweight or obese, with more than 5% already obese.
The 2007 Foresight Report, a report complied by a panel of leading experts and commissioned by the UK Government, warned that if trends in overweight and obesity continue to rise, there is a real prospect that by 2050, ‘Britain could be a mainly obese society’. It predicted that by that date, 60% of men and 50% of women in the UK could be obese. The Department’s Investing for Health Strategy in 2002 had estimated that by 2010 the cost of obesity to the NI Economy could exceed £500m per annum.
Obesity has been variously described to us as a ‘well established epidemic’, a ‘tsunami’, a ‘crisis’ and a ‘population time bomb’. It is a problem that will have an enormous impact, not just on the health of the population, but something that threatens to engulf the entire health service and it will have a very serious impact on society and the economy. For many people obesity is seen primarily as a vanity or aesthetic issue. However, it has very serious and life-threatening health implications through a wide range of conditions, such as heart disease, type 2 diabetes, some forms of cancer, and high blood pressure. We were told that obesity could cause the present generation growing up to have a shorter life span than their parents.
In this report the Committee looked at both the current strategic approach to the prevention of obesity and the availability of weight management or other services to deal with obesity related ill health.
Prevention
To date, no country in the world has been able to develop an overall strategic approach that has significantly reduced obesity prevalence. However, the recent development of the Healthy Weight, Health Lives strategy in England, represents the first national population-wide strategy but it is too early yet to judge its effectiveness. It is clear that obesity levels have increased steadily over many years and it will take a long-term response to reverse this trend.
In Northern Ireland the Department of Health has moved away from the Fit Futures initiative, which focussed on tackling obesity in children and young people, and has begun to develop a whole life course approach, similar to the Healthy Weight, Health Lives strategy in England. While we support the development of the life course approach we have concerns that the Fit Futures initiative has not been formally signed off and implemented.
All Departments and sectors have a crucial role to play in tackling obesity and all need to be involved and committed to the development of the new life course strategy. We recommend that the strategy should be jointly led by the health and education Departments, as has happened in England. There must be single strong effective leadership to drive the strategy forward and, given the potential for significant cost benefits and the consequences of failure to invest, it needs to be provided with significant resources.
Most Departments outlined the action they currently undertake relating to obesity. As identified in the Fit Futures initiative the importance of working with children and young people on nutrition and exercise cannot be over emphasised. The Department of Education has a particularly crucial role in this and, while we welcome the action being taken on nutrition in schools, we call on that Department to make PE in schools compulsory and subject to regular monitoring.
We recognise the potential for the draft 10 year Strategy for Sport and Physical Recreation in Northern Ireland, developed by the Department for Culture, Arts and Leisure in 2007/08, to contribute to a reduction in obesity and we call for it to be resourced and implemented without further delay.
While the cause of obesity can be described in simple terms as an imbalance between the amount we eat and the level of exercise we undertake it cannot be solved by individuals alone. There are many and varied environmental factors, from the accessibility and marketing of food, to transport, planning and other issues that dissuade a healthy diet and physical exercise and these must be tackled. Referred to as the ‘obesogenic environment’, its influence and impact is not widely understood or adequately addressed.
Other issues dealt with in the report include, the role of the new Public Health Agency, the role of local authorities, the potentially positive and negative roles of the media, as well as the need for a community approach and the need to tackle health inequalities. We also identify the need for better co-ordinated research and more representative and reliable data collection.
Weight Management Services
We are very concerned to learn about the current levels of obesity related ill health throughout Northern Ireland and particularly by the number of severely obese patients for whom lifestyle and drugs have failed. These patients now face the prospect of bariatric surgery and the subsequent need for lifelong medical follow-up treatment. We are gravely concerned at the dearth of services at primary and secondary level to deal with those who have serious medical conditions related to severe obesity and the absence of any services to prevent further weight gain in patients with lower degrees of overweight.
We witnessed the frustration of frontline clinicians who told us that services designed to address specific clinical conditions, such as diabetes, cannot adequately address the needs of obese patients. The absence of effective interventions for children with obesity was also highlighted to the Committee.
It is estimated that as many as 50,000 people in Northern Ireland may be eligible for bariatric surgery and this service is currently not provided within Northern Ireland. Last year around 80 people were referred for bariatric surgery to Great Britain. It has been estimated that the cost of treating just 1,000 patients and providing the necessary medical follow-up could be around £10 -£15 million.
On the positive side we recognise that small weight losses do produce health gains and research shows that even a modest reduction in weight of 10% can have a significant impact on a patient’s health. Further delay in providing a comprehensive range of appropriate weight management services will result in greater long term costs. An urgent review to develop such a range of services must be undertaken now.
Summary of Recommendations
1. Obesity is the most serious and most challenging public health issue that we face at this time and it is also one of the most complex. There is therefore an urgent need to develop and implement a comprehensive and robust strategy to address the issue. (Paragraph 49)
2. We share the deep concern of those who expressed regret that the Fit Futures Implementation Plan has not been formally signed off and implemented. The failure to do so has, we believe, created uncertainty and a potential hiatus until a full strategy is in place. (Paragraph 50)
3. We welcome and support the plans by the Department to develop a life course strategy however we fully recognise that tackling obesity effectively is not solely a matter for the health service. We note that the Fit Futures Report contained a joint target with the Departments of Education and Culture, Arts and Leisure. We strongly recommend that the new life course strategy be developed jointly in partnership with other departments, particularly the Department of Education, as has happened in England. (Paragraph 51)
4. Growing levels of obesity will continue to generate enormous costs to society, particularly the health and social care sector in the years ahead. Given this and the potential for significant cost benefits, we belief it is imperative that substantial and sustained resources are provided to implement the new life course strategy. We would urge that this funding be ring-fenced for at least the first phase of implementation (3-5 yrs) to ensure that it is not impacted by other acute and emerging priorities.(Paragraph 52)
5. It is very clear that single strong effective leadership is crucial in tackling obesity but the exact locus of that leadership has been the subject of debate. We recommend that the question of who provides overall leadership be considered in depth during the development of the Life Course Strategy and widely consulted upon before reaching a decision. (Paragraphs 57-58)
6. We recognise that the establishment of the new Public Health Agency provides a unique opportunity to develop a joined-up approach across all Government Departments, public sector agencies including local authorities, the private sector, and the voluntary and community sectors to tackle obesity. We advocate that the Agency make this issue a top priority and we urge all departments to play their part in delivering a concerted long-term response. (Paragraph 62)
7. We recommend that the Department commission an urgent audit of existing obesity-related initiatives so that the need for evaluation or further research can be identified and examples of good practice can be rolled out more widely. We recommend that the Public Health Agency, perhaps in conjunction with the planned All-island Obesity Observatory, develops and maintains a central data base of projects and develops standardised evaluation tool kits. (Paragraph 70)
8. We recommend that the Department, in conjunction with the Health and Social Care Board, develops a range of evidence-based referral options for use by primary care practitioners. (Paragraph 82)
9. We urge the Minister to exert influence at a national level to introduce the allocation of Quality and Outcomes Framework (QOF) points for positive obesity management rather than simply for maintaining a register of obese patients. (Paragraph 83)
10. We call on the Minister, as a matter of urgency, to undertake a comprehensive review of weight management services at all levels for adults and children. The review must address the need for dedicated obesity clinics and a separate bariatric service for Northern Ireland, including the provision of bariatric surgery and the lifelong medical follow-up for individuals required following such surgery. The review should also consider the merits of adopting examples of good practice from elsewhere, such as the Counterweight programme in Scotland and the Carnegie Weight Management programme in England. (Paragraph 100)
11. We urge the Department and the Food Standards Agency to continue to work with manufacturers and to exert pressure at a national and European level to introduce regulatory controls on the levels of salt and saturated fat in manufactured foods. (Paragraph 108)
12. We fully support the calls for a single, consistent food labelling scheme using the traffic light system and urge the Minister and the Food Standard Agency Northern Ireland to consider whether such a system could be made mandatory on all food retail products. We also call for more action to enforce a similar clear and simple nutrition labelling system at non-retail outlets, such as restaurants and catering establishments. (Paragraph 114)
13. While recognising the difficulty in regulating food portion sizes in catering and similar settings, we urge the Department and the Food Standards Agency Northern Ireland to examine how issues like food promotion and pricing impact on portion sizes and how they might be influenced. (Paragraph 118)
14. We believe there is confusion over what exactly constitutes ‘five portions of fruit and vegetables a day’ and particularly around the size and content of a portion. We urge the Public Health Agency to examine how greater clarity and understanding about this health message, and how it might impact on levels of obesity, can be achieved. (Paragraph 120)
15. We call on the Executive to ensure that the Strategy for Sport and Physical Recreation in Northern Ireland is properly resourced and implemented without further delay and that this work dovetails with the development of the life course obesity strategy. (Paragraph 128)
16. We urge each and every Department to recognise that they have a crucial role to play in responding to the obesity epidemic either through direct action or through policies and practices that impact on the obesogenic environment. (Paragraph 135)
17. We call on the Department of Education to make at least 2 hours of PE in schools compulsory and subject to regular monitoring by the Educational and Training Inspectorate. (Paragraph 142)
18. We urge the full involvement of local councils in developing the new life course strategy. (Paragraph 147)
19. We urge the Minister to work with colleagues throughout the UK to explore the feasibility of banning the advertising of food and drink products that are high in fat, salt or sugar before the 9 pm watershed. (Paragraph 152)
20. We call on the Minister to develop a comprehensive media approach as part of the life course strategy and to consider, for example, how new and emerging media such as text and Twitter could be used to engage with young people. (Paragraph 153)
21. We call on the Executive to fully recognise the potential impact of the obesogenic environment on the health and wellbeing of the population and to consider the merits of introducing a system whereby the impact of all major policy decisions are subject to an obesity proofing exercise. (Paragraph 162)
22. In developing the Life Course Approach we urge the Department to take account of health inequalities and particularly the need to address the higher levels of obesity in areas of social deprivation. (Paragraph 171)
23. We recognise the benefits for both employers and employees of promoting healthy lifestyles in the workplace and we urge all employers to consider initiatives that promote healthy eating and greater levels of exercise in the workplace. (Paragraph 176)
24. We urge the Department to examine how data collection can be improved through reform and better funding of the Child Health System. This should facilitate extending BMI measurements beyond Primary One children. Enhanced funding should also facilitate better collection of adult data based on actual BMI measurements rather than self-reporting. (Paragraph 187)
Introduction
1. Obesity is a complex condition which poses a serious threat to health and well-being on a global scale and, to date, no country in the world has been able to develop an effective overall approach to successfully address the issue. The Committee is conscious that within Northern Ireland around 60% of the adult population and 25% of children are either overweight or obese and this is predicted to grow significantly over coming years. The Committee recognises that action must be taken now to prevent the cost to the health service and to society generally from escalating out of control.
2. This report sets out the results of the Committee examination of the current strategic approach to tackling obesity and its impact on health and well-being. In particular the Committee has looked at:
- the scope and appropriateness of the current approach to the prevention of obesity and the promotion of lifestyle change;
- the availability of weight management or other intervention services to tackle obesity related ill health; and
- what further action is required, taking account, of the potential to learn from experience elsewhere.
3. The Committee invited written submissions from a wide range of organisations and groups both within Northern Ireland and further afield and placed notices in the main newspapers. As with many public health issues the Committee recognised that tackling obesity is not just a matter for the health Department and, accordingly invited views from all Departments and Assembly Statutory Committees. The Committee took formal evidence from seventeen separate organisations over a four month period from February to June 2009. Recognising the importance of research into methods of tackling obesity and the need to incorporate that research into policy and practice, the Committee organised a Research Round-Table Event in Parliament Buildings involving a number of eminent academic experts in the field from throughout the United Kingdom and the Republic of Ireland and a small number of key stakeholders.
4. We are grateful to all those who helped us with this Inquiry, including those who provided oral or written evidence and those who participated in the Research Event. We are particularly grateful to those from outside Northern Ireland who came and shared their expertise and experience with us.
Background
Health Implications
5. The Department defined obesity as “a condition where weight gain has got to the point that it poses a serious threat to health".[1] The severity of that risk to health from being overweight or obese does not appear to be widely recognised or understood. The Executive Director of the Northern Ireland Food and Drink Association reminded the Committee that only 6% of people understand the risks of being overweight. He said “Obesity is seen as a vanity rather than a health issue, and we must change that mindset".[2] The British Medical Association put it very starkly saying that obesity “is a population time bomb that will, perhaps, cause the generation growing up to have a shorter lifespan than their parents".[3] The Public Health Agency pointed to recent studies which “suggest that the risk of premature death in people with obesity is similar to that seen in people who smoke more than 10 cigarettes a day. Obesity is therefore not an aesthetic issue – it shortens life and increase the risk of a range of conditions".[4]
6. The Department in its evidence listed ten serious conditions associated with obesity and added that, “evidence also indicates that obesity can reduce life expectancy by approximately 9 years; and can impact on emotional/psychological well-being and self-esteem, especially among young people."[5] The British Medical Association listed the four most common health problems associated with obesity as heart disease, type 2 diabetes, hypertension and osteoarthritis.[6]
7. The British Heart Foundation Northern Ireland pointed out that, “heart and circulatory disease is Northern Ireland’s biggest killer – responsible for more than one in three deaths each year"[7]. The Foundation stated that, “obesity is, in itself, an independent risk factor for heart disease, but it can also be seen as an accumulator, in that it has an effect on other risk factors including diabetes and hypertension, which is also linked to stroke".[8] The British Heart Foundation Northern Ireland referred to the INTERHEART study which estimated that 63% of heart attacks in Western Europe are caused by abdominal obesity[9].
8. Mr Iain Foster, Diabetes UK, explained the impact of obesity as a significant factor in the number of those suffering from type 2 diabetes in Northern Ireland. He stressed the importance of getting beyond the misconception that diabetes is a mild condition. He said, “It is not mild; it is a chronic condition that has no cure. Type 1 diabetes will take up to 20 years off a person’s life expectancy. Type 2 diabetes will take up to 10 years off a person’s life expectancy." Mr Foster stressed that while obesity has no connection to type 1 diabetes “weight contributes to around 80% of cases of type 2 diabetes".[10] Dr Michael Ryan, a frontline clinician, estimated that “about 90% of the patients that attend my diabetes clinics have weight-related issues". Dr Naresh Chada, DHSSPS, pointed out that 65,000 to 70,000 people suffer from type 2 diabetes and said that, “if we do not halt the year-on-year increase in obesity, we could have another 10,000 to 15,000 people with diabetes in Northern Ireland by the early to middle part of the next decade."[11]
9. A Report by the Northern Ireland Audit Office into Obesity and Type 2 Diabetes in Northern Ireland[12] confirms that weight gain is a major influence on the prevalence of type 2 diabetes which is the most common form of diabetes. The Report also highlighted the increasing prevalence of type 2 diabetes in younger people, partly due to lifestyle factors such as diet, lack of physical activity and obesity. This supports the statement by Dr Ryan who said that, “When I was training, type 2 diabetes was called ‘maturity-onset diabetes’. Nowadays, I see 18 and 19-year-old people with that condition, and paediatricians are seeing it in the under 16s. That was unheard of."[13] The Health Minister, in a debate in the Assembly on diabetes, acknowledged that, “the Health Service as we know it will be overwhelmed in twenty years time if we do not tackle diabetes, obesity, and lifestyle. Hospitals are filled with people, who, had they made different lifestyle choices 20 or 30 years ago, would not be there."[14]
10. The link between obesity and cancer is perhaps not so widely recognised. However, Dr Chada, DHSSPS, warned that, “Cancer — particularly gynaecological cancers — are also associated with obesity. I refer to cancer of the uterus, cervix and ovary. Men may be affected by bowel and prostate cancer. A certain proportion of cancers can be attributed to obesity."[15] Action Cancer highlighted that, “two thirds of cancer can be prevented through lifestyle changes, such as more exercise and a change in eating habits"[16] while the British Medical Association pointed out that “obesity increases the likelihood of developing cancers such as breast, colon, endometrial, oesophageal, kidney and prostate cancer by up to 33%"[17].
11. The Royal College of Psychiatrists argued that, “people with mental illness and those with learning disabilities are more likely than the general population to be obese, to have physical health problems arising from this, and to have difficulty managing weight." The Royal College suggested that the reasons for this are complex and could include living in an area of social deprivation, inactivity, medication factors, emotional eating, as well as a reluctance of medical practitioners “to raise the issue of weight with a person who is already vulnerable"[18]. The Belfast Health and Social Care Trust Physiotherapy Service agreed that, “people with mental illness are predisposed to the development of obesity by the nature of their illness; the situation is however made worse by the fact that the medication prescribed for the treatment of their condition does in fact further increase their likelihood of developing obesity".[19]
12. The Chartered Society of Physiotherapy suggested that, “The incidence of falls is another factor that has an impact… an obese person’s muscles become weaker — their muscle tone lessens and their balance reduces; therefore, the risk of falls or of osteoporosis from not doing weight-bearing exercises is increased."[20]
13. Nevertheless, the British Medical Association and others stressed to the Committee “there is nothing about this problem that is inevitable"[21]. Dr Ryan agreed, saying that, “The impact of obesity and overweight is worse than all the cancers put together, on an epidemiological basis, and yet we can intervene, and it can be prevented if caught early enough."[22] In his written evidence Dr Ryan stated that, “there is incontrovertible evidence that weight reduction, however achieved, is effective in reducing morbidity and prolonging life".[23] The Belfast Health and Social Care Trust Physiotherapy Service referred to the Crest Guidelines which “highlight the fact that even a 10% reduction in weight can induce up to a 50% reduction in obesity related cancer deaths, up to a 50% reduction in the development of diabetes as well as having a significant positive impact on lowering blood pressure and cholesterol levels."[24]
Cost of Obesity
14. In addition to the serious health implications for individuals, policymakers are increasingly concerned that the growing obesity problem will place a substantial financial burden on their respective health finances. This is particularl y pertinent within the four universal, tax-funded health systems of the NHS. According to the 2007 Foresight Report in the United Kingdom “by 2050, 60 per cent of males and 50 per cent of females could be obese, adding £5.5 billion to the annual cost of the NHS, with wider costs to society and business estimated at £49.9 billion."[25]
15. Many of the submissions to the Inquiry pointed to the enormous social and economic costs of obesity, not only for the health and social care service, but for the overall economy and wider society. Belfast City Council pointed out that, “the social and economic costs of obesity are enormous and have the potential to increase significantly over the coming years."[26] The Institute of Public Health told us that, “The loss of productivity and the costs of care and treatment of obesity and related conditions have serious effects on the economy and threaten to engulf the health service. Obesity is estimated to cause 450 deaths per year, £14.2 million in lost productivity and £90 million cost to health and social care."[27]
16. The Northern Ireland Audit Office Report[28] concluded that in Northern Ireland the cost attributable to the lack of physical activity includes over 2,100 deaths each year but it found that no robust estimate of the overall health care costs of treating diabetes was available from the Department. Sustrans reminded us that the Department’s Investing for Heath Strategy back in 2002 had estimated that obesity caused over 450 deaths per annum; equivalent to over 4,000 expected years of life lost; 260,000 working days lost each year; and the approximate cost to the economy of £500 million.[29] The British Medical Association suggested that, “tackling obesity could save the health service in Northern Ireland £8.4 million, reduce sickness absence by 170,000 days and add an extra ten years of life onto an individual’s life span."[30]
17. There were also warnings that things could get worse. Professor McCartan, Sport NI, said that, “One of our concerns is that, if we do not act quickly, the problem will simply get bigger. That is why we are saying that Government must act now. The longer we delay, the more it will cost in future and the bigger the problem will be when we finally decide to act."[31]
Measuring Obesity (BMI)
18. One of the key methods used to measure obesity prevalence around the world is Body Mass Index (BMI). BMI is a simple index of weight-for-height and is recognised by the World Health Organisation (WHO) as the most useful mechanism in providing a population-level measurement of overweight and obesity. Adults with a BMI of 25-30 are classified as being overweight and those with a BMI of 30 or more are classified as obese. However, it is also recognised that there are certain limitations associated with BMI while recent research has advocated the measurement of waist circumference as being more closely associated with mortality and morbidity than BMI.[32]
19. The Obesity Management Association, for example, argued that, “BMI as a benchmark is outdated and restrictive – it does not allow all health factors to be taken into account."[33] Dr Ryan said, “I accept that the BMI is an imperfect measure. I have been waiting for 20 years for the perfect measure. The difficulty is that meanwhile, patients are dying. We cannot wait for the perfect measure".[34]
Causes of Obesity
20. Historically, obesity had been thought of as a simple matter of an imbalance between energy intake and energy expenditure or, in other words, an imbalance between the amount we eat and the level of physical activity we undertake. However, many of the submissions to the Inquiry were keen to point out that the cause of obesity is often a complex mix of genetic, physiological, behavioural and environmental factors. Although the specific causes of obesity at an individual level are varied it is accepted that, “at the heart of obesity lies a homeostatic biological system that struggles to maintain energy balance to keep the body at a constant weight. This system is not well-adapted to a fast-changing world, where the pace of technological progress has outstripped human evolution."[35]
21. The South Eastern Health and Social Care Trust suggested that, “obesity should be understood in a wider context than simply a lifestyle choice concerning nutrition or physical activity. Obesity is often combined with issues of mental health, self esteem, isolation, family support and emotional wellbeing."[36] Ballymena Borough Council argued that, “One school of thought would suggest that obesity is due entirely to personal lifestyle and diet choices. Another however is that people today generally do not have less willpower nor do they eat more than previous generations and that it is important to look beyond the obvious and to accept that society has radically altered over the last 5 decades, with major changes in work patterns, transport, food production and sales. It is thought that these changes have exposed a common underlying biological tendency to both put on weight and retain it.[37]
22. Action Cancer pointed out that, “it is important to remember that nobody chooses to be overweight. People choose certain behaviours that have poor health consequences."[38] Conservation Volunteers argued that, “It is recognised that the fundamental causes of obesity are lack of physical exercise and poor diet. A number of other factors are also being taken into consideration, such as increased consumption of high calorie energy dense foods, increased levels of TV watching, use of games consoles, advertising and promotion of unbalanced diet, availability of convenience food, cost of healthy food options, inadequate cooking skills, and transport and planning decisions."[39] It is also clear that there are definitive links between poverty, poor diet and obesity – see paragraphs 163 et seq.
23. It is also accepted that the pattern of growth during early life is one determinant of the future risk of obesity. “A baby’s growth rate in the womb and beyond is in part determined by parental factors, especially with regard to the mother’s diet and what and how she feeds her baby".[40] The period soon after birth is believed to be a time of ‘metabolic plasticity’ and while there is less evidence of a link between actual birth weight and obesity, it is weight gain in early life that appears to be the critical issue. Breast-fed babies show slower growth rates than formula-fed babies and this may contribute to the reduced risk of obesity later in life. It appears that low birth weight babies may be susceptible to a catch-up rapid weight gain while other babies may experience this as a direct result of their diet.[41]
24. Research published recently also suggested that there is a strong link in obesity between mothers and daughters and fathers and sons, but not across the gender divide. The study concluded that, “Childhood obesity today seems to be largely confined to those whose same-sex parents are obese, and the link does not seem to be genetic. Parental obesity, like smoking, might be targeted in the interests of the child."[42]
25. Dr Jane Wilde, Institute of Public Health in Ireland, summed it up saying, “At the heart of the problem is the imbalance between what we take in and what we put out — in other words, the energy we expend. All the studies that have examined the issue from a scientific angle say that the problem will not simply be solved by individuals … we really must take a wider view and see the problem in a social, environmental and economic context."[43] The recognition that obesity is a complex issue therefore means that it requires, as the Public Health Alliance pointed out, “integrated cross-cutting solutions and involve much more than interventions and services aimed at addressing lifestyle and behaviours".[44]
Trends
A Major Global Public Health Problem
26. In recent decades, there has been a significant rise in levels of overweight and obesity in many countries around the world. According to the World Health Organisation (WHO), excess body weight poses one of the most serious public health challenges of the 21st century.’[45] According to the WHO’s latest projections, globally, in 2005 there were approximately 1.6 billion adults (15 years and over) overweight and at least 400 million obese. Twenty million children under the age of 5 years were overweight globally in 2005. Furthermore, the WHO projected that by 2015, there will be approximately 2.3 billion overweight adults and more than 700 million will be obese.[46] In Europe alone, it is projected that the rapidly increasing prevalence of obesity will include 150 million adults and 15 million children by 2010.[47]
Figure 1: Percentage of the adult population assessed as obese in a selection of countries from around the world (Obese defined as BMI = 30kg/m2)[48][49]
27. A substantial body of research and empirical evidence in recent years highlights the continuing rise in overweight and obesity within both industrialized and developing/low income countries around the world. In a number of the major developed countries including the UK and the USA, the rates of obesity have doubled in the last 25 years. An OECD report published in 2009 analyzing past and projected future trends in a number of selected member countries concluded that prevalence rates of obesity and pre-obesity have been continuing to increase relentlessly in recent decades and will continue to do so in the decade ahead. The report states that, “projected trends in adult overweight and obesity (15-74 years) over the next 10 years…predict a progressive stabilization or slight shrinkage of pre-obesity rates in many countries with a continued rise in obesity rates."[50] This statement correlates with the percentage of obese adults within many of the industrialized countries around the world, including within the United Kingdom and the Republic of Ireland as illustrated in Figure 1. While specific figures for Northern Ireland are not included in Figure 1, levels of overweight and obesity continue to rise with around a quarter of the adult population in Northern Ireland classified as obese (see below). This follows a similar trend in other parts of the United Kingdom and the Republic of Ireland.
Obesity Prevalence in UK and ROI
28. Overweight and obesity prevalence rates among children and adults throughout the United Kingdom and the Republic of Ireland have continued to rise in recent decades to the extent that the scale of the problem is increasingly recognized as having become an ‘epidemic’. Available data for the four jurisdictions of the United Kingdom and the Republic of Ireland show significant prevalence rates for obesity and overweight. According to the Foresight report[51], in 2003/2004, the mean body mass index (BMI) of men and women in the UK general population was 27kg/m2, which is outside the healthy range of between 18.5-25 kg/m2. Significantly, the Foresight report warned that if trends in overweight and obesity continue to rise, there is a real prospect that by 2050, ‘Britain could be a mainly obese society’. According to the report, the rates of obesity are estimated to rise by 2035, to 47% of men and 36% of women in the UK. The headline figure that emerged from the report is that by 2050, 60% of men and 50% of women in the UK could be obese.[52]
29. Meanwhile, in the Republic of Ireland, the 2007 Survey of Lifestyle, Attitudes and Nutrition in Ireland (SLAN) reported that 39 per cent of the adult population were overweight and 25 per cent were obese. Following a similar trend in the UK, overweight and obesity levels in the Republic of Ireland have continued to rise or remained the same over the period of the previous two surveys in 1998 and 2002. Obesity levels based on self-reported data have increased over the period of the three surveys, from 11% in 1998 to 15% in 2002 and levelled off at 14% in 2007. Overweight levels have increased between 1998 (31%) and 2002 (33%) and increased again in 2007 (36%).[53] While these figures do not include measured BMI of individuals and are reliant on self-reported data through completion of questionnaires, the data indicates there has been a significant rise in the prevalence of overweight and obesity in the Republic of Ireland in the last decade.
Obesity Prevalence in Northern Ireland
30. Like other parts of the United Kingdom, levels of overweight and obesity have risen significantly throughout the population of Northern Ireland in recent years. On 13 November 2008 at the opening of the All-Island Conference on Obesity (‘Obesity: weighing up the evidence’), Health Minister, Michael McGimpsey, acknowledged that “There is no doubt that the obesity time bomb in Northern Ireland is ticking louder than ever. Our level of obesity, especially amongst our children is incredibly worrying."[54]
31. At the same conference, Dr Brian Gaffney, chief executive of the former Health Promotion Agency, citing figures from Northern Ireland’s 2002 public health strategy Investing for Health stated that an estimated 450 deaths a year are attributable to obesity and that obesity costs the local economy approximately £500 million per year. Investing for Health predicted that if the upward trend in the rising obesity levels continued ‘by 2010, 23% of women and 22% of men will be obese’. The extent and seriousness of the obesity problem in Northern Ireland is reflected in the fact that figures predicted in Investing for Health were already surpassed by the figures to emerge from the 2005/06 Health and Social Well-Being Survey. According to the survey, 25% of men and 23% of women in Northern Ireland were identified as having a BMI of 30 or over and therefore classified as obese.
Table 1: Proportion of Adults in each Health and Social Services Board areas who were overweight or obese by gender (2005-2006)[55]
| Overweight | Obese | |||||
| HSSB | All | Male | Female | All | Male | Female |
| Eastern | 32% | 36% | 29% | 21% | 21% | 21% |
| Northern | 37% | 38% | 35% | 26% | 27% | 24% |
| Southern | 35% | 41% | 29% | 28% | 27% | 28% |
| Western | 36% | 44% | 28% | 23% | 26% | 21% |
| NI | 35% | 39% | 30% | 24% | 25% | 23% |
32. According to the Child Health System (managed by the former four Health and Social Services Boards) in 2003-04, one in four girls and one in five boys in Northern Ireland were found to be overweight or obese in Primary One. The percentage of children classified as obese in Primary One has increased year on year since 1997. More recent data from DHSSPS shows that the level of obesity in Primary One has declined slightly since 2003-04 from 5.7% of the age group to 5.1%. Moreover, the Young Hearts study of 12 to 15 year olds living in Northern Ireland reported that levels of overweight and obesity increased in the decade 1990-2000.[56]
33. In September 2007, the DHSSPS provided additional funding across the former four Health and Social Services Board areas to collect and record BMI measurements of all Year 8 and Year 9 pupils. In their submission to the Inquiry, the Southern Health and Social Services Board noted that, ‘To date, 89% of Year 8 pupils [have had] their weight recorded and this indicates that 11% of children weighed fell into the obese category and 1% in the underweight category’.[57]
Figure 2: Obesity prevalence trends in Northern Ireland from 1997/98 to 2004/05 for P1 pupils, with possible trajectories for 2005/06 to 2010/11[58]
34. In her review of the comparative analysis of anti-obesity policies in operation throughout the devolved regions, Musingarimi[59] highlights a number of points which currently undermine the comparative analysis of the prevalence rates across the UK. Firstly, she points to the fact that in the UK data on health (including overweight and obesity) are collected separately in the devolved regions and currently there is no single UK-level obesity surveillance survey undertaken. Musingarimi argues that the employment of different methods of data collection within the UK undermines the quality of data available ‘which inhibits any truly reliable comparison of obesity prevalence rates in the four countries’. For example, data for measuring levels of obesity and overweight in England and Scotland is collected using actual measurements of height and weight, whereas in Wales and Northern Ireland less reliable self-administered questionnaires are used. Secondly, Musingarimi concludes that there are ‘critical issues’ particularly in Wales and Northern Ireland relating to the availability of reliable and accurate data on the prevalence rates of obesity
Current Approach
35. The Department in its written submission explained the development of policy over recent years in relation to tackling obesity.[60] The Department referred to the publication of the Investing for Health Strategy in March 2002 which set out how the commitment of ‘working for a healthier people’ in the Programme for Government would be achieved.
36. The development of policy subsequently included the establishment by the Ministerial Group on Public Health of the Fit Futures Taskforce to examine options for preventing overweight and obesity in children and young people. Considerable consultation and engagement took place leading to the publication of the Fit Futures Report in 2006. Following completion of the report a Fit Futures Implementation Plan was developed and published for consultation in February 2007. However, shortly after publication of the draft Implementation Plan, which focused on children and young people, the Department altered its approach stating that it recognised the need to develop a whole population approach to tackling obesity.
37. The Northern Ireland Commissioner for Children and Young People pointed to the fact that, “to date no information is available on the Department of Health, Social Services and Public Safety (DHSSPS) website as to the status of the implementation plan… If these actions are fully implemented it will have a positive effect on the health and wellbeing of children, in particular the levels of child hood obesity."[61] The Department acknowledged that the Fit Futures Implementation Plan was not finalised and it sought to reassure the Committee that, “while this implementation report was not formally published by the Department, progress has been, and continues to be, made to deliver on its recommendations and actions at both the regional and local level."[62]
Targets
38. The Department pointed out that the Fit Futures Report “contained a joint target, between DHSSPS, the Department of Education (DE), and the Department of Culture, Arts and Leisure (DCAL), ‘to halt the rise in obesity in children by 2010’"[63]. The Committee also noted that the 2002 Investing for Health Strategy contained a target ‘to stop the increase in the levels of obesity in men and women so that by 2010 the proportion of men who are obese is less than 17%, and of women, less than 20%’.[64] This target will clearly not be achieved and it may be appropriate to question the determination to do so given that the emphasis until recently has been on efforts to reduce overweight and obesity in children. The Committee notes that a review of Investing for Health Strategy is currently underway.
Funding
39. The Department in its submission to the Inquiry stated that it had “allocated £832,000 to the implementation of Fit Futures in 08/09. In addition, a further £550,000 and £300,000 has been allocated for work around promoting physical activity and improving food and nutrition respectively." By comparison the Department noted that in Scotland an additional £40 million has been allocated over a three year period under the Comprehensive Spending Review 2007.[65]
40. The provision of specific funding to address obesity was not identified by respondents as a major issue at this juncture. The Committee recognises that, while it is clear that adequate resources to tackle the problem must be provided, it is difficult to identify the extent of existing resources devoted to the issue. The Committee noted, for example, that the Department was unable to provide the Northern Ireland Audit Office with any robust estimate of the overall health care costs of treating diabetes.[66]
Life Course Approach
41. The Department advised the Committee that as a result of the findings of the Foresight report it decided to develop a life course approach to preventing obesity. As part of this the Department established a cross-sectoral Obesity Prevention Steering Group in February 2008 “to oversee the progress against the Fit Futures recommendations, and lead the development of an overarching policy to prevent obesity across the life course". To support the work of the Obesity Prevention Steering Group four policy advisory sub-groups have been set up to deal with food and nutrition; physical activity; education, prevention and public information; and data and research.[67]
42. In its final evidence to the Committee on 18 June 2009 the Department gave further details of the plans and timescale for addressing obesity across the life course. Officials stressed that the 10-year strategic framework “will be outcome-focused and outcome-based. It will take a thematic approach to the life course." The planned timescale involves the development of the framework between October 2009 and January 2010 and, following public consultation, “we hope to launch the strategy by June 2010".[68]
43. The proposed strategy in Northern Ireland is based on the approach adopted in the English obesity strategy Healthy Weight, Healthy Lives launched in January 2008. The English strategy, which is the only population-wide strategy being implemented in the United Kingdom currently, was developed in response to the findings of the Foresight Report.[69] The strategy in England is being taken forward by a Cross-Government Obesity Unit led jointly by the Department of Health and the Department for Children, Schools and Families and reports to a new Cabinet Committee on Health and Well-being. Clara Swinson, Deputy Director of the Cross-Government Obesity Unit in the Department of Health, told the Committee that, “in England, about 60% of adults and 30% of children are overweight or obese. The Foresight expert review, launched in 2007, said that that figure would rise if nothing was done. The experts predicted various stages up until 2050, by which time the majority of adults would be obese and only 10% would be a healthy weight... our strategy is based on the areas that are identified in the Foresight report, which looks at both individual action and the wider environment because of the obesogenic and passive-obesity issues."[70]
44. A number of respondents expressed mixed views on the Department’s current approach. Sustrans stated that, “We believe that policy in Northern Ireland is moving the right way. Fit Futures is offering a vision of joined-up policy on physical activity... However, until recently, there has been little done to actually implement Fit Futures and despite good initiatives by the Health Promotion Agency and the Physical Activity Coordinators the most recent NI Physical Activity Strategy was back in 1998-2002. It is therefore welcome and of the utmost importance, that the DHSSPS is producing an Obesity Strategy for Northern Ireland".[71]
45. However, Belfast City Council argued “that despite the increased focus afforded by government, obesity is becoming more prevalent and the current strategy and target to ‘by March 2010, halt the rise in obesity’ does not yet appear to be delivering significant outcomes."[72] Iain Foster, Diabetes UK said, “Andrew Dougal [NI Chest Heart and Stroke Association] and I sit on the Department’s obesity prevention steering group, and although it is still early days for it, neither of us is overly excited or optimistic about it making one dot of a difference to most people’s lives."[73]
46. Ballymena Borough Council expressed concern that “there appears to be no cohesive strategy available at present for guidance for those with an interest in this issue… This strategy [Fit Futures] remains in draft format although many of the key priorities contained within it are being addressed by various organisations through their own agendas ... This lack of strategic direction has led to a very ‘piecemeal’ approach to the issue of obesity".[74] Banbridge District Council called for a Northern Ireland strategy to tackle adult obesity to be “drafted and implemented as soon as possible."[75]
47. Pauline Mulholland, British Dietetic Association, expressed concern that allied health professionals are not directly involved in the obesity prevention steering group arguing that they have an important role to play on the group. She also pointed out that, “the British Dietetic Association was not invited to sit on the food and nutrition subgroup, even though such matters are our core business" but she acknowledged that this has been rectified and there is now a dietician on the subgroup.[76]
48. In developing its strategy the Department of Health in England has as its ambition “to be the first major nation to reverse the rising tide of obesity and overweight in the population by ensuring that everybody is able to maintain a healthy weight".[77] DHSSPS has also adopted an optimistic approach telling the Committee that, “there are opportunities for Northern Ireland to take a leading role in this worldwide problem by developing and implementing a cross-cutting, comprehensive, long-term strategy that brings together multiple stakeholders. The Department through its development of an Obesity Prevention Strategic Framework is determined to take on this challenge."[78]
49. Obesity is the most serious and most challenging public health issue that we face at this time and it is also one of the most complex. There is therefore an urgent need to develop and implement a comprehensive and robust strategy to address the issue.
50. We share the deep concern of those who expressed regret that the Fit Futures Implementation Plan has not been formally signed off and implemented. The failure to do so has, we believe, created uncertainty and a potential hiatus until a full strategy is in place.
51. We welcome and support the plans by the Department to develop a life course strategy however we fully recognise that tackling obesity effectively is not solely a matter for the health service. We note that the Fit Futures Report contained a joint target with the Departments of Education and Culture, Arts and Leisure. We strongly recommend that the new life course strategy be developed jointly in partnership with other departments, particularly the Department of Education, as has happened in England.[79][100]
66. Dr Wilde, Institute of Public Health in Ireland, took a similar view saying “there are hundreds of small interventions in schools, communities, workplaces, and so forth. That must be set in a regional strategy so that there is some coherence between what happens across Northern Ireland and what happens locally."[101] Pauline Mulholland, British Dietetic Association, concurred saying, “The point is to combine the best examples of what has worked across the region and to roll them out in the mainstream. At the same time, we must consider what has been tried and tested and what fits with a particular local community, because all communities are different."[102]
67. The British Medical Association felt that it was a role for the Public Health Agency to “research what works and what does not work … many people have been working hard in health action zones, and so forth, in communities. … the best practices have not been spread throughout the Province."[103] The British Dietetic Association shared the view that, “the new Regional Agency for Public Health and Social Well-being provides the opportunity to evaluate such schemes across Northern Ireland and to decide which of them to commission to create the best outcomes for the public."[104]
68. This issue was also recognised by the Public Health Agency, as Dr Carolyn Harper told the Committee, “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."[105]
69. We found that there are numerous initiatives throughout Northern Ireland aimed at addressing or preventing obesity, which have been developed and implemented by a very wide range of bodies and agencies. However, lots of these initiatives have been developed in isolation and many have not been evaluated to assess their effectiveness. In addition there is no central data collection or inventory of projects and this undoubtedly leads to duplication of effort.
70. We recommend that the Department commission an urgent audit of existing obesity-related initiatives so that the need for evaluation or further research can be identified and examples of good practice can be rolled out more widely. We recommend that the Public Health Agency, perhaps in conjunction with the planned All-island Obesity Observatory, develops and maintains a central data base of projects and develops standardised evaluation tool kits.
Weight Management
71. A major element of our terms of reference is to look at the availability of weight management and other intervention services to treat people suffering from obesity related ill health. We have already seen that around 24% of the adult population are clinically obese and many of them have significant health problems directly related to their obesity. The Department stated that, “Obesity management is integral to the management of other conditions such as coronary heart disease, stroke, atrial fibrillation and diabetes."[106] Dr Michael Ryan, a consultant chemical pathologist who described himself as a ‘clinician in the front line’, told us that, “90% of the patients [he sees] for diabetes; about 80% who attend cardiac clinics; 70% who attend our gastrointestinal clinics, and about 60% who attend respiratory clinics have significant co-morbidity that is linked to weight and obesity."[107] The Obesity Management Association reminded the Committee that, “Overweight people will become obese, by which time the challenge to provide effective treatment has multiplied… Early medical intervention is essential rather than a last option".[108]
72. Dr Ryan went on to say that, “the difficulty is that there is no service for those patients. A large proportion of the population needs professional help."[109] He argued passionately in written and oral evidence to the Committee that, “the lack of a comprehensive, strategically planned service for the overweight and obese adult is a major shortcoming of the current healthcare system." He suggested that, “The current ‘system’ consists of a wide range of ‘interventions’ championed by enthusiastic and well meaning individuals but the lack of overall co-ordination renders many of the programs difficult to evaluate."[110]
Primary Care
73. The Department in its submission pointed to two elements of the 2004 General Medical Services Contract that provide incentives for GP practices to help improve the quality of care provided to patients with conditions related to obesity.[111] Under the Quality and Outcomes Framework (QOF) GPs receive additional funding based on achievement against a number of indicators. The Department advised that since April 2006 the establishment of a register of patients who have a Body Mass Index (BMI) of 30 or more has been included as a QOF indicator. The Department explained that the purpose of this was to encourage GPs to “provide interventions, that would, based upon the best available evidence and recommendations by the National Institute for Health and Clinical Excellence (NICE), reduce the prevalence and severity of conditions linked to obesity".[112] In addition the Department stated that it had provided an additional £800k from 2006 by way of a Directed Enhanced Service (DES) to enable GPs to develop a written protocol for patients with a BMI of 30 or more. Directed Enhanced Services are a series of more specialised services that GPs may choose to provide.
74. The Department reported that all GP practices in Northern Ireland have fully participated in these schemes. However, Abbott, a private global healthcare company, pointed out that points under the QOF scheme are only available for maintaining a register of patients with a BMI of 30 or over and not for providing advice to patients on weight management. Abbott argued that, “allocating QOF points to obesity management, as has happened with smoking cessation, would be an effective way of incentivising better weight management in primary care and improving patient outcomes".[113]
75. Dr Theo Nugent, British Medical Association NI, suggested that GPs are well placed to identify patients with weight management problems and to manage some of the associated health related illnesses but that they “are not terribly well placed to give people good advice on how to control their obesity". He explained that, “there is little problem when someone turns up with a fallout from his or her obesity, such as diabetes. There are services available to help them to deal with that. However, a colossal workload is required when an individual is referred with what the dietetic service term ‘simple obesity’… There is a limit to where we can send people before they develop problems, and it is difficult for GPs to see how they can motivate individuals or encourage self-motivation in families."[114]
76. The British Medical Association and a number of district councils referred to the Healthwise Scheme which is run by councils in conjunction with HSC Trusts and allows participating GPs, nutritionists, physiotherapists and specialist nurses to prescribe exercise to patients they think will benefit from supervised physical activity. However, it is not available in all areas. Katrina Morgan, NILGA, explained that Healthwise, which runs in a number of council areas, “is funded by the Eastern Health and Social Services Board and offers a free 12-week programme. Patients are referred to a leisure centre to participate in the programme, and that referral can be based on anything from weight or obesity problems to general health problems. The participants are evaluated at the end of the 12-week programme."[115] Teresa Ross, Chartered Society of Physiotherapy, gave further details saying, “the fitness instructor and the physiotherapist in a leisure centre work in partnership to assess the patient and set up an individual programme for them. The fitness instructor then takes control of the exercise programme."
77. Ms Ross suggested that this was “a positive way to progress and would allow the health system to target people who are at risk of ill health, as opposed to those who are actually ill. Therefore, it is important to develop the idea of prescribing exercise, and it should be rolled out."[116] Gerry Bleakney, Public Health Agency, confirmed that, “there is a scheme in the eastern area and part-schemes in the southern and northern areas." However, she suggested that “the evidence base to support it is questionable ... 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."[117] The Western Health and Social Care Trust advised that there are three successful GP exercise referral schemes running in the western area.[118]
78. Professor Eamonn McCartan, Sport NI, argued strongly that, “GP referrals can address some of the barriers that prevent people who are not particularly active, who are overweight and who have an issue with their body image from exercising… People need a pathway, encouragement, direction and mentoring. That can be done, particularly for those social groups that cannot see the benefits of physical activity and exercise."[119]
79. The Committee noted that an evidence-based Care Pathway for the management of overweight and obesity in primary care was published by the NHS in England in 2006. For adults, the priority of intervention in primary care is reducing risk factors for the patient “rather than to return them to an ‘ideal’ or healthy weight range".[120] This acknowledges the fact that small weight losses do produce health benefits, while more significant changes result after a loss of 5-10 per cent of body weight. The aim is also to prevent further weight gain in patients with lower degrees of overweight.
80. A good practice example of a Primary Care Specialist Obesity Service, established to treat people with morbid obesity within a primary care setting, is that established by Birmingham East and North PCT. The aim of the service is to provide more intensive specialist support, than would generally be possible in a primary care setting, from a multi-professional team.[121]
81. Dr Ryan suggested that we adopt the approach of the Counterweight programme used in Scotland. He explained that it “is primary-care based and provides specifically trained staff to deal with obesity. It is rigorously evaluated by the University of York and the University of Aberdeen. Counterweight has produced credible evidence of the cost-effectiveness of that type of programme."[122] Professor Iain Broom, Robert Gordon University in Aberdeen and Chairman of Counterweight, and a colleague Hazel Ross, took part in the Committee Research Event and elaborated on the Counterweight programme and confirmed that it “is the first large scale primary care weight management programme in the UK to show clinically effective weight reduction using a structured approach to care".[123]
82. We are concerned about the lack of clear direction for dealing with obesity in primary care settings in Northern Ireland. We are also concerned that initiatives such as the Healthwise Scheme, whereby supervised physical activity can be prescribed, are not available in all areas. We recommend that the Department, in conjunction with the Health and Social Care Board, develops a range of evidence-based referral options for use by primary care practitioners.
83. We urge the Minister to exert influence at a national level to introduce the allocation of Quality and Outcomes Framework (QOF) points for positive obesity management rather than simply for maintaining a register of obese patients.
Secondary Care
84. The Department told us that, “Patients with significant weight management/obesity issues which may be directly or indirectly linked to their condition are seen and treated in almost every service within secondary care… Historically it has been the presenting condition that is treated and managed, although obesity issues may be one of a number of contributing factors in the development of the disease/condition."[124]
85. Dr Ryan argued that this was still the case saying that, “Current clinical services, designed to address specific clinical conditions, such as diabetes, cannot adequately address the special needs of the obese patient. Clinical services are becoming effectively ‘silted up’ with patients whose primary cause for attendance is ‘overshadowed’ by the co-morbidity of excess weight. Addressing the obesity can be more beneficial, in terms of health gain for the patient, than dealing with the ‘primary’ cause of attendance."[125] The Department did acknowledge that, “specialist supporting dietetic services need to be further developed to meet current and anticipated future demands. There will need to be additional staff, primarily dieticians and nurses, and training/specialist knowledge enhanced in secondary care."[126]
86. Pauline Mulholland, British Dietetic Association, stressed the key role undertaken by dieticians in the management of clinical obesity and said that, “People aspire to lose a significant amount of weight over a short period, and sometimes that puts them off accessing our services. We need to manage such expectations and promote the message that if individuals can be encouraged to lose 10% of their weight and to maintain that weight loss, they can achieve significant health benefits. The evidence shows that a 10% weight loss will reduce blood pressure and cholesterol, improve the control of blood sugar for people with diabetes, and reduce the death rates for a number of conditions."[127]
87. Dr Ryan argued for the use of a managed clinical network model of services delivery saying that, “it is now well established and has been shown to be an effective means of delivering targeted services for specific reasons. The approach to weight management at all levels of intervention should be supported by the managed clinical network. Much of the cost of such a programme is already embedded in the system".[128]
88. The need for effective interventions for children was also highlighted to the Committee. Currently one in four children in Northern Ireland is either overweight or obese and Dr Wilde, Institute of Public Health in Ireland, pointed out that, “The evidence shows that most children who are overweight or obese carry that through the rest of their lives."[129] Dr Mark Rollins, consultant paediatrician, argued that, “there are 400,000 children in Northern Ireland, 100,000 of whom are currently overweigh and obese. Some 60% to 70% of children are going to be obese as adults. That is a fact… In Northern Ireland, we have no intervention programmes at all. We are starting from a complete base."[130]
89. At the Committee Research Event Professor Paul Gately, Professor of Exercise and Obesity at Leeds Metropolitan University, spoke about an academic unit called Carnegie Weight Management that he leads. He highlighted a major concern that while “there are 4.5 million children in the UK who are overweight or obese… 70% of parents identify their overweight child as having normal weight".[131] Carnegie Weight Management provides family based multi-disciplinary intervention programmes at a range of levels from after-school activities to a residential camp for severely obese children. The Committee noted ongoing discussion between Carnegie and clinicians in the Northern Health and Social Care Trust and welcomed plans by Helping Hand Ltd to develop five pilot intervention programmes based on Carnegie for post primary children throughout Northern Ireland.[132]
90. The former Southern Health and Social Services Board stated that, “People who are obese are initially provided with advice through primary care services. They can access specialist drug treatments and dietetics advice through this route. NI has high rates of prescriptions of drug treatments for obesity. There is little evidence that attendance at specialist secondary care obesity clinics is more effective in achieving weight loss than interventions in primary care. However, such clinics may have a role in assessing patients who may be eligible for surgical intervention. As NI does not have a surgical treatment programme, there is no specialist obesity clinic in NI at present."[133]
91. The former Western Health and Social Services Board took a different approach arguing that, “while many patients can be managed in a community obesity clinic setting, there is a need for investment in specialist services in secondary care. We acknowledge that physicians in diabetes and endocrinology are appropriate specialists to manage such a service. However, they are already overwhelmed by the demand, as the diabetes epidemic has put additional pressure on the services that they are facing."[134]
Bariatric Services
92. The needs of very severely obese patients often require special services. Tracey Gibbs, College of Occupational Therapists, explained that, “On a day-to-day basis, that has major implications for transporting patients in hospital beds, the use of hoists and porters’ chairs, and for the use of seating in hospitals and in the patient’s home." However, she cautioned that “Although there is a lot of emphasis on the global epidemic of obesity, it is also important to consider the needs of the obese person. It must be ensured that they are treated with respect and dignity and that stigma and discrimination are avoided. A person who is overweight may feel socially isolated or excluded."[135]
93. In the course of the Inquiry the Committee learned, for example, that the NI Fire and Rescue Service had been called out on 40 occasions over the past five years to deal with bariatric incidents at a total cost to the Fire and Rescue Service of £85,000. These were mainly calls to assist ambulance personnel or other health services staff to deal with severely obese patients.[136]
94. Bariatric surgery has increasingly been used as a method of treating severely obese patients when other approaches fail and research suggests that this type of surgery has increased “more than five-fold within 5 years in most developed countries".[137] Bariatric procedures can be divided into those that reduce food intake (gastric restrictions) and those that reduce food uptake from the digestive tract (malabsorption).
95. Guidance from the National Institute for Health and Clinical Excellence (NICE) in 2008 recommended that bariatric surgery to aid weight loss should be available to patients meeting certain body mass index (BMI) criteria. The former Southern Health and Social Services Board told us that, “It is estimated that there are more than 50,000 people in NI who could be eligible for bariatric surgery using NICE criteria. This number is expected to rise at a further 5% each year. Although NICE estimate that only 2-4% of these people would come forward for surgery, this is by no means certain. The cost of treating only 2% of the eligible NI population (i.e. 1,000 patients) and providing the necessary long-term follow-up could be in the order of £10 - £15 million."[138] The Board also explained that “a multidisciplinary team assessment is necessary to ensure patient suitability for surgery and the long-term lifestyle changes it requires. In addition, surgeons need to be able to offer a full range of techniques, including laparoscopic surgery, and undertake a minimum volume of procedures to achieve and maintain skills. Appropriate follow up services, including the input of dieticians and specialist physicians, need to be in place. At present not all of these skills are available within NI… In light of the potential numbers of patients in NI who would meet NICE criteria, the current funding position, and the financial consequences of providing treatment for all those who might present, it has been agreed by Boards that, within the current CSR period, bariatric surgery cannot be commissioned routinely for patients meeting the NICE-recommended BMI criteria."[139]
96. The former Western Health and Social Service Board agreed saying that, “There is a lack of funding around bariatric services for patients in Northern Ireland who have persistent obesity when lifestyle and other drugs fail. Bariatric surgery has been shown to reverse diabetes and reduce mortality and there is an issue about equity to services which are available in other parts of the UK."[140]
97. David Galloway, DHSSPS, told us that, while bariatric surgery is not currently commissioned by the health boards in Northern Ireland, “last year, £1·5 million was made available to ensure that some 120 people had access to bariatric surgery from providers in Great Britain. The boards are currently discussing how they might progress that issue in 2009-2010 to ensure that that service is provided to the people who are most likely to benefit from it."[141] The Department subsequently advised that approximately 80 patients had bariatric surgery outside Northern Ireland in 2008/09 and that “for 2009/10 the legacy Health Boards agreed to fund short term bariatric services pilot with a budget of £1.5m and a target of providing treatment in England during the year for between 100 and 150 patients. The Department has no plans at this time to provide this surgery in Northern Ireland."[142]
98. Elsewhere in this report we deal with the need for a strategic approach to the prevention of obesity. However, we are gravely concerned about the extent of existing obesity-related ill health and the distinct absence of appropriate services at all levels. We are shocked to learn of the number of severely obese patients that attend diabetic and other clinics and particularly by the realisation that more than 50,000 people in Northern Ireland may be eligible for bariatric surgery.
99. We highlight the fact that even a modest reduction in weight can have a significant impact on a patient’s health and that addressing obesity may be more beneficial than dealing with the resulting illness.
100. We call on the Minister, as a matter of urgency, to undertake a thorough review of weight management services at all levels for both adults and children. The review must address the need for dedicated obesity clinics and the critical and urgent need for a separate bariatric service for Northern Ireland, including the provision of bariatric surgery and the lifelong medical follow-up for individuals required following such surgery. The review should also consider the merits of adopting examples of good practice from elsewhere, such as the Counterweight programme in Scotland and the Carnegie Weight Management programme in England.
Diet And Exercise
101. While the rapid increase in obesity over recent decades has not simply been down to an imbalance between diet and exercise it is clear that these two issues need to be addressed from a range of perspectives. As Newry and Mourne District Council pointed out “poor dietary habits and decreasing physical activity have become ingrained in the population and it will take a long-term approach involving many organisations to make any substantial changes in this culture".[143] In this chapter we look at what is being done to address these issues and to encourage the adoption of healthier lifestyles.
Healthy Eating
102. A major contributory factor behind the rising levels of overweight and obesity in Northern Ireland is that people are consuming food and drink products that contain high levels of saturated fat, sugar and salt. Dr Jane Wilde, Institute of Public Health in Ireland, said it was important to examine what the food sector might reasonably be expected to do about addressing obesity and suggested “if we let the situation continue as it is, without some greater checks on what is happening to the food sector, we will do a grave disservice to people in Northern Ireland. There is a requirement on the food sector to act responsibly within a certain timescale. It is important to go beyond a voluntary approach by the food sector… we are talking about issues such as food labelling, pricing, availability, subsidies, local production, and so forth. That is a crucial issue."[144]
103. The Food Standards Agency Northern Ireland is the body charged with responsibility to ensure that all food is safe to eat and has as its vision ‘healthy eating for all’. The Agency is closely involved in the Obesity Prevention Steering Group and leads the Food and Nutrition subgroup. The Agency was keen to point out that “healthy eating is all about balance". Its three key work strands are, “Firstly, influencing food products to ensure that healthier options are made available to people so that they can make their own choices; secondly, influencing people so that they are aware that the healthy choice is the easier choice; and thirdly, influencing the environment, particularly the food environment, so that some of the barriers to making healthy choices are removed."[145]
104. One of the Agency’s dietary heath targets is to reduce the population’s intake of salt and saturated fat. Andrea Marnoch, Food Standards Agency Northern Ireland, explained that, “We know that on average, people eat far more saturated fat than is recommended, and rising levels of obesity suggest that energy intakes exceed energy requirements. Following the success of the FSA’s work on salt reduction, the agency developed a programme of initiatives to try to reduce the level of saturated fat from its current level of 13·3% of energy intake to the recommended level of 11%."[146] Michael Bell, Northern Ireland Food and Drink Association, agreed that there is a need for balance and claimed that “Correcting the ingredients of the members of the association’s products is like squeezing a balloon. If the balloon is constricted so that, in the retail channel, one can buy only products that are low in sugar, fat, salt and, therefore, somewhat bland, people will eat more carry-outs or make alternative meals at home, adding more salt."[147]
105. The Food Standards Agency Northern Ireland advised that it “has identified the key food groups that contribute to levels of saturated fat and added sugar intakes, and it is working with the food industry on reductions in those food groups. The focus for that work is dairy products, meat and meat products, biscuits, cakes and pastry, snacks, confectionery, soft drinks and retail sectors."[148] Maria Jennings, Food Standards Agency Northern Ireland, explained that, “the issue is to drive down the overall amount of saturated fat that people are eating and to increase the levels of polyunsatured fats that they consume."[149]
106. The Committee recognises that much of the work with food manufacturers and major food retailers takes place at a UK level but the importance of action at a local level cannot be ignored. Clara Swinson, Department of Health in England, explained that, “We are looking to increase the information that is available to consumers through, for instance, nutritional labelling on products in supermarkets and stores, and labelling in non-retail settings such as fast-food restaurants."[150]
107. At an individual level, Dr Michelle McKinley, Queens University Belfast, suggested that, “More work must be done to find out what exactly are the best dietary approaches to offer to people who are trying to lose weight and to find dietary approaches that will not have any detrimental effects on the health of that person in the longer term. More research must be done, but the low-fat, high-fibre approach is still the standard weight-loss diet that is recommended and supported by health professionals."[151]
108. We welcome and encourage the ongoing work of the Food Standards Agency Northern Ireland to reduce the levels of saturated fat, salt and sugar in food. This has made significant progress to date but we believe that much more needs to be done. We urge the Department and the Food Standards Agency to continue to work with manufacturers and to exert pressure at a national and European level to introduce regulatory controls on the levels of salt and saturated fat in manufactured foods.
Food Labelling
109. Many respondents referred to the need for improved food labelling. Victoria Taylor, British Heart Foundation, argued that there needed to be “a single system of front-of-pack food labelling that is clear and that people will understand."[152] Andrew Dougal, NI Chest Heart and Stroke Association, supported this call saying, “Government should act now to empower people to make sensible choices. They will not be able to do so unless there is effective, simplified and comprehensible nutritional labelling on the front of the pack — it should not be written in tiny figures on the side panel, making it difficult for some people to read."[153]
110. Maria Jennings, Food Standards Agency Northern Ireland, explained that, “The agency has been working for a long time to provide a simple signpost on the front of food packaging that will let consumers know exactly what is in a pack… After extensive consumer research, the agency produced a simple scheme that is based on traffic lights — red, amber and green — for the four main nutrients, that is, fat, saturated fat, salt and sugar. A number of retailers and manufacturers, including several in Northern Ireland, have adopted the agency’s scheme. During the same period, a number of similar schemes appeared. Consumer and health groups started to ask for one simple and easily understood scheme that could be applied to all foods."[154] The Agency advised that an alternative front of pack labelling approach based on Guideline Daily Amount information, known as GDA Scheme but without use of traffic light colours, has been adopted by some retailers and manufacturers.[155]
111. Commenting on the Guideline Daily Amount scheme Andrew Dougal, NI Chest Heart and Stroke Association said that, “I am not innumerate, but I find it difficult to understand them. I find the traffic light system to be very positive, as is using the terms “low", “medium" and “high" to describe the various contents of food. Sixteen major companies have deviated from the traffic-light system recommended by the Food Standards Agency before it had the opportunity to launch that campaign. That has caused huge public confusion… We would like to see all companies sticking to one simple system that people understand."[156] Michael Bell, NI Food and Drink Association said that, “Our members are increasingly engaged in providing nutritional labelling on packaging. Virtually all our members’ products at the retail channel display either the Food Standards Agency (FSA) traffic-light system or the guideline daily amount (GDA) system. To date, that is less developed at the food service channel."[157]
112. Ms Jennings also referred to an independent survey of food labelling commissioned by the Department and the Agency which published its report in May 2009. She said that, “Not surprisingly to us, the study found that a single, consistent front-of-pack labelling scheme would be most helpful to consumers. Overall, the evidence shows that the strongest label is that which combines the words “high", “medium" and “low" with the traffic light colours red, amber and green, and with the percentage guideline daily amounts (GDA), with levels of nutrients expressed as a portion of the product."[158] Ms Jennings advised that the findings of the survey will be considered and there would be consultation on the next steps.
113. Dr McKinley, Queens University Belfast, explained that measures like food labelling “have been designed to help the consumer to make healthier choices, and research now focuses on whether those strategies are helping the consumer effectively or whether other approaches should be considered."[159] The Food Standards Agency Northern Ireland pointed out that, “evidence from adopters indicates high levels of consumer approval for this approach, shifts in sales towards healthier products and that the traffic light approach provides a powerful incentive to companies to reformulate their products to reduce levels of the nutrients highlighted on FoP [Front of Pack]".[160]
114. We believe that clear and simple food labelling is essential to enable consumers to make healthy choices. We fully support the calls for a single, consistent Food Labelling scheme using the traffic light system and urge the Minister and the Food Standard Agency Northern Ireland to consider whether such a system could be made mandatory on all food retail products. We also call for more action to enforce a similar clear and simple nutrition labelling system at non-retail outlets, such as restaurants and catering establishments.
Food Portion Sizes
115. The Department in its submission acknowledged that increased food portion sizes is one of a number of factors put forward in hypotheses to explain the general increasing intake of energy. This hypothesis is supported by research undertaken by the Centre for Food and Health at the University of Ulster and presented to the Committee at the Research Event. The research found that ‘increased food portion sizes resulted in significant and sustained increases in food intake in both men and women’ and that ‘the ready availability and consumption of large food portions (particularly of energy dense foods) may be a major factor in contributing to the obesity epidemic’.[161]
116. It is also an issue recognised by others including the Public Health Agency. Dr Carolyn Harper told the Committee that, “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."[162]
117. The Food Standards Agency Northern Ireland told us that it “is working with the food industry to identify opportunities to reduce the size of single serve portions, for example of soft drinks and sweet and savoury snacks. It is also considering how best to provide consumer advice on appropriate portion size. An academic workshop has concluded that the evidence base on portion size and weight gain justifies these actions. Re-alignment of in-store promotions which could encourage increased consumption of energy dense, salty foods to promotion of healthier foods also has a part to play."[163]
118. Larger food portion sizes are undoubtedly contributing to increasing obesity prevalence and this issue must be addressed seriously. While recognising the difficulty in regulating food portion sizes in catering and similar settings, we urge the Department and the Food Standards Agency Northern Ireland to examine how issues like food promotion and pricing impact on portion sizes and how they might be influenced.
Mixed Messages
119. Some respondents to the Inquiry referred to the campaign which promotes eating five portions of fruit and vegetables a day to stay healthy. The Committee recognised that while this campaign has been ongoing for a number of years there is still confusion over what it means in practice and how people can fulfil their five a day target. Mrs Marnoch, Food Standards Agency Northern Ireland, explained that, “according to the World Health Organisation, one should eat at least five portions of fruit or vegetables a day. Therefore it is recommended that you eat more than five."[164] Dr Eddie Rooney, Public Health Agency, acknowledged the confusion and said that, “The five-a-day message has been around for quite some time, but we need to do some more work on public awareness."[165]
120. We believe there is confusion over what exactly constitutes ‘five portions of fruit and vegetables a day’ and particularly around the size and content of a portion. We urge the Public Health Agency to examine how greater clarity and understanding about this health message, and how it might impact on levels of obesity, can be achieved.
Exercise
121. A number of respondents referred to fundamental changes in our lifestyles over recent decades and suggested that through undertaking less manual work, the introduction of machines, changes in methods of transport, and by our children undertaking less active play and spending long hours on computer games, that we have moved from being an active society to a sedentary society. The Northern Ireland Commissioner for Children and Young People claimed that children “cannot find safe, affordable, accessible and age appropriate play and leisure activities. This is having a profound impact on the ability of children and young people to stay active and healthy."[166] John News, Sport NI, pointed out that, “It is a startling figure that 70% of us are not physically active enough… more than 2,000 people in Northern Ireland will die this year as a result of physical inactivity."[167]
122. The World Health Organisation defines physical activity as ‘all movements in everyday life, including work, recreation, exercise and sporting activities’.[168] Sport NI pointed to the value of sport and physical activity as a means of ensuring that people have a better physical and emotional quality of life. Sustrans highlighted the focus on promoting walking and cycling as a beneficial physical activity in the NICE Guidance[169] but expressed concerns about the regular policy references to sport. Sustrans argued that, “it is most important that policy makers recognise sport as only a minority slice in the pie of physical activity, and not the most likely to appeal to currently inactive and/or overweight individuals."[170] Sport NI was keen to point out that, “there is a traditional framework for sport as it is seen on television, but sport is a much more expansive and expanded sector than simply competitive sport … there are various forms of physical activity".[171]
123. Sustrans pointed out that, “historic approaches to the promotion of physical activity have often sought to promote ‘exercise’, ‘fitness’ and ‘sport’ … these are not likely to be appealing to most inactive or overweight individuals. As the Chief Medical Officer for England has put it, ‘for most people, the easiest and most acceptable forms of physical activity are those that can be incorporated into everyday life. Examples include walking or cycling instead of travelling by car’."[172]
124. The Department of Culture, Arts and Leisure advised that, “Over the past 2-3 years DCAL, in partnership with SNI [Sport NI], has been developing a new 10 year Strategy for Sport and Physical Recreation in Northern Ireland. The aim is to provide a high level template for the development of sport and physical recreation in Northern Ireland which reflects the aspirations and priorities of all sports stakeholders. The new Strategy is also expected to inform the direction of future investment."[173] DCAL also provided details of a three month consultation in 2007/08 and pointed out that “the draft estimated at the time that the funding the shortfall facing stakeholders to fully deliver all targets at c.£20m per annum over 10 years". DCAL went on to explain “Following completion of the consultation exercise in January 2008, a final version of the Strategy for Sport and Physical Recreation was submitted to the Northern Ireland Executive in December 2008 for consideration at a future meeting."[174]
125. The Northern Ireland Commissioner for Children and Young People acknowledged that the strategy “is comprehensive and if implemented in full would provide increased opportunities for children and young people to participate in quality sport and physical recreation across a range of settings but mainly through schools and community based activities." However, the Commissioner expressed serious concern that, “the draft strategy was subject to consultation in late 2007 and to date it has not been finalised nor has it been implemented. DCAL must allocate appropriate funding to the all actions to ensure the full strategy can be implemented in full."[175]
126. Sport NI praised the strategy saying that it “will have a significant effect in increasing participation in sport and in increasing the physical activity of our young people, although not only of our young people. Properly resourced and implemented, it will go some way to addressing obesity levels." However, Sport NI would not be drawn on the reasons for the delay in finalising the strategy saying, “Responsibility for publishing the strategy lies with others, not with us."[176]
127. Other Departments sought to assure the Committee of their commitment to promote exercise. The Department for Employment and Learning pointed out that it “is an active member of the NI Physical Activity Implementation Group. This Group is taking forward the recommendations in the NI Physical Activity Strategy which aims to increase levels of health related physical activity particularly among those who exercise least."[177] The Department for Regional Development pointed out that it “has developed strategies over recent years and put operational initiatives in place to encourage a change in travel behaviour, away from the use of the private car towards more sustainable and healthier means of travel, such as walking and cycling".[178] [See also paragraph 132 below]
128. We welcome the development of the draft 10 year Strategy for Sport and Physical Recreation in Northern Ireland by the Department for Culture, Arts and Leisure. However, we have major concerns about the ongoing delay in finalising and implementing this strategy. We believe the strategy has the potential to contribute significantly to increasing levels of physical activity and counteract growing obesity prevalence. We therefore call on the Executive to ensure that the Strategy for Sport and Physical Recreation in Northern Ireland is properly resourced and implemented without further delay and that this work dovetails with the development of the life course obesity strategy.
Role of other Departments,
Bodies and Sectors
129. There was a clear recognition among respondents that tackling obesity is beyond the capacity of the health service alone. The Northern Ireland Commissioner for Children and Young people summed it up saying “While the Department for HSSPS must take a lead in implementing measures to tackle childhood obesity, other departments have an important role in implementing other strategies and policies that have an impact on the ability of children and young people to lead healthy and active lifestyles."[179] All Government departments were invited to make a submission to the Inquiry. Most departments responded highlighting the work they are undertaking in the battle against obesity particularly through actions related to the Fit Futures Strategy for children. Three Departments, the Office of the First and Deputy First Minister, the Department of the Environment, and the Department of Enterprise, Trade and Investment, indicated that they had no comments on the Inquiry.
130. The Department for Employment and Learning (DEL) assured the Committee that it “is committed fully to the aims and objectives of Fit Futures, the Investing for Health Strategy, and the NI Physical Activity Strategy, all of which focus on the importance of tackling obesity". DEL also highlighted its role in working with further and higher education bodies and in sector skills development.[180] The Department for Culture, Arts and Leisure explained the work it has been doing over the past 2-3 years, in partnership with Sport NI and other stakeholders, to develop a new 10 year Strategy for Sport and Physical Recreation in Northern Ireland (see paragraphs 124-126 above).[181] The Minister for Finance and Personnel stated that he was “supportive of the strategy of prevention not only because it can reduce treatment costs but also because of the wider economic and societal benefits." He added, “Nevertheless, I would stress that any funding required to implement future recommendations from the Inquiry will need to be secured from the existing departmental budgets."[182]
131. The Minister for Agriculture and Rural Development pointed to a strategy in preparation by the Forest Service to develop the recreational and social use of its forests and suggested that, “the draft strategy … recognises a number of opportunities relating to health and well-being that are relevant to the obesity inquiry". The Minister also suggested that “promoting the consumption of natural farm products, including milk, could form part of a wider drive to encourage healthier diets".[183]
132. The Department for Regional Development explained that it “has developed strategies over recent years and put operational initiatives in place to encourage a change in travel behaviour, away from the use of the private car towards more sustainable and healthier means of travel, such as walking and cycling." DRD pointed out that the Regional Development Strategy in 2001 “recognised the importance of the need to change the local travel culture and at the same time contribute to more active and healthier lifestyles. In particular, the Strategy recognised the need to revive the healthy habits of walking and cycling, for short journeys, by people of all ages". DRD also highlighted the potential positive impact of the Regional Transportation Strategy, the Cycling Strategy, the Walking Strategy, and the Travelwise Safer Routes to Schools Initiative.[184]
133. The Department for Social Development pointed to “an overall programme focus on healthy lifestyles, healthy eating and weight management" supported under the Department’s Neighbourhood Renewal Strategy. DSD also advised about the introduction of a specific new medical code for obesity in October 2008 which has enabled the department to record that “from that date there are 52 Disability Living Allowance (DLA) claims and 64 Incapacity Benefit (IB) claims where obesity is recorded as their main disabling condition".[185]
134. Northern Ireland Environment Link (NIEL) pointed to the links between poverty, poor diet and obesity and argued that, “the department with responsibility for targeting social need and the anti-poverty strategy therefore needs to be fully involved in the development and implementation of plans and programmes designed to tackle obesity issues."[186] We note and welcome the recent Inquiry into Child Poverty by the Committee for the Office of the First and deputy First Minister.[187]
135. We urge each and every Department to recognise that they have a crucial role to play in responding to the obesity epidemic either through direct action or through policies and practices that impact on the obesogenic enviroment.
136. The Department of Education (DE) in its submission recognised the vital role that education has in equipping children and young people for life and that, “the education system in general has always been to the forefront in encouraging healthy lifestyles and providing children and young people with the foundations on which to build for active and healthy lives in the future".[188] In evidence to the Committee officials from the Department of Education explained the development of a rolling programme to implement new nutritional standards in schools between 2005 and 2007 and referred to the provision of “an additional £3 million to support the increase in quality of schools meals". Officials also explained that the Educational and Training Inspectorate now looks at how schools are performing in this area and said that “the results have largely been very positive in the first tranche of schools to have been inspected".
137. DE also recognised that, “competing sources of food in schools were reducing the impact of the new nutritional standards" referring to “other food that is provided in schools through vending machines, tuck shops, break-time snacks and drinks, breakfast clubs and food brought into schools in packed lunches and snacks". As a result the Department has developed a ‘whole school approach to nutrition’ and officials advised that consultation on that policy is due to start in September 2009. [189] Alan McMullan, DE, told the Committee that, “the food in schools policy will bring forward proposals for legislation that will affect other food in schools and give us the power to totally ban things".[190]
138. The Committee noted the CATCH program (Coordinated Approach to Child Health), which operates in over 7,000 schools in the USA and has been evaluated in over 80 peer reviewed publications. It brings together schools, families and communities to teach children how to be healthy for their lifetime. Healthy behaviours are reinforced through a coordinated approach in the classroom, in the cafeteria, in physical education and at home.[191]
139. In relation to physical activity in schools Louise Warde Hunter, DE, pointed out that, “PE is a separate area of learning in the curriculum, which is compulsory across all key stages. At least two hours of PE per week is recommended, but how schools take that recommendation onboard may vary". When asked about how this target is monitored and whether there is any way to enforce the minimum of two hours of PE each week, Ms Hunter acknowledged that data on this is not gathered by the Department and said “Our position is that these are guidelines, and an inspection could ask how those guidelines are being followed and whether it is appearing in the school development plan." Jill Fitzgerald, DE, explained that “The scenario here is different to that in England where two hours of PE a week has been made compulsory. We are in a scenario where no subject is compulsory for any given time. Therefore, although a subject is compulsory in the curriculum — as PE is — the Department is not in a position to say how much time it should be allotted. To do it for PE would make it different from all other subjects and constrain schools in their teaching of the curriculum."[192]
140. Apart from the Health Department, we believe that the Department of Education has probably the most pivotal role to play in tackling obesity. This view is reflected in our recommendation (see paragraph 51) that the development and implementation of the Life Course Approach should be undertaken jointly by these two Departments.
141. We welcome and support the work that is taking place to develop and implement high nutritional standards in all schools and we encourage the Department of Education to explore whether any lessons can be learned from the CATCH (Coordinated Approach to Child Health) programme in the United States.
142. We are greatly concerned that the two hours PE per week in schools is not compulsory, as is the case in England. We are also concerned that data indicating whether schools are adhering to this recommendation is currently not being collected. We call on the Department of Education to make at least 2 hours of PE in schools compulsory and subject to regular monitoring by the Educational and Training Inspectorate.
Role of Local Authorities
143. Karen Smyth, NILGA, told the Committee that, “Local government is particularly well placed to tackle regional issues such as obesity at local level and to initiate projects that make a real difference to local communities".[193] Many District Councils highlighted specific initiatives they currently undertake to tackle obesity in their areas. NILGA, at the request of the Committee, undertook a survey of all district councils and 14 responded. Details are at Appendix 3, Page 482.
144. In addition a number of respondents pointed to the potential for district councils to increase and enhance their efforts to tackle issues like obesity under the new structures arising from the current Review of Public Administration. Specifically, a number saw the introduction of community planning in 2011 as providing “opportunities for Councils to come together with other organisations to undertake the sort of work, which can make a difference on this issue"[194]. Belfast City Council referred to opportunities arising from the reorganisation of health and social care structures arguing that they will mean “a greater role for local government through participation in the new Regional Agency for Public Health and Social Wellbeing and in local commissioning".[195] Sport NI agreed that, “a central tenet of the review [of public administration] is community planning" and suggested that, “Sport Northern Ireland can take the lead role in the development of a physical activity strategy in partnership with the district councils and their agents. In that way, we can establish the major objectives, key performance indicators and a level of accountability as has been experienced in Scotland."[196]
145. Ballymena Borough Council argued that, “Interventions based on improved nutrition and increased physical activity can be effective for some individuals, but tackling the obesity problem for the total population will require interventions that target the environment as well, for example food policy and marketing and the transport infrastructure… the ideal forum for addressing such wide-ranging topics would be through the process of community planning and the associated power of well-being, roles to be assigned to the new Councils through the current RPA."[197]
146. Teresa Ross, Chartered Society of Physiotherapy, was positive about the opportunities saying, “the new agencies provide a positive forum for us to build upon. Their involvement in local communities will be a good influence, and the involvement of local council representatives will help to build a better future."[198] Rob Phipps, DHSSPS, also supported the importance of community planning saying that it “will give a role to the agencies and the local councils. Local councils will be important, and leisure centres, in particular, will have a crucial role to play."[199]
147. We fully recognise and endorse the crucial role local councils currently play in tackling obesity. We welcome the commitment by councils to expand and enhance their role further when the new community planning proposals come into effect. We urge the full involvement of councils in developing the new life course strategy.
Role of the Media
148. There is a general recognition that “the power of advertising is massive, particularly on young people"[200] and that “the media has a role to play in encouraging improvements in children’s diet and exercise".[201] The British Heart Foundation argued that, “children need to be protected from aggressive marketing of foods high in fat, saturated fat, salt and sugar" and it called “for a ban on such advertisements on television before 9 pm."[202] The British Medical Association also called for “the banning of advertising and marketing to children of unhealthy foods."[203] Diabetes UK called for “Increased pressure/partnership with the food industry in relation to food production, labelling and advertising".[204]
149. Ofcom, the media watchdog, explained that research had found that, “advertising (amongst other factors) had a modest, direct effect on children’s food choices and a larger but unquantifiable indirect effect on children’s food preferences, consumption and behaviour." Ofcom also explained that it had introduced a range of measures between February 2007 and January 2009 which restricted the scheduling of television advertising of food and drink products that are high in fat, salt or sugar in or around programmes aimed at children on the main commercial channels and on children’s channels. In a subsequent review in December 2008 Ofcom found that as a result “overall children saw 29% less HFSS (food high in fat or salt or sugar) advertising between 18.00 and 21.00." and it “estimated that the advertising restrictions, once fully implemented, would reduce child HFSS impacts (the number of times an HFSS advert is seen by a child aged 4-15) by some 41% of the 2005 level".[205]
150. The British Heart Foundation expressed concern that despite the Ofcom restrictions “millions of children are still exposed to such adverts during pre-watershed family programmes such as the X Factor or Coronation Street" and it called on the Assembly to “adopt a position of favouring a mandatory ban on pre watershed advertising of HFSS foods to children on television, and strict regulation of non-broadcast marketing methods".[206]
151. There were concerns expressed by some respondents that a negative message in advertising simply turns people off. Michael Bell, Northern Ireland Food and Drink Association, argued that, “some of the approaches that have been taken involve trying to win over the public by negative rather than positive messaging. The FSA used images of sick bags and slugs to try to change consumer behaviour at various points in the food industry. That imagery turns people off instead of encouraging them to carry the message forward."[207] The Obesity Management Association also argued that, “advertising by the Government puts the accent on obesity and becoming ill, however advertising that if you become slim, you become fit and happy tends to work better – especially with children."[208]
152. The power of advertising and the media as both a positive and a negative influence in relation to obesity cannot be over emphasised. It is clear that the advertising of food and drink products that are high in fat, salt or sugar have a significant impact particularly on young people. We urge the Minister to work with colleagues throughout the UK to explore the feasibility of banning the advertising of food and drink products that are high in fat, salt or sugar before the 9 pm watershed.
153. We support the approach of promoting healthy eating and exercise through positive advertising rather than negative messages. We call on the Minister to develop a comprehensive media approach as part of the life course strategy and to consider, for example, how new and emerging media such as text and Twitter could be used to engage with young people.
Obesogenic Environment
154. Several respondents, including the former Northern Health and Social Services Board and the Northern Ireland Cycling Forum, were keen to remind the Committee that the causes of the obesity epidemic are complex and that leading authorities, such as the World Health Organisation and the authors of the Foresight Report, had highlighted “the need to tackle the obesogenic environment in which a range of factors in our physical, socio-economic and cultural environment act to promote calorie intake and discourage physical activity."[209] The Department also pointed out that, “Increasingly it has been acknowledged that the causes of obesity are associated with a wide range of inter-related factors, from the physical, socio-economic and cultural environment, which act to promote calorie intake and discourage physical activity. These factors are referred to collectively as the ‘obesogenic’ environment."[210]
155. In relation to physical activity, Sustrans argued that, “the key factor, but one which is unfortunately sometimes overlooked in discussion of policy and interventions on active living, is that the environment is the central determinant in people’s individual choices. Over recent decades we have allowed the environment within which we live to become dissuasive of physical activity … In order to raise physical activity levels, we need to make the environment more conducive to active living, and this includes transforming the streets to be more walking and cycling friendly."[211] Sustrans also referred to a paper it had co-authored in 2003 which had proposed that, “modification of social, economic, and environmental factors may yield greater health dividends than individual lifestyle approaches. Indeed such interventions may be necessary before individual lifestyle approaches can be effective."[212]
156. Food environments include availability and accessibility to food and food advertising and marketing. It is recognised that the food environment and the built environment are closely related and the Foresight Report concluded that further work is required “to examine how aspects of the built environment or building design influences people’s food habits e.g. the proximity of shops to schools or the location of vending machines".[213]
157. DHSSPS acknowledged that, “There are many and varied contributors to the obesity problem and these are societal as well as individual responsibilities. This idea suggests that understanding and tackling the obesogenic environment is necessary to complement school and family-based interventions."[214]
158. Sport NI suggested a number of practical measures relating to planning, play facilities and public transport and argued that, “in the long term, those decisions will create a situation whereby society, by default, encourages a culture of physical activity. Physical activity should not be considered a bolt-on; we must plan for such a society now, because it will be cheaper in the long run."[215] The British Heart Foundation urged the Assembly to “oversee urban planning policies which promote physical activity" and called on the Assembly to “dedicate at least as much energy on encouraging participation in physical activity as for competitive sports."[216]
159. Tackling the obesogenic environment was also an issue raised at the Research Event and it concluded that, “it is only when the Government take obesity seriously, and when there are proper policies that relate to obesity at Government, economic, financial and pricing level, that we are going to see really good change."[217]
160. The Committee learned that organisations, academics and communities in the North East of England, recognising that obesity cannot be successfully addressed with isolated interventions, have come together to form an obesogenic environment network (North East Obesogenic Environment Network). It regards tackling the obesogenic environment as looking at the environment, planning, design, transport, physical activity, food, policy and culture. The aim of the network is to have an impact on obesity “through integrated cross-sectoral initiatives and projects".[218]
161. The obesogenic environment can have a major impact on both our eating habits and the amount of physical exercise that we undertake. However, we believe that the link between ‘passive obesity’ and the environment is not yet widely understood. Initiatives tend to be isolated and piecemeal. The full impact of the obesogenic environment needs to be addressed in a comprehensive and empirical manner.
162. We call on the Executive to fully recognise the potential impact of the obesogenic environment on the health and wellbeing of the population and to consider the merits of introducing a system whereby the impact of all major policy decisions are subject to an obesity proofing exercise.
Others Issues
Health Inequalities
163. Many respondents highlighted the links between poverty and obesity. Action Cancer pointed to research which found that, “people on lower income have higher propensity for fast food diets and food with little nutritional value. Additionally, people with little disposable income are less motivated to engage in regular exercise due to the high costs associated with gyms or sports clubs."[219] Dr Colin Hamilton, British Medical Association, suggested that, “looking back 50 or 60 years, one discovers that obesity was not a working-class problem, but, rather, one of the middle and other classes — the people who had money to spend on food. Nowadays, the situation has totally reversed."[220] John News, Sport NI, agreed saying that, “the settings are important; not everyone wants to go to a council-owned leisure centre, but neither can everyone afford to go to a private health club or leisure centre. The health inequalities across Northern Ireland show a definite correlation between socio-economic status and participation in sport and physical activity."[221]
164. The Public Health Alliance pointed to research it had undertaken in 2007 to examine the scope and extent of food poverty in Northern Ireland. That research concluded that, “there is strong evidence to indicate that people living in food poverty almost always have a diet which predisposes them to the risk of obesity".[222] Andrew Dougal, NI Chest Heart and Stroke Association, pointed out that success in preventing heart disease and stroke had been achieved in the higher socio-economic groups and while he agreed with the total-population approach he argued that, “there may be a need to focus on the more deprived groups in society to ensure that those people are empowered to change their lifestyles".[223]
165. Andrea Marnoch, Food Standards Agency Northern Ireland, reported on the findings of the low income diet and nutrition survey (LIDNS), carried out between 2003 and 2005, and published in 2007. Its aim was to study material deprivation in the diets of the bottom 15% of the population. It concluded that, “compared with the general population, the low-income population was less likely to consume wholemeal bread and tended to consume more non-diet soft drinks, more processed meats, more whole milk and more table sugar. Consumption of fruit and vegetables fell well below the recommended level of five portions a day, and consumption of oily fish was very low."[224]
166. While the rates of obesity have increased most among adults and children from poorer backgrounds, research has also found that the widening of obesity inequalities is more evident among women than men.[225] The Fit Futures Report also suggested that, “Higher rates of obesity have been found in adults, especially women, with mild to moderate learning disabilities that live in the community than in the general population"[226] while, as noted earlier, the Royal College of Psychiatrists reported that, “people with mental illness and those with learning disabilities are more likely than the general population to be obese". [227]
Community Approach
167. Many respondents, including Health and Social Care Trusts and former Health and Social Services Boards, highlighted the need to take a community-based approach to tackling obesity. A number pointed to a project developed in France entitled Ensemble, Prévenons l’Obésité des Enfants (EPODE), which means ‘together, we can prevent obesity in children’ as an example worth emulating. Dr Eddie Rooney, Public Health Agency, explained that, “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."[228] The former Northern Health and Social Services Board argued that the most promising approach is through “community based interventions focussing on diet and physical activity in children and have been used as the basis for a programme involving over 130 towns in France, Belgium and Spain. The early data available is encouraging but full report won’t be available for several years (EPODE)."[229]
168. Clara Swinson, Department of Health, London, explained that England had set up a specific community project based on the EPODE idea. She said, “The healthy community challenge fund, which we abbreviate to Healthy Towns, is a fund of £30 million over three years. We looked at some successes achieved in towns in France through the EPODE project and developed the idea for England. Evidence shows that, although no society as a whole has tackled obesity, there has been some success on a community level when people really got together and worked across agencies."[230]
169. In evidence to the Committee, the new Public Health Agency was keen to stress that it will be addressing issues like obesity from a community perspective. Dr Rooney said that, “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… It must be done in communities and working with them…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."[231]
170. Professor Frank Kee, Queen’s University Belfast, referred to a new social marketing campaign document, issued recently by the Department of Health in London, which focuses on how people make decisions and introduces the idea of rewarding healthy choices. He explained that, “An innovative research scheme, Points4Life, has been launched in Manchester. It is based on loyalty cards for supermarkets, and people will be rewarded with more points if they buy healthy options or if they take more exercise…Before the scheme was launched, consumer market research was carried out in Manchester to find out what the voters wanted, so Points4Life is exactly what the community wants." Professor Kee also advised that he has included the concept in a research proposal that, “will study the impact of the Connswater Community Greenway in east Belfast … on physical activity behaviours in the local area. We will build the idea of a loyalty card into that project, whereby people who use the Greenway can be rewarded with redeemable points in local retail outlets." [232]
171. In developing the Life Course Approach we urge the Department to take account of health inequalities and particularly the need to address the higher levels of obesity in areas of social deprivation.
172. We applaud and support the recognition by the Public Health Agency that it needs to address issues like obesity from a community perspective.
Workplace Health
173. The British Heart Foundation and others pointed out that, “The workplace offers significant potential as a setting to promote healthy lifestyles to the adult working population. This is well recognised in the UK but to date under-utilised."[233] Dr Colin Hamilton pointed to variations in workplace schemes saying that, “the BMA has a good programme of yearly checks for its staff, including blood pressure, weight, and so forth… the NHS is a poor employer in that respect… There are some good employers in the Province and others that are not so good. During a credit crunch, the temptation is probably to run down, rather than improve, such services."[234]
174. Other examples of workplace health schemes included Newry and Mourne Council which advised that it has developed a number of programmes such as encouraging the use of the Council’s leisure facilities by staff and Councillors through reduced rates and free access. The Council said that, “a weight management support group has also been set up for staff to encourage each other to reach and maintain a healthy weight."[235] The Assembly, in a written submission, highlighted the positive action it is taking as an employer to promote healthy eating in the workplace and to encourage greater levels of exercise.[236]
175. The British Heart Foundation also highlighted the Well@Work workplace health initiative which it jointly funded across nine regional projects and 32 workplaces in England. Evaluation of this two year initiative found that, “several projects achieved modest increases in employees’ healthy behaviours. However…one-off projects did not sustain behaviour change in the absence of strong management involvement and supportive environments within the workplace." The Foundation called for the Northern Ireland Assembly to “Review and update the Workplace Health Strategy to ensure that workplaces are helping to support health and wellbeing."[237]
176. We recognise the benefits for both employers and employees of promoting healthy lifestyles in the workplace and we urge all employers to consider initiatives that promote healthy eating and greater levels of exercise in the workplace.
Research
177. A number of organisations highlighted the need for greater co-ordination of research. The former Western Health and Social Services Board called for “a better evidence-base of what interventions actually do work which reflect the setting and target audience for which they are being designed".[238] Belfast City Council agreed highlighting “a real need for rigorous and robust research in the field of prevention during an individual’s life course and in particular preventing childhood obesity and promoting early years intervention…There are few local studies on prevention; much of the research which has been carried out is inadequate to allow for specific recommendations to be made."[239] Action Cancer told the Committee that, “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."[240]
178. At the outset of the Inquiry Dr Jane Wilde, Institute of Public Health in Ireland, drew attention to this need “to bring research, policy and practice together to try to work out what we know and also to identify any gaps". She said that, “there is every danger in Northern Ireland that there will be more and more interventions, and we will not know what is working or not working."[241] At Dr Wilde’s suggestion the Committee convened a round-table meeting of leading academic researchers on obesity from throughout the United Kingdom and the Republic of Ireland, a small number of key stakeholders from within Northern Ireland and members of the Committee. (Details of the Research Round-Table Event are at annex 5) The aim of the Research Event was to make practical recommendations to include in this report.
179. A number of important issues were identified at the Research Event. The conclusions included:
- The importance of a strong partnership between the research community, stakeholders, communities, politicians and policy makers;
- The need to develop a database of existing interventions and ensure that they are based on firm evidence of effectiveness;
- The need to identify examples of good practice and roll them out across Northern Ireland;
- The need to learn from experience elsewhere and adopt not just short-term interventions but longer-term research based systems interventions;
- The need for cross-government working to ensure that obesity is seen as a top priority for Northern Ireland and the Executive and not just a matter for the health service;
- The need to address the dearth of existing weight management interventions urgently;
- The need to challenge sectors in the obesogenic environment that may not be obesity friendly; and
- The need for government to take obesity seriously and address pricing at different levels.
180. A number of respondents pointed to the development of an all-island Obesity Observatory similar to one funded by the Department of Health in England. The Department indicated that this was one of a number of outcomes of cross-border co-operation.[242] In evidence to the Committee Dr Wilde suggested that the obesity observatory “will be a one-stop shop for evidence and data, particularly local data."[243] Professor Frank Kee, QUB, agreed saying that the observatory “will help us to communicate more effectively to various bodies, including health bodies and local councils, our knowledge of what works and what does not work". He went on to argue that it “must be multi-sectoral and multidisciplinary. It is important for the new [Public Health] agency, and for academics, to build capacity that will help us to model the consequences of different policies."[244] The former Western Health and Social Services Board claimed that “there is a need for further development of the All-Ireland Obesity Observatory, in terms of ensuring that we can get a better understanding of what initiatives are being taken forward and have greater collaboration between those identifying core issues and those delivering appropriate services."[245]
Data Collection
181. The primary method employed by the DHSSPS to collect and analyse overweight and obesity prevalence rates among children in Northern Ireland is the Child Health System. Currently, as part of this, the School Nursing Service undertakes the measurement and recording of the weight and height of Primary One children on an annual basis.
182. In addition to the data generated by the Child Health System, the other key source of data informing the development of Fit Futures and the wider Investing for Health Strategy is the Health and Social Wellbeing Survey which was last carried out in 2005-2006. The Health and Social Wellbeing Survey which was previously conducted in 1997 and 2001 focuses on a range of different health issues including mental health, cardiovascular disease, physical activity, smoking and drinking and obesity. The Survey takes the form of self-reporting questionnaires. Therefore a certain degree of caution needs to be employed when considering the overweight and obesity figures, given the potential for underestimation of weight and overestimation of height.
183. During the Committee’s Research Round-Table Event, Professor Frank Kee and Professor Barbara Livingstone highlighted the need to improve the data collection systems currently supporting the Department’s obesity prevention strategy. Professor Kee stated that, ‘We need surveys that are fit for purpose, and for the last two iterations of the health and well-being survey we have not had measures of BMI. We must ensure that we have physical measurements in future health and well-being surveys in Northern Ireland.’[246] Professor Livingstone argued that, ‘one of the major gaps in this part of the world is that that we do not have really good surveillance on monitoring data, and you cannot really evaluate anything until you have that in place.’[247] We note that, for example, in New Zealand the Healthy Eating, Healthy Action strategy launched in 2008 is supported by an integrated research, evaluation and monitoring framework which measures the effectiveness of on-going initiatives while building a strong evidence base.[248]
184. It is widely accepted that the availability of reliable and accurate data is critically important in the continued development and implementation of a regional or national obesity strategy. The data provides not only an indication of the effectiveness of existing strategies in place but also feeds critical information into the on-going evaluation process to ensure specific initiatives are tailored to different population groups. The need for effective surveillance data becomes even more important within the current context of the development of a life course strategy in Northern Ireland.
185. We stress the importance of a strong partnership between researchers, stakeholders, communities, politicians and policy makers. We welcome the fact that one of the four policy advisory sub-groups, set up as part of the Obesity Prevention Steering Group, will deal with research and data and that it is led by an academic researcher.
186. We strongly support the development of the All-island Obesity Observatory which will have an important role in providing effective obesity surveillance and intelligence to practitioners, policy-makers and the wider community.
187. We share the concerns expressed about the current limitations in the collection and measurement of obesity among children and adults in Northern Ireland. We urge the Department to examine how data collection can be improved through reform and better funding of the Child Health System. This should facilitate extending BMI measurements beyond Primary One children. Enhanced funding should also facilitate better collection of adult data based on actual BMI measurements rather than self-reporting.
Conclusion
188. The levels of obesity in Northern Ireland, as elsewhere, have increased dramatically in recent years and it is without doubt the most serious and complex public health challenge facing society today. Despite this the enormity of the situation is not widely recognised. Obesity threatens to overturn the considerable health gains of recent times and, if not checked, will have grave implications for the economy and for society and could totally overwhelm the health service. As one witness told us, “Smoking and drinking may be damaging to public health, but they are nothing compared with what obesity will do to our population over the next 10 or 20 years."
189. There is an urgent need to develop and implement a broad and vigorous strategy to begin to turn the tide of obesity across the different population groups in Northern Ireland. We note that the Department has moved away from a strategic response focusing on tackling obesity in children and young people to the development of a life course approach to obesity prevention. We welcome and support the life course approach but it must have clear, effective leadership that fully engages all departments and sectors with a focus on continuous evaluation and improvement.
190. In tackling obesity the potential impact of a wide range of factors in the physical, socio-economic and cultural environment, known as the obesogenic environment, on both our eating habits and our levels of exercise needs to be better understood and addressed.
191. As well as taking action to reduce and prevent obesity, an effective range of services to manage and treat the rapidly increasing number of people who currently suffer from serious and life threatening obesity-related illnesses must be put in place. Obesity is already ‘silting up’ a range of clinical and other services and it is not sufficient to treat the medical symptoms without addressing the underlying weight problems. Even a modest reduction in weigh of 10% can have a dramatic impact on a patient’s health.
192. Throughout this report we have referred to valuable examples of good practice in other jurisdictions that we could learn from. Perhaps the most important of these is the recent development of the Healthy Weight, Health Lives strategy in England, the first national population-wide strategy aimed at tackling obesity. In relation to weight management services we have highlighted established and effective initiatives in England and Scotland that may be of benefit in Northern Ireland.
[1] Volume 2, Appendix 3, Page 288
[2] Appendix 2, Paragraph 1245
[3] Appendix 2, Paragraph 316
[4] Volume 2, Appendix 3, Page 578
[5] Volume 2, Appendix 3, Pages 288-289
[6] Volume 2, Appendix 3, Page 431
[7] Volume 2, Appendix 3, Page 365
[8] Appendix 2, Paragraph 1043
[9] Yusuf S et al on behalf of the INTERHEART Study Investigators (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study), The Lancet; 364: 937-952
[10] Appendix 2, Paragraph 1058
[11] Appendix 2, Paragraph 119
[12] Obesity and Type 2 Diabetes in Northern Ireland, Report by the Comptroller and Auditor General, NIA 73/08-09 14 January 2009
[13] Appendix 2, Paragraph 463
[14] Official Report Volume 41 No 6, Monday 8 June 2009, p 243
[15] Appendix 2, Paragraph 120
[16] Appendix 2, Paragraph 240
[17] Volume 2, Appendix 3, Page 431
[18] Volume 2, Appendix 3, Page 237
[19] Volume 2, Appendix 3, Page 353
[20]Appendix 2, Paragraph 524
[21]Appendix 2, Paragraph 316
[22]Appendix 2, Paragraph 442
[23] Volume 2, Appendix 3, Page 275
[24] Crest ‘Guidelines for the Management of Obesity in Secondary Care’ June 2005; OB32
[25] Butland, B. et al (2007) ‘Tackling Obesities: Future Choices – Project Report’, 2nd edition, Government Office for Science: 5
[26] Volume 2, Appendix 3, Page 315
[27] Volume 2, Appendix 3, Pages 356-357
[28] Obesity and Type 2 Diabetes in Northern Ireland, Report by the Comptroller and Auditor General, NIA 73/08-09 14 January 2009
[29] Sustrans OB37; Investing for Health, DHSSPS March 2002
[30] Volume 2, Appendix 3, Page 432
[31] Appendix 2, Paragraph 758
[32] Price et al (2006) ‘Weight, shape, and mortality risk in older persons: elevated waist-hip ratio, not high body mass index is associated with a greater risk of death’, Am J Clin Nutr, 84 (2): 449-460 cited in P. Musingarimi (2008) Obesity in the UK: A Review and Comparative Analysis of Policies within the Devolved Regions, International Longevity Centre: 8.
[33] Volume 2, Appendix 3, Page 247
[34]Appendix 2, Paragraph 247
[35]Butland, B. et. Al. (2007) Obesities: Future Choices – Project Report, Second Edition, Foresight, Government Office for Science, Section 3, page 48
[36] Volume 2, Appendix 3, Page 332
[37] Volume 2, Appendix 3, Page 381
[38] Appendix 2, Paragraph 241
[39] Volume 2, Appendix 3, Page 234
[40] Butland, B. et. Al. (2007) Obesities: Future Choices – Project Report, Second Edition, Foresight, Government Office for Science, Section 3.2, page 47
[41] Volume 2, Appendix 4
[42] E M Perez-Pastor et al. Assortative weight gain in mother–daughter and father–son pairs: an emerging source of childhood obesity. International Journal of Obesity 33: 727-735
[43] Appendix 2, Paragraph 10
[44] Volume 2, Appendix 3, Page 364
[45] World Health Organisation (2007) The challenge of obesity in the WHO European Region and the strategies for response, WHO: 1.
[46] World Health Organisation (2006) ‘Obesity and Overweight’, Fact sheet No.311.
[47] World Health Organisation (2007) The challenge of obesity in the WHO European Region and the strategies for response, WHO: 1
[48] National Obesity Observatory (2009) ‘NOO News – Newsletter from the National Obesity Observatory’, Issue 2, May, NOO: 6.
[49] Reference to ‘Ireland’ within Figure 1 reflects the percentage of obesity among the adult population in the Republic of Ireland and illustrates figures from the Survey of Lifestyle, Attitudes and Nutrition (SLAN) commissioned for the Department of Health and Children.
[50] Sassi, F. et al (2009) The Obesity Epidemic: Analysis of Past and Projected Future Trends in Selected OECD Countries, Organisation for Economic Cooperation and Development: 42.
[51] Butland, B. et al (2007) ‘Tackling Obesities: Future Choices – Project Report’, 2nd edition, Government Office for Science: 24.
[52] See Butland, B. et al (2007) ‘Tackling Obesities: Future Choices – Project Report’, 2nd edition, Government Office for Science: 24-41.
[53] Department of Health and Children (2007) Survey of Lifestyle, Attitudes and Nutrition in Ireland – Main Report, Department of Health and Children: 100-101.
[54] DHSSPS (2008) ‘Obesity time bomb is ticking louder than ever – north and south’, Press release.
[55] Data in this table provided by Public Health Information and Research Branch, DHSSPS.
[56] International Journal of Obesity (2005) Ten year trends for fatness in Northern Irish adolescents: the Young Hearts Projects, repeat cross-sectional study, 29: 579-585 – cited in NIAO (2007) The Performance of the Health Service in Northern Ireland, NIAO: 14.
[57] Southern Health and Social Services Board and Southern Investing for Health Partnership (2009) Submission to the Inquiry: 2.
[58] DHSSPS (2009) Evidence to DHSSPS Health Committee inquiry on Obesity, DHSSPS: 4.
[59] Musingarimi, P. (2008) Obesity in the UK: A Review and Comparative Analysis of Policies within the Devolved Regions, International Longevity Centre: 11.
[60] Volume 2, Appendix 3, Pages 291-296
[61] Volume 2, Appendix 3, Page 257
[62] Volume 2, Appendix 3, Page 291
[63] Volume 2, Appendix 3, Page 292
[64] Investing for Health, DHSSPS March 2002, Chapter 13
[65] Volume 2, Appendix 3, Page 293
[66] See paragraph 16 above
[67] Volume 2, Appendix 3, Page 294
[68] Appendix 2, Paragraph 1408
[69] Butland, B. et al (2007) Obesities: Future Choices – Project Report, Second Edition, Foresight, Government Office for Science.
[70]Appendix 2, Paragraphs 1374- 1375
[71] Volume 2, Appendix 3, Page 373
[72] Volume 2, Appendix 3, Page 316
[73] Appendix 2, Paragraph 1106
[74] Volume 2, Appendix 3, Pages 381-382
[75] Volume 2, Appendix 3, Page 267
[76] Appendix 2, Paragraph 542
[77] Healthy Weight, Healthy Lives: One Year On, Department of Health, April 2009, Executive Summary
[78] Volume 2, Appendix 3, Page 299
[79] The Cross-Government Obesity Unit in England is led jointly by the Department of Health and the Department for Children, Schools and Families.
[80] Appendix 2, Paragraph 14
[81] Appendix 2, Paragraphs 1069-1070
[82] Volume 2, Appendix 5, Paragraph 327
[83] Volume 2, Appendix 5, Paragraph 358
[84] Volume 2, Appendix 5, Paragraphs 374-375
[85] Appendix 2, Paragraph 862
[86] Volume 2, Appendix 3, Page 270
[87]Appendix 2, Paragraph 1383
[88] Volume 2, Appendix 3, Page 580
[89] Volume 2, Appendix 3, Page 236
[90]Appendix 2, Paragraph 1051
[91]Appendix 2, Paragraph 9
[92]Appendix 2, Paragraph 883
[93] Appendix 2, Paragraph 12
[94] Volume 2, Appendix 3, Page 280
[95] Volume 2, Appendix 3, Page 261
[96] Volume 2, Appendix 3, Page 381
[97] Appendix 2, Paragraph 251
[98] Appendix 2, Paragraph 686
[99] Volume 2, Appendix 3, Page 367
[100]Appendix 2, Paragraph 785
[101]Appendix 2, Paragraph 13
[102] Appendix 2, Paragraph 532
[103]Appendix 2, Paragraph 330
[104] Appendix 2, Paragraph 499
[105] Appendix 2, Paragraph 898
[106] Volume 2, Appendix 3, Page 295
[107]Appendix 2, Paragraph 424
[108] Volume 2, Appendix 3, Page 247
[109]Appendix 2, Paragraph 424
[110] Volume 2, Appendix 3, Page 278
[111] Volume 2, Appendix 3, Pages 295-296
[112] Volume 2, Appendix 3, Page 296
[113] Volume 2, Appendix 3, Page 325
[114]Appendix 2, Paragraphs 335-337
[115]Appendix 2, Paragraph 681
[116]Appendix 2, Paragraph 551
[117]Appendix 2, Paragraphs 918-919
[118] Volume 2, Appendix 3, Page 477
[119]Appendix 2, Paragraphs 778-779
[120] NHS, Care pathway for the management of overweight and obesity, May 2006, www.library.nhs.uk/SpecialistLibrarySearch/Download.aspx?resID=270413 page 6
[121] http://domuk.org/wp-content/uploads/2008/05/ben-pct-primary-care-specialist-obesity-service-march-08.ppt
[122] Appendix 2, Paragraph 490
[123] Volume 2, Appendix 5, Page 737
[124] Volume 2, Appendix 3, Page 297
[125] Volume 2, Appendix 3, Page 275
[126]Appendix 2, Paragraph 490
[127]Appendix 2, Paragraph 501
[128]Appendix 2, Paragraph 432
[129]Appendix 2, Paragraph 70
[130] Volume 2, Appendix 5, Paragraph 90
[131] Volume 2, Appendix 5, Paragraph 44
[132] Volume 2, Appendix 3, Paragraph 561
[133] Volume 2, Appendix 3, Paragraph 328
[134] Volume 2, Appendix 3, Paragraph 269
[135]Appendix 2, Paragraphs 506-507
[136] Volume 2, See Appendix 4
[137] Korenkov, M. and Sauerland S. (2007), Clinical Update: bariatric surgery, The Lancet, 370, 1988-1990
[138] Volume 2, Appendix 3, Paragraph 328
[139] Volume 2, Appendix 3, Paragraph 329
[140] Volume 2, Appendix 3, Paragraph 269
[141]Appendix 2, Paragraph 130
[142] Volume 2, Appendix 3, Page 309
[143] Volume 2, Appendix 3, Paragraph 345
[144]Appendix 2, Paragraph 21
[145]Appendix 2, Paragraph 940
[146]Appendix 2, Paragraphs 942-943
[147]Appendix 2, Paragraph 1273
[148]Appendix 2, Paragraph 946
[149]Appendix 2, Paragraph 979
[150]Appendix 2, Paragraph 1377
[151]Appendix 2, Paragraph 642
[152]Appendix 2, Paragraph 1053
[153]Appendix 2, Paragraph 1073
[154]Appendix 2, Paragraphs 948-951
[155] Volume 2, Appendix 3, Page 540
[156]Appendix 2, Paragraph 1041
[157] Appendix 2, Paragraph 1238
[158]Appendix 2, Paragraph 952
[159] Appendix 2, Paragraph 640
[160] Volume 2, Appendix 3, Page 540
[161] Volume 2, Appendix 5, Paragraph 110
[162] Appendix 2, Paragraph 896
[163] Volume 2, Appendix 3, Page 539
[164]Appendix 2, Paragraph 1004
[165]Appendix 2, Paragraph 921
[166] Volume 2, Appendix 3, Page 259
[167] Appendix 2, Paragraph 788
[168] Fit Futures: Focus on Food, Activity and Young People, Report to the Ministerial Group on Public Health (Northern Ireland), DHSSPS, Dec. 2005, page 25
[169] National Institute for Health and Clinical Excellence Guidance on physical activity and the environment, 2007
[170] Volume 2, Appendix 3, Page 373
[171]Appendix 2, Paragraph 753
[172] Volume 2, Appendix 3, Page 372
[173] Volume 2, Appendix 3, Page 334
[174] Volume 2, Appendix 3, Page 335
[175] Volume 2, Appendix 3, Page 260
[176] Appendix 2, Paragraph 792
[177] Volume 2, Appendix 3, Page 231
[178] Volume 2, Appendix 3, Page 361
[179] Volume 2, Appendix 3, Page 261
[180] Volume 2, Appendix 3, Pages 231-235
[181] Volume 2, Appendix 3, Page 334
[182] Volume 2, Appendix 3, Page 436
[183] Volume 2, Appendix 3, Page 394
[184] Volume 2, Appendix 3, Pages 361-362
[185] Volume 2, Appendix 3, Page 442
[186] Volume 2, Appendix 3, Page 348
[187] Volume 2, Appendix 3, Page 227
[188] Volume 2, Appendix 3, Page 453
[189]Appendix 2, Paragraph 1309
[190]Appendix 2, Paragraph 1343
[191] www.catchinfo.org/whatis.asp
[192]Appendix 2, Paragraph 1328
[193]Appendix 2, Paragraph 670
[194] Volume 2, Appendix 3, Page 345
[195] Volume 2, Appendix 3, Page 316
[196]Appendix 2, Paragraph 811
[197] Volume 2, Appendix 3, Page 383
[198]Appendix 2, Paragraph 530
[199]Appendix 2, Paragraph 1417
[200]Appendix 2, Paragraph 824
[201] Volume 2, Appendix 3, Page 434
[202] Volume 2, Appendix 3, Page 367
[203] Volume 2, Appendix 3, Page 434
[204] Volume 2, Appendix 3, Page 547
[205] Volume 2, Appendix 3, Page 221
[206] Volume 2, Appendix 3, Page 367
[207]Appendix 2, Paragraph 1279
[208] Volume 2, Appendix 3, Page 248
[209] Volume 2, Appendix 3, Page 403
[210] Volume 2, Appendix 3, Page 296
[211] Volume 2, Appendix 3, Page 372
[212] Lawlor et al, Journal of Epidemiology and Community Health 2003;57:96–101
[213] Butland B. et. al. (2007) Obesities: Future Choices – Project Report, Second Edition, Foresight, Government Office for Science, Section 3.4.3, page 54
[214] Volume 2, Appendix 3, Page 290
[215]Appendix 2, Paragraphs 822-823
[216] Volume 2, Appendix 3, Page 366
[217] Volume 2, Appendix 5, Paragraph 362
[218] Research paper appendix 4 p 13 of 33. www.neoen.org.uk
[219] Volume 2, Appendix 3, Page 312
[220]Appendix 2, Paragraph 396
[221]Appendix 2, Paragraph 810
[222] Volume 2, Appendix 3, Page 364
[223]Appendix 2, Paragraph 1108
[224]Appendix 2, Paragraph 963
[225] Law, C. et. al. (2007), Obesity and health inequalities, Obesity Reviews, 8 (Suppl. 1), 19-22
[226] Fit Futures: Focus on Food, Activity and Young People, Report to the Ministerial Group on Public Health (Northern Ireland), DHSSPS, Dec. 2005, page 35
[227] Volume 2, Appendix 3, Page 238
[228]Appendix 2, Paragraph 920
[229]Appendix 3, Page 403
[230]Appendix 2, Paragraph 1391
[231]Appendix 2, Paragraph 932
[232]Appendix 2, Paragraph 609
[233] Volume 2, Appendix 3, Page 369
[234]Appendix 2, Paragraph 329
[235] Volume 2, Appendix 3, Page 345
[236] Volume 2, Appendix 3, Pages 552-560
[237] Volume 2, Appendix 3, Page 369
[238] Volume 2, Appendix 3, Page 270
[239] Volume 2, Appendix 3, Pages 318-319
[240]Appendix 2, Paragraph 253
[241]Appendix 2, Paragraph 23
[242] Volume 2, Appendix 3, Page 295
[243]Appendix 2, Paragraph 24
[244]Appendix 2, Paragraph 635
[245] Volume 2, Appendix 3, Pages 269-270
[246] Volume 2, Appendix 5, Paragraph 279
[247] Volume 2, Appendix 5, Paragraph 267
[248] See Ministry of Health (New Zealand) (2008) Healthy Eating – Healthy Action Oranga Kai- Oranga Pumau: Progress on Implementing the HEHA Strategy: Ministry of Health: 23.
Appendix 1
Minutes of Proceedings
Thursday, 15 January 2009
Senate Chamber, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mr Thomas Buchanan MLA
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mrs Carmel Hanna MLA
Mr Sam Gardiner MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mrs Noelle Bourke (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
The meeting commenced at 2.01 pm in public session with the Deputy Chairperson in the chair.
9. Consideration of the Terms of Reference for the Committee Inquiry
The Committee agreed the Draft Terms of Reference for the Inquiry on Obesity.
The Committee agreed a list of relevant organisations for a consultation on the Inquiry on Obesity with one addition.
The Committee agreed a Draft Press Release for the Inquiry on Obesity.
The Committee agreed to liaise with the Public Accounts Committee regarding the Northern Ireland Audit Office Report on Obesity and Type 2 Diabetes in Northern Ireland.
[Extract]
Thursday, 26 February 2009
Senate Chamber, Parliament Buildings
Present: Mrs Iris Robinson MP MLA (Chairperson)
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mrs Carmel Hanna MLA
Mr Sam Gardiner MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Mrs Michelle O’Neill MLA (Deputy Chairperson)
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mrs Noelle Bourke (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Ms Sue Ramsey MLA
The meeting commenced at 2.09 pm in public session.
6. Committee Inquiry into Obesity
Evidence session with the Institute for Public Health in Ireland
Members took evidence from:
Dr Jane Wilde Chief Executive, Institute for Public Health
A question and answer session ensued. The Chairperson thanked the witness for attending.
4.40 p.m. Mr Tommy Gallagher left the meeting.[Extract]
Thursday, 5 March 2009
Room 135, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mr Thomas Buchanan MLA
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mrs Carmel Hanna MLA
Mr Sam Gardiner MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mrs Noelle Bourke (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
The meeting commenced at 2.01 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity
Evidence session with Departmental officials
Members took evidence from:
Andrew Elliott Director of Population Health
Naresh Chada Senior Medical Officer
Rob Phipps Health Development Branch
David Galloway Acting Director of Secondary Care
A question and answer session ensued. The Chairperson thanked the witnesses for attending.
2.08 p.m. Mrs Carmel Hanna joined the meeting.
2.12 p.m. Mr Thomas Buchanan joined the meeting.
2.30 p.m. Mr Tommy Gallagher left the meeting.
2.40 p.m. Mr Tommy Gallagher rejoined the meeting.
2.57 p.m. Ms Sue Ramsey left the meeting.
3.05 p.m. Mrs Carmel Hanna left the meeting.
Evidence session with Action Cancer
Members took evidence from:
Geraldine Kerr Acting Chief Executive, Action Cancer
Caroline Hughes Research & Evaluation Officer, Action Cancer
Treasa Rice Health Promotion Manager, Action Cancer
A question and answer session ensued. The Chairperson thanked the witnesses for attending.
3.06 p.m. Mrs Carmel Hanna rejoined the meeting.
3.14 p.m. Mr John McCallister joined the meeting.
3.20 p.m. Ms Sue Ramsey rejoined the meeting.
3.43 p.m. Mrs Carmel Hanna left the meeting.
3.53 p.m. Mrs Carmel Hanna rejoined the meeting.
[Extract]
Thursday, 12 March 2009
Senate Chamber, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mr Thomas Buchanan MLA
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mrs Carmel Hanna MLA
Mr Sam Gardiner MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mrs Noelle Bourke (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
Mr Tommy Gallagher MLA
The meeting commenced at 2.03 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity
Evidence session with the British Medical Association (Northern Ireland)
Members took evidence from:
Theo Nugent BMA (NI) General Practitioners Committee
Colin Hamilton BMA (NI) Committee for Public Health Medicine and Community Health
Chairman
Nigel Gould BMA (NI) Deputy Secretary
Ivor Whitten BMA (NI) Assembly and Research Officer
A question and answer session ensued. The Chairperson thanked the witnesses for attending. The Committee agreed to write to the Health & Social Care Trusts to request a sample of hospital menus.
2.14 p.m. Mr John McCallister joined the meeting.
2.17 p.m. Mr Thomas Buchanan joined the meeting.
2.55 p.m. Ms Sue Ramsey left the meeting.
2.58 p.m. Mr John McCallister left the meeting.
2.58 p.m. Dr Kieran Deeny left the meeting.
3.02 p.m. Dr Kieran Deeny rejoined the meeting.
3.06 p.m. Ms Sue Ramsey rejoined the meeting.
[Extract]
Thursday, 26 March 2009
Senate Chamber, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mr Thomas Buchanan MLA
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mr Sam Gardiner MLA
Mr John McCallister MLA
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mrs Noelle Bourke (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
Mrs Carmel Hanna MLA
Mrs Claire McGill MLA
The meeting commenced at 2.10 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity
Evidence session with Dr Ryan, Northern Health & Social Care Trust
Members took evidence from:
Michael Ryan Consultant Chemical Pathologist, Northern Health & Social Care Trust
A question and answer session ensued. The Chairperson thanked the witness for attending.
2.20 p.m. Dr Kieran Deeny joined the meeting.
2.48 p.m. Mr John McCallister joined the meeting.
[Extract]
Thursday, 2 April 2009
Senate Chamber, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mr Thomas Buchanan MLA
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mr Sam Gardiner MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mrs Noelle Bourke (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
Mrs Carmel Hanna MLA
Ms Sue Ramsey MLA
The meeting commenced at 2.04 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity
Evidence session with the Allied Health Professions
Members took evidence from:
Pauline Mulholland Board Member, British Dietetic Association (NI)
Tracey Gibbs Chairperson, College of Occupational Therapy
Teresa Ross Chartered Society of Physiotherapy
A question and answer session ensued. The witnesses agreed to provide the Committee with additional information. The Chairperson thanked the witnesses for attending.
2.54 p.m. Mr Tommy Gallagher left the meeting.
[Extract]
Thursday, 23 April 2009
Queens University Belfast
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mr Thomas Buchanan MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
Ms Sue Ramsey MLA
Dr Kieran Deeny MLA
The meeting commenced at 2.11 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity
Evidence session with Queens University Belfast
Members took evidence from:
Professor Frank Kee Deputy Director, Centre for Public Health, QUB
Dr Michelle McKinley Principal Investigator, Centre for Public Health, QUB
Ms Mairead Boohan Deputy Director, Centre for Medical Education, QUB
A question and answer session ensued. The Deputy Chairperson thanked the witnesses for attending.
2.20 p.m. Mr Thomas Buchanan joined the meeting.
The Committee noted a number of research topics for consideration at a round table event being organised for Tuesday 19 May 2009. Members were asked to provide any views to the Committee office.
Evidence session with NILGA
Members took evidence from:
Karen Smyth Head of Policy, NILGA
Katrina Morgan Leisure Operations Manager, Belfast City Council
A question and answer session ensued. The witnesses agreed to provide the Committee with additional information. The Deputy Chairperson thanked the witnesses for attending.
3.04 p.m. Mr Tommy Gallagher left the meeting.
3.21 p.m. Mr Tommy Gallagher rejoined the meeting.
[Extract]
Thursday, 30 April 2009
Senate Chamber, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr John Render (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
The meeting commenced at 2.03pm in public session with the Deputy Chairperson in the chair.
3. Committee Inquiry into Obesity, Evidence session with Sport NI
Members took evidence from:
Eamonn McCartan Chief Executive, Sport NI
John News Participation Manager, Sport NI
A question and answer session ensued. The witnesses agreed to provide the Committee with additional information. The Deputy Chairperson thanked the witnesses for attending.
3.00 p.m. Ms Sue Ramsey left the meeting.
3.07 p.m. Ms Sue Ramsey rejoined the meeting.
[Extract]
Thursday, 14 May 2009
Room 135, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mrs Claire McGill MLA
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
Mr Thomas Buchanan MLA
Mr John McCallister MLA
The meeting commenced at 2.02 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity
Evidence session with the Public Health Agency
Members took evidence from:
Dr Eddie Rooney Chief Executive, Public Health Agency
Dr Carolyn Harper Director of Public Health, Public Health Agency
Ms Gerry Bleakney Health Promotion Commissioner, Public Health Agency
Before the evidence on obesity Dr Rooney and Dr Harper updated the Committee on Swine Flu. Following the presentation on obesity a question and answer session ensued. The witnesses also advised on the implementation of a recommendation by the Committee on suicide & self harm. The Deputy Chairperson thanked the witnesses for attending.
2.26 p.m. Dr Kieran Deeny joined the meeting.
3.10 p.m. Mr Alex Easton left the meeting.
3.11 p.m. Dr Kieran Deeny left the meeting.
10. Any other business
The Deputy Chairperson reminded Members of a round table research event taking place on Tuesday 19 May as part of the Committee’s inquiry into obesity.
[Extract]
Thursday, 21 May 2009
Senate Chamber, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mrs Carmel Hanna MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
Mr Thomas Buchanan MLA
Mr Sam Gardiner MLA
Ms Sue Ramsey MLA
The meeting commenced at 2.05 pm in public session with the Deputy Chairperson in the chair.
6. Committee Inquiry into Obesity
Evidence session with the Food Standards Agency
Members took evidence from:
Maria Jennings Deputy Director, Food Standards Agency
Andrea Marnoch, Head of Dietary Health Unit, Food Standards Agency
A question and answer session ensued. The witnesses invited the Committee to visit the office of the Food Standards Agency. The Deputy Chairperson thanked the witnesses for attending.
2.37 p.m. Mr Tommy Gallagher left the meeting
2.51 p.m. Mr Tommy Gallagher rejoined the meeting
2.54 p.m. Dr Kieran Deeny left the meeting
2.56 p.m. Mrs Carmel Hanna left the meeting
2.57 p.m. Dr Kieran Deeny rejoined the meeting
2.57 p.m. Mrs Carmel Hanna rejoined the meeting
Evidence session with the British Heart Foundation, Northern Ireland Chest Heart and Stroke Association and Diabetes UK.
Members took evidence from:
Andrew Dougal Northern Ireland Chest Heart and Stroke Association
Iain Foster Diabetes UK Northern Ireland
Victoria Taylor British Heart Foundation
A question and answer session ensued. The Deputy Chairperson thanked the witnesses for attending.
3.01 p.m. Mr John McCallister joined the meeting
3.28 p.m. Mr Tommy Gallagher left the meeting
3.58 p.m. Mr Tommy Gallagher rejoined the meeting
[Extract]
Thursday, 28 May 2009
Room 135, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
The meeting commenced at 2.03 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity.
Evidence session with Dr Una Lynch, Queens University Belfast.
Members took evidence from:
Dr Una Lynch Queens University Belfast
A question and answer session ensued. The Deputy Chairperson thanked the witness for attending.
[Extract]
Thursday, 11 June 2009
Senate Chamber, Parliament Buildings
Present: Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mr Thomas Buchanan MLA
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Tommy Gallagher MLA
Mr John McCallister MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies: Mrs Iris Robinson MP MLA (Chairperson)
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mrs Claire McGill MLA
Ms Sue Ramsey MLA
The meeting commenced at 2.03 pm in public session with the Deputy Chairperson in the chair.
5. Committee Inquiry into Obesity.
Evidence session with Northern Ireland Food & Drink Association.
Members took evidence from:
Michael Bell Executive Director, Northern Ireland Food & Drink Association
Mr John McCallister made a declaration of interest that he was a shareholder in a food processing company which may be a member of the Northern Ireland Food & Drink Association
A question and answer session ensued. The Deputy Chairperson thanked the witness for attending.
9 Committee Inquiry into Obesity.
Evidence session with officials from the Department of Education
Members took evidence from:
Louise Warde Hunter Department of Education
Alan McMullan Department of Education
Jill Fitzgerald Department of Education
A question and answer session ensued. The witnesses agreed to provide the Committee with additional information. The Deputy Chairperson thanked the witnesses for attending.
[Extract]
Thursday, 18 June 2009
Room 135, Parliament Buildings
Present: Mrs Iris Robinson MP MLA (Chairperson)
Mr Thomas Buchanan MLA
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Sam Gardiner MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Mrs Michelle O’Neill MLA (Deputy Chairperson)
Ms Sue Ramsey MLA
In Attendance: Mr Hugh Farren (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies: Mr Tommy Gallagher MLA
Mrs Carmel Hanna MLA
The meeting commenced at 2.02 pm in public session.
2.43 p.m. Ms Sue Ramsey left the meeting.
2.59 p.m. Mr Alex Easton left the meeting.
2.59 p.m. Dr Kieran Deeny joined the meeting
5. Committee Inquiry into Obesity.
Evidence session with the Department of Health, London
Members took evidence from:
Clara Swinson Deputy Director, Cross Government Obesity Unit
A question and answer session ensued. The Chairperson thanked the witness for attending.
3.02 p.m. Mr Alex Easton rejoined the meeting.
3.15 p.m. Ms Sue Ramsey rejoined the meeting.
Evidence session with officials from the Department of Health, Social Services and Public Safety
Members took evidence from:
Rob Phipps DHSSPS
Christine Jendoubi DHSSPS
Dr Naresh Chada. DHSSPS
Dr Kieran Deeny made a declaration of interest that he was a member of a local Commissioning Group.
A question and answer session ensued. The Chairperson thanked the witnesses for attending.
[Extract]
Thursday, 10 September 2009
Senate Chamber, Parliament Buildings
Present: Mr Jim Wells MLA (Chairperson)
Mr Alex Easton MLA
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mrs Dolores Kelly MLA
Mr John McCallister MLA
Mrs Michelle O’Neill MLA (Deputy Chairperson)
Ms Sue Ramsey MLA
In Attendance: Mrs Stella McArdle (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies: Mr Thomas Buchanan MLA
Mrs Claire McGill MLA
The meeting commenced at 2.00 pm in public session.
4.38 p.m. the meeting moved to closed session.
11. Consideration of draft Committee report on obesity
The Committee considered and agreed paragraphs 1 –70 of the draft report.
[Extract]
Thursday, 17 September 2009
Senate Chamber, Parliament Buildings
Present: Mr Jim Wells MLA (Chairperson)
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mrs Dolores Kelly MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Mrs Michelle O’Neill MLA (Deputy Chairperson)
Ms Sue Ramsey MLA
Mrs Iris Robinson MP MLA
In Attendance: Mrs Stella McArdle (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies:
The meeting commenced at 2.03 pm in public session.
4.19 p.m. the meeting moved to closed session.
4.35 p.m. Ms Sue Ramsey left the meeting.
10. Consideration of draft Committee report on obesity
The Committee considered and agreed paragraphs 71 – 91 of the draft report.
The Committee considered and agreed paragraphs 92 – 99 and deferred consideration of paragraph 100 of the draft report.
The Committee considered and agreed paragraph 101 of the draft report.
The Committee considered and agreed paragraphs 102 – 107 and deferred consideration of paragraph 108 of the draft report.
The Committee considered and agreed paragraphs 109 – 128 of the draft report.
The Committee considered and agreed paragraphs 129 – 133 and deferred consideration of paragraphs 134 - 135 of the draft report.
The Committee considered and agreed paragraphs 136 – 192 of the draft report.
The Committee considered and agreed the executive summary of the draft report.
[Extract]
Thursday, 1 October 2009
Senate Chamber, Parliament Buildings
Present: Mr Jim Wells MLA (Chairperson)
Dr Kieran Deeny MLA
Mr Alex Easton MLA
Mr Sam Gardiner MLA
Mrs Carmel Hanna MLA
Mrs Dolores Kelly MLA
Mr John McCallister MLA
Mrs Claire McGill MLA
Mrs Michelle O’Neill MLA (Deputy Chairperson)
Mrs Iris Robinson MP MLA
In Attendance: Mrs Stella McArdle (Clerk)
Mr Mark McQuade (Assistant Clerk)
Mr Neil Sedgewick (Clerical Supervisor)
Mr Joe Westland (Clerical Supervisor)
Mr David Irvine (Clerical Officer)
Apologies: Ms Sue Ramsey MLA
The meeting commenced at 2.01 pm in public session.
5.22 p.m. the meeting moved to closed session.
10. Consideration of Committee report on obesity
The Committee considered the draft report on its Inquiry into obesity.
The Committee considered and agreed amendments to paragraph 22, 62, 83, 95, 96, 97, 100, 108, 114, 120, 129,134, 135 and 152 of the draft report.
The Committee agreed the summary of recommendations
The Committee agreed that Appendix 1 to 6 be included in the report.
The Committee ordered the Report on the Inquiry into obesity to be printed.
The Committee agreed that an extract of today’s Minutes of Proceedings should be included in Appendix 1 of the report and were content that the Chairperson agrees the minutes relating to this to allow them to be included in the printed report.
The Committee agreed that a printed copy of the report be sent to each of the witnesses who gave oral evidence and those organisations who made written submissions to the inquiry.
The Committee agreed that the Department should be provided with a copy of the report in advance of the debate in the Assembly.
The Committee noted that a motion for the debate of the report in Plenary would be discussed at the next Committee meeting.
[Extract]
Appendix 2
Minutes of Evidence
26 February 2009
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Witness:
Dr Jane Wilde |
Institute of Public Health in Ireland |
1. The Chairperson (Mrs I Robinson): This evidence session will form part of the Committee’s inquiry into obesity. Members will find a briefing paper from the Clerk, and other relevant information, in their packs. We have already received a large number of submissions, copies of which are also provided for members’ attention.
2. Dr Wilde, you are very welcome. The usual format will apply — you will have up to 10 minutes for your presentation, after which members may ask questions.
3. Dr Jane Wilde (Institute of Public Health in Ireland): Thank you very much indeed. First, I want to say how pleased we are that the Committee has chosen to hold an inquiry into obesity. In particular, we believe that a focus on prevention is a very important part of tackling the problem, and it is on that aspect that I will concentrate today.
4. I very much welcome the opportunity to appear before the Committee. I think that the best way to approach such a complicated subject is to select five or six points to talk about. First, I want to comment on the extent and impact of obesity. Secondly, I will talk about why I think there has been such a huge rise in obesity, and why we need a strategic response that is long term and sustainable. Of course, in the short term, we also need a response to the problems that currently exist.
5. Thirdly, I want to emphasise the importance of a cross-Government approach to this very important public health issue — and I am sure that the Committee has heard that point many times. However, I will also highlight the need to reach well outside Government to the community and private sectors, because if we do not do that, there is no way in which we can tackle this huge issue.
6. My fourth points relate to evidence: what we know, and how we need to build a better evidence base about what actually works and what will help to stop the big increase in obesity levels. Finally, I want to say something about what we need to learn from elsewhere, because, of course, very many countries are facing the same crisis.
7. I will start with the first point about the extent and the impact of obesity. There is no one here who does not know that obesity is on the rise. However, it is really alarming when one starts to examine the problem in more detail. Obviously, like yourselves, I was aware of the rise in obesity levels, but when I think of how obesity is a risk factor for so many conditions — whether it be heart disease, cancer, joint problems or hypertension — I begin to see that it really matters and has a profound effect on the health of people in Northern Ireland.
8. Recent data suggests that well over half of the adult population, nearly 60%, is either overweight or obese, with about a quarter of adults being obese. Of course, there is also a huge rise in obesity levels among children. Nearly one quarter of primary 1 children will be overweight or obese in the next few years.
9. We carried out a study to find out about the rates of diabetes, and we forecast that, between 2005 and 2015, the number of people in Northern Ireland with diabetes will rise by about 17,000. As a result of that increase, by the year 2015, about 84,000 people in Northern Ireland will have type 2 diabetes. We considered the issue across the island and reckon that that number will be 280,000. Therefore, the scope of the problem is large, and its impact huge. Not only is there a cost to individuals, but there is the cost to society through loss of productivity and the cost to the health and social care system.
10. Thus, we are facing a very big issue. Why is that happening? At the heart of the problem is the imbalance between what we take in and what we put out — in other words, the energy we expend. All the studies that have examined the issue from a scientific angle say that the problem will not simply be solved by individuals. Quite honestly, it is not as though half a million adults in Northern Ireland decided that they wanted to get fatter. It is not about that. Yes, that is an issue, but we really must take a wider view and see the problem in a social, environmental and economic context.
11. I very much hope that, during the course of the inquiry, the Committee will see the obesity problem as a wider societal issue. Although there is obviously a need to inform and educate individuals, any action must reach out to include the food sector, the planning sector, practically every Government Department, and people right across Northern Ireland. That is really all I want to say about the extent and impact of the problem.
12. To follow on from that, we have watched obesity levels rise over perhaps 20 or 30 years, so we must plan a long-term response. It will not be a case of being able to say in the next two years, “OK, we have sorted this problem out". Yes, there could be short-term gains, but we really must be in this for the long haul, and we must have a strategic response. I know that the Department of Health, Social Services and Public Safety is putting together a briefing paper for the Committee to outline how the issue is being tackled, and hopefully departmental officials will appear before the Committee to explain it. I will not say any more about that because that is the Department’s work.
13. However, the purpose of the strategy is to ensure some coherence between what is happening locally and what is happening across Northern Ireland. Someone asked me whether much was being done, and I said that there are hundreds of small interventions in schools, communities, workplaces, and so forth. That must be set in a regional strategy so that there is some coherence between what happens across Northern Ireland and what happens locally.
14. We also have to be clear about who is responsible for what, because, with so much going on and so many people and organisations being involved, it is really important that there is some leadership, accountability, responsibility and a mechanism for reporting on what is happening. As well as the long-term strategy, we need things right now. Many adults are overweight, and we need to decide how we will help them and how we will stop them from becoming more overweight. I am not concentrating on the treatment care side, because that is not my prime business, but we need to be very careful, particularly with the recession, that what is happening with regard to eating and physical activity is not causing people more harm.
15. Cost is a big issue, and we have to think about the people who will be disproportionately affected by the recession and about what we can do to try to make it easier for people to eat healthy, nutritious food on a low income. That is an urgent issue, and some ideas about what we could do include, for example, having good studies and good co-ordinated action, particularly with young people.
16. What about cross-Government action? If one considers the reasons for obesity, it is clear that all Departments need to be involved. A major issue is how the Committee for Health, Social Services and Public Safety can help by advocating cross-departmental, cross-party support for such an important issue. I am not sure whether it is standard practice to write to all the other Committees.
17. The Chairperson: We have done that.
18. Dr Wilde: It is important to get a call from the other Committees about how they view the issue in relation to their policies, because the last thing that we need in Northern Ireland is one Department going in one direction and the other Departments going in a different direction. It is so easy for action in one area to undermine action in another area. For example, we could say that we want the built environment to concentrate on encouraging physical activity and by providing green space and play space, but, at the same time, other Departments could be developing plans for building on similar sites. If we were not to take that into account, it would totally undermine the health benefits.
19. Many of the issues concerning obesity are upstream, in that they are trying to create a wider social policy. During the recession, when finances are really under pressure, it is important that those sorts of issues do not get lost, and they can get lost. Therefore, I urge that some emphasis be given to those issues if possible.
20. The Committee could play a significant role by insisting on the health impact assessment of Government policy. All planning applications should be examined in relation to their impact on health and on the obesogenic environment — for example, questions must be asked about whether they are helpful or harmful with regard to obesity. I am sorry about the terminology.
21. Although the impact of obesity falls on the health sector, and there is much that the health sector can do, it is up to many other sectors outside Government to do something. For example, I am particularly interested in what the food sector might reasonably be expected to do about addressing obesity. Obviously, it is a complicated area. However, if we let the situation continue as it is, without some greater checks on what is happening to the food sector, we will do a grave disservice to people in Northern Ireland. There is a requirement on the food sector to act responsibly within a certain timescale. It is important to go beyond a voluntary approach by the food sector. It is such a big area that I hardly know where to start, but we are talking about issues such as food labelling, pricing, availability, subsidies, local production, and so forth. That is a crucial issue.
22. The issue of how to integrate research into policy is huge. Perhaps the Committee might consider convening a round-table meeting of some of Northern Ireland’s leading researchers on obesity, diabetes prevention, and so forth, to try to gather the scientific evidence that might help in order to have a conversation about what you need to know and what they have to offer.
23. It is important to bring research, policy and practice together to try to work out what we know and also to identify any gaps. There is every danger in Northern Ireland that there will be more and more interventions, and we will not know what is working or not working. The idea of a continuous improvement in evidence is very important.
24. At the institute, we are trying to develop an initiative, currently called an “obesity observatory", to which we hope people will be able to turn for evidence when it is gathered. It will be a one-stop shop for evidence and data, particularly local data. People will be able to find out about the obesity situation, and obesity determinants, in their own council areas. I hope that that will be a helpful addition.
25. I have not mentioned the role of different sectors of the Health Service, whether in primary care or public health; I hope that there may be some questions or debate about that.
26. Northern Ireland is not the only place that is facing this problem. It is a major issue for all middle- to high-income countries, and is, sadly, becoming an issue in low-income countries. Not only are there one billion people across the world who do not have enough to eat but one billion people who have had too much to eat and are overweight or obese. We are facing an amazing global situation in relation to food.
27. Closer to home, what can be learned from Europe, the UK and the island of Ireland? We can probably learn quite a lot, but we are all struggling. The big issue might be for us to decide what we want to co-operate on rather than simply saying that we should have good relations with other parts of the UK and other parts of Ireland. Let us actually decide what it is that we want to learn from other places, and what we can test to help other places.
28. I will finish by acknowledging that the issue of obesity is very important and to wish the Committee good luck with the inquiry. I am happy to answer any specific queries. Thank you.
29. The Chairperson: Thank you very much for your presentation. It is an all-encompassing issue. We have written to Departments, but I think that, so far, there has been very little uptake.
30. The Committee Clerk: There have been a couple of responses.
31. The Chairperson: The deadline has just passed, so those Departments have not stepped up to the chalk line.
32. Mr Gardiner: It is lovely to see you, Jane, and you are very welcome. I will give you a little bit of encouragement; I was pleased to hear yesterday evening, at a meeting of the board of governors of Dickson Primary School in Lurgan, that an additional 10 children now attend the breakfast club. That is where we have to start — the primary school. Parents are dropping their children off — I will not saying “dumping" — on their way to work, and whereas those children would normally have had a packet of crisps and a bar of chocolate or something like that, they are now eating healthy food and fresh fruit. I welcome that.
33. Those children all have their own bottles — plastic, admittedly — with their names and the name of the school on them, and there is a water fountain so that they can get water as often as they need to during the day. I think that we are making a start. We must start at an early age.
34. Perhaps it is slow learners or people with a disability who are not active or fit who fall into the category of obesity. How do we get over that difficulty?
35. Dr Wilde: Breakfast clubs play an important role not only in nutrition but in wider health and well-being, social cohesion, and so forth. They are to be welcomed and should be protected during any public finance pressures.
36. Your second point was about the connection between obesity and people who have difficulty learning. There is ongoing research in your local health board area into that issue. I do not know whether there are any results yet, but I know that special programmes have been developed.
37. Mr Gardiner: Is that happening in areas other than Craigavon?
38. Dr Wilde: I do not know, but that is well worth exploring.
39. Mr Gardiner: It is worth checking out.
40. Dr Wilde: I am happy to follow that up.
41. Mr Gardiner: More publicity is needed on the subject to bring it home to people.
42. The Chairperson: Quite a number of schools across Northern Ireland have embarked on breakfast clubs with an emphasis on healthy eating. As Sam said, many parents have to hold down two jobs and are, therefore, rushing off to work and are leaving — not dumping — their children off as soon as the school gates open, so it is good to know that they are getting a sensible breakfast. That is important to the education of young people.
43. Mrs O’Neill: Thank you, Jane, for your presentation. A key point that you made was that the impact falls on the Department of Health, Social Services and Public Safety. Although a consistent approach must be taken across all Departments, the brunt of the financial cost of tackling obesity and the associated health problems falls on that Department. That is important for the Committee’s inquiry.
44. Many good things are happening, but, according to the University of Ulster, no country has led the way or been able to bring a marked turnaround or a significant change in how obesity affects their country. Are you aware of examples of good practice to which we could look? The Department’s submission states that there is an opportunity for it to take a leading role in that worldwide problem. That is an ambitious target. There is much work to do, including pushing Departments to work together and to co-ordinate their approach as to how they tackle it. What are your thoughts on that?
45. Dr Wilde: You raised the issue of whether any country has really cracked the problem of obesity. Many countries have good strategies and plans, but the issue is to find out what is actually working. Norway, for example, has been able to shift its national diet in a positive way. It has done so by a combination of pricing, subsidies, information, education and labelling. A strong Government–society approach was taken seriously, and a major effort was made.
46. Mauritius and Brazil have also had strong initiatives. Brazil promoted physical activity, and Mauritius focused on food. I hear that the levels of obesity are levelling off in France, but I do not think that we can turn to any one country, particularly one that is close to us, and copy it. All countries are struggling with the problem a little bit.
47. If we decided that we wanted to become the best country in that regard, we could do so. However, that would take some going. I would love to be able to be part of Northern Ireland’s becoming the best at obesity prevention. We would be doing such a wonderful thing for the health of people in Northern Ireland, and we would save a fortune in lost productivity and health and social care costs. Who knows what the opportunities might be for local food co-operatives and for achieving better educational results in schools from children who were well fed? The benefits could be gigantic. That would happen only if the issue of obesity were made a serious cross-Government priority, and that is a big ask.
48. Mrs O’Neill: A Programme for Government commitment is to halt the rise in obesity by 2011, so at least that is down on paper.
49. Dr Wilde: It is down on paper, and that must also mean something serious in practice.
50. Dr Deeny: You are very welcome, Jane. I agree with you; those of us who provide primary care must do our bit as well.
51. I want to focus on education; which is a cross-departmental issue. Nowadays, some schools place a great deal of importance on academic qualifications and do not give enough time to sport, exercise and physical education. That is a concern in my local area. Should schools be required to devote a certain amount of hours in the week to physical exercise and sport? I am worried that children are very wrapped up in GCSEs and A levels.
52. I am not one to talk; I need to lose a bit of weight myself. However, there is a huge difference between Omagh 15 years ago and the town today. I see young girls who are much heavier than girls of the same age 15 years ago. I do not think that they are getting the amount of exercise and physical education in school that they should. Academic achievement is so important now, that exercise is not a priority. Should the Department of Education say to schools that they should devote two or three hours a week to physical exercise for their pupils?
53. Dr Wilde: Absolutely; I totally agree with you. To go back to the previous question: can we be the best? Yes we can, but only if we have that kind of serious commitment. What you are saying is spot on. I echo the point that you made. One only has to walk around to see what is happening. Children do not engage in enough physical activity, but that could be changed.
54. Mr McCallister: You have probably gathered that the Chairperson’s suggestion to hold this inquiry received unanimous support. It is such an important issue for the Committee. Most of my colleagues are in agreement; one of the biggest difficulties for the Committee and for the Department of Health, Social Services and Public Safety is getting other Departments to buy in and invest in what is needed. There is no financial reward; as Michelle pointed out, the burden falls entirely on the Department for Health, Social Services and Public Safety.
55. Committee members spent the morning with representatives of the British Heart Foundation and discussed the problems of obesity and diet. You mentioned diabetes; in your opening remarks, you also mentioned writing to other Committees. I sit on the Committee for Regional Development, which takes a significant interest in initiatives such as the Safe Routes to Schools programme. That programme is running in 18 schools across Northern Ireland, and it gets parents and kids to walk to school in order to build an exercise regime into their day and take away their excuse that they do not have time to take exercise. We must replicate that across all Departments.
56. As Kieran said, the Department of Education must have a role, and so should the Department for Regional Development. We must make exercise safe, accessible and easy for people. The Department of Education can play a role in teaching people about diet and about preparing a healthy meal on a budget. There are many issues to discuss.
57. I come from an agricultural background, so food labelling has always been a concern. I was speaking to my colleague Jim Nicholson MEP a few nights ago, and he told me that the European Parliament has been discussing food labelling for more than 20 years, and whether food labels should include health information and other details such as the country of origin and the ingredients. There is also an issue about making such information easy to read. Those are important matters for us all; European rules limit what we can do in Northern Ireland about food labelling.
58. Dr Wilde: You identified excellent local interventions and asked whether they can be mainstreamed across Northern Ireland. It would be great to have the determination not to leave such interventions to be replicated at a gradual pace. Rather, on recognising a good intervention that is seen to work, whether it is regulatory or involves physical activity, it should extend to all schools.
59. Europe presents a difficulty in that measures that were introduced to protect people now act against them. However, there are ways in which Northern Ireland can get round some of the difficulties. It is amazing how many people are interested in obesity. Even as I waited before today’s meeting, I talked to various people about the subject. Everyone has a part to play, and everyone has an idea about what could be done better to tackle obesity. Of course we should be able to introduce good labelling systems here, and we should not tolerate systems that are bad for our health. Why should we? It is ridiculous.
60. I want to pick up on the cost to the Health Service. It occurred to me that, although much of the cost falls on the Health Service, if we consider the issue in a wider sense and take into account the loss of productivity, and so forth, a significant amount of the cost falls on other Departments; but it is not necessarily calculated in the same way. Perhaps more evidence to demonstrate that might stimulate other Departments to make further efforts.
61. Mr McCallister: To follow on from employment issues, time lost as a result of obesity and, as Kieran mentioned, its effects on education, perhaps the cost to business could also be measured. In the Department of Health, Social Services and Public Safety, the cost is measured in pounds, shillings and pence.
62. Dr Wilde: Given the huge impact of obesity on the people of Northern Ireland, it seems strange that it is not a high priority across Government. It is not as though the people who make policies and devise programmes are immune to the harm that we are discussing.
63. Mrs Hanna: Good afternoon, Jane; you are most welcome. We all have a personal interest in trying to control our weight.
64. The Programme for Government identifies obesity as an issue, which is a start. The Committee has talked about having a cross-departmental meeting on children’s mental health with the Committee for Education. Obesity, with its effect on self-esteem, creates huge mental-health issues for children, particularly if they continue to carry excess weight that they find more and more difficult to lose. The Committee has discussed and analysed obesity, and there is a huge interest in the subject. You mentioned evidence, and that is important; many pilot schemes are not picked up on because of a lack of evidence that they work.
65. I am trying to think of small, practical measures that could make a difference. Schools, for example, can take practical initiatives, such as having breakfast clubs and making sport fun rather than purely competitive, which applies to girls in particular. Girls tend not to play sport and seem to walk around eating crisps. When driving through any town or through the countryside at the end of a school day or at lunchtime, boys are at least kicking a ball around.
66. More legislation is also required, particularly in the food sector, because nothing changes behaviour more than that. Any legislation must be based on ensuring that people understand obesity, and it must take into account the issues of poverty and affordability. Some people do not have the choice, even when they know that they should be eating more fruit, to go to Marks and Spencer to buy lovely berries, mangoes, and so forth, and they need much more support.
67. I hope that tackling obesity will be a priority of the new public health agency, and that you and others who have been working on the issue will have a huge influence on that. At an informal meeting, the Committee heard an extremely interesting presentation on obesity. I cannot remember the doctor’s name, but much of his presentation focused on mind over matter and the psychology of obesity.
68. The Chairperson: The doctor is called Michael Ryan.
69. Mrs Hanna: Michael Ryan; I found him fascinating. People need to be motivated and to want to change. It is not that we do not all want to lose that half-stone, stone, or whatever; it is about being so motivated that it will happen. Much more interesting work could be done. I know people — not too far from me and from my heart — who have an issue with their weight. It is difficult, because people get very defensive and upset when they talk about losing weight, even though they want to. It is a hugely difficult area, and the psychology around it is important. That, along with the small, practical things that we can do at the start, make a difference.
70. Dr Wilde: The evidence shows that most children who are overweight or obese carry that through the rest of their lives. There is a high risk that, if a child is overweight or obese, he or she will be overweight or obese as an adolescent and as an adult, which has a harmful effect on people’s psychological well-being.
71. What role could the new public health agency and the new structures play? I would like the issue to be co-ordinated and, as they say, “rolled out". One often asks what small, practical things could happen. Part of my difficulty is that I find it hard to grasp what is happening across Northern Ireland. I would like the agency to play some role in putting together an inventory of what is happening, but I do not mean that it has to spend five years doing that. It could highlight what is working, what may be working and what is not working. We should be replicating situations that are working. It is not that I have a whole range of other small ideas; in fact, lots and lots of small ideas may not be the way forward. However, that is not to take away from the urgency of the situation. We must develop a system whereby we learn from what we are doing, rather than doing this, that and the other, and seeing how it goes.
72. A point was made about making things attractive. At the heart of the matter, there is the issue of how we make it attractive to eat more fruit, vegetables and salads, and how we make it attractive to exercise. That is what the creation of a better social environment is all about. We should learn a little from what has happened in other public-health issues, such as smoking. Everybody tried to turn the tide from smoking being seen as attractive thing to do, to smoking being seen as not attractive. There are definite possibilities in relation to physical activity and nutrition.
73. Mrs Hanna: What is your view on mind over matter? Michael Ryan had a theory that people needed to be put into a particular frame of mind to be ready to lose weight.
74. Dr Wilde: That makes sense to me. However, I do not know enough about the science of it. Nevertheless, one could imagine that that is true. If one is feeling low, one does not believe that anything can be done. It reminds me of the question about Northern Ireland being the best. It will not be the best if everyone believes that they are hopeless.
75. Mrs Hanna: Dr Ryan said that there are techniques to motivate people.
76. The Chairperson: One of the saddest things that I heard some time ago was about children who were afraid to get dirty because of the nature and quality of their clothes. I thought that it was very sad that children were afraid to get their clothes dirty and that their mothers did not allow them to go out to play. They then become couch potatoes and obese because there is no physical activity in their lives. If we are to consider children specifically, we also want to get them away from sitting for hours on end at computers. That is another area that needs to be addressed.
77. There is great concern in respect of those people in areas of deprivation. However, another tier of people is falling into that trap because of high mortgage payments going out, while their properties are worth less than half the value of what they used to be. They too are struggling, and something has to give; sadly, that is usually the quality of food. As houses are taken over by building societies and banks, I think that we will see more people fall into the trap of need.
78. Mr Easton: I have just eaten a packet of Minstrels so I am feeling a bit guilty. I consider myself to be a typical ordinary person who goes out shopping and, I have to be honest, does not read labels — my wife should be doing that but she is not. I believe that the majority of people do not read labels, and therefore, it will be a really tough task not only to educate people, but to try to make them do it. I do not know what the answer is; it is going to be very difficult. I am guilty of it and I will admit to that.
79. I do not understand why the cost of food is so high among all the big retailers, given that oil prices have gone down. In shops such as Tesco, there will be two packets of biscuits for the price of one, or something like that, and, I have to admit, I will buy them. Reductions do not tend to be on the good food, they are always on junk food. We need to look at what can be done to try to make retailers reduce the price of good food. I am guilty of all those things; however, I acknowledge that there could be huge savings for the Health Service, and an improvement in people’s general health, if something could be done.
80. The Chairperson: To save your marriage — and you are only just married — I will presume that you meant that you and your wife should do the shopping together. [Laughter.]
81. He is only a few months married, so one has to give him a little bit of leeway.
82. Dr Wilde: I totally understand your position regarding labels; apart from anything else, the labelling is usually so small that you need to have very good eyesight to read it. Other things, such as the traffic light system — which I am sure you have heard of — are more straightforward, and organisations such as the Food Standards Agency will be able to give you information about that system.
83. There is the further issue of how to make sure that what is sold in supermarkets is not always biased toward the unhealthy option, and it would be good to have some conversations on that with the food industry in Northern Ireland. You are similar to many in the population, in that for at least half the population, health is not a driving force when they go shopping. Therefore, we have to acknowledge that people are not necessarily going into shops to look for the healthy option; they are going in for high quantity and low cost. It is quite unrealistic for us to be pushing the healthy option if that is not aligned with the cost option. We have to take that on.
84. The Chairperson: The manufacturers and the food industry have to revisit the whole concept of how they promote foods, given that, worldwide, there is an economic spiral which does not seem to be petering out.
85. Mr Gallagher: Do you view alcohol and its associated lifestyle as a problem? Are there measures that should be taken to tackle problems such as alcohol advertising?
86. Dr Wilde: Public health problems such as alcohol, obesity, diabetes and heart disease — and the approaches to them that would make a difference — are all related. Education, for example, should be provided on all aspects of health, including alcohol, mental health, food and exercise. There should be an integrated approach to health and to cross-Government interest in it.
87. If I were asked whether obesity should be the top priority, I would say that it must be a key priority. The top priority should be to have a strong public-health approach that recognises the need to integrate our education, school, food and private-sector policies. Otherwise, it will be a case of having a discussion about obesity, then a discussion about alcohol, and then a discussion about something else. That is not the way forward.
88. Legislation on alcohol is a completely different issue, about which I did not come prepared to talk. I may have missed the point of your question. Perhaps I would be in a better position to respond if you clarified your thinking on the matter.
89. Mr Gallagher: There is a rise in alcohol consumption here, and I think that there is health damage associated with that. I want to know what you think about that issue.
90. Dr Wilde: There are major public-health issues associated with alcohol and young people’s use of alcohol. There are also issues in relation to pricing and availability. The general points that I have made about obesity also apply to alcohol.
91. Mr Gallagher: Is there a link between alcohol and obesity?
92. Dr Wilde: Alcohol is full of calories and could, therefore, be related to weight. I am not sure about the exact nature of the relationship between alcohol and obesity. Perhaps Kieran could help me out on that point; I need some assistance. [Laughter.]
93. Dr Deeny: The relationship is basically as you have described — it concerns the amount of calories that alcohol contains.
94. Dr Wilde: Alcohol is a risk factor for most of the illnesses for which obesity is a risk factor, such as cancer, heart disease, high blood pressure and stroke. Part of the purpose of trying to do something about obesity is to reduce levels of heart disease, cancer, and so on. Therefore, we should be doing something about alcohol as well.
95. The Chairperson: All of the members who indicated that they wanted to ask questions have done so. I will read a piece of information and then ask a couple of related questions.
96. Research Services’ ‘Obesity Inquiry Research Paper’ quotes ‘Tackling Obesities: Future Choices — Project Report’ and states:
“Research commissioned by the UK Government’s Foresight programme examining ways of tackling obesity, revealed that, ‘the causes of obesity are embedded in an extremely complex biological system, set within an equally complex societal framework [and] will take several decades to reverse those factors driving current obesity trends.’ "
97. It goes on to state that a key difference between the devolved regions in addressing obesity is the setting of obesity-related targets. England and Northern Ireland — where the current targets set by the Department of Health, Social Services and Public Safety are to halt the rise in obesity by 2011 — have set direct obesity-related targets, but Wales and Scotland have not.
98. Is setting such a general and short-term target realistic? Is it achievable or measurable? Can I canvass your views in relation to the effectiveness of setting targets as part of an overarching strategic framework?
99. Dr Wilde: I will answer the second question first, on whether I think that setting targets is a good idea. I personally think that it is a good idea, because it gives us something to aim for. It forces us to measure things which will help us to work out what the gap is: it is only when you set the target that you can see what needs to be done, and where we are in relation to that.
100. There are issues around whether the targets should be as general as halting the rise in obesity, or whether it should also be about setting specific targets for men, women, young people, and different ethnic and geographical groups, as the Northern Ireland Audit Office report recommended, which would make this a bit more sophisticated. I think that we should be doing that. In some cases, we do not have the information or data to be able to do that, but a debate around targets would encourage us to get that information, which I believe is important.
101. The important thing is not to have endless discussions about what the targets are — that would become a complete waste of time — but to set some general targets, like halting the rise in obesity, and then set some specific targets. The halt in the rise of obesity target is aimed at children. We should have a target for adults, and we should have a target for men and women, but we really need to think, not just about end-point targets, but about what the intermediate indicators are, that would be a bit more practical.
102. For example, to return to Kieran’s point about physical activity, we could gather information on how many hours of physical activity that children get in schools, and set a target for that. We could find out how many people are eating five portions of fresh fruit and vegetables a day, and so on, and that would help us to work out where we are in relation to what might be called intermediate indicators, that we assume would lead to a reduction in obesity.
103. Yes, there should be a good monitoring system with good targets, and good data to support that, which would be fed back. One of the things that I did not say is that in all of the work that is going on, and as the Department develops its strategy, it is really important that things are put back into the public domain so that we know what is happening; so that people like you, the politicians, get a sense of what is going on. That would help to better inform the public about what action is happening, and I think that targets can help that.
104. The Chairperson: Thank you, Jane for your time and for answering questions. It is a huge subject matter, which is far-reaching, and affects all Government Departments and every walk of life. It will be interesting to see what comes out of the inquiry.
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
Mrs Claire McGill
Ms Sue Ramsey
Witnesses:
Dr Naresh Chada |
Department of Health, Social Services and Public Safety |
105. The Deputy Chairperson (Mrs O’Neill): I welcome Andrew Elliott, the director of population health, Dr Naresh Chada, a senior medical officer, Rob Phipps from the health development branch, and David Galloway, the acting director of secondary care. I invite the witnesses to make a short presentation, which will be followed by questions.
106. Mr Andrew Elliott (Department of Health, Social Services and Public Safety): Thank you for inviting us here today and for helping me to skip introducing my colleagues. My responsibilities include improving and protecting the health of the population — in other words, the public health policy remit, reporting to the Chief Medical Officer — and I am accompanied by David Galloway, who will pick up on matters of concern to the Committee, concerning the treatment of obese people.
107. The Department of Health, Social Services and Public Safety welcomes the Committee’s interest in this important health issue for our times and for the future. As members are probably aware, this matter has been described as a time bomb, which will have a significant impact on the health and, indeed, wealth of all our futures. We live — at least in this part of the world — in a time of abundant food, but our ancient physiology is based on famine. Consequently, our bodies are designed to seek out, and consume at every possible opportunity, salt and — more pertinently for the purposes of this discussion — sugar. Therefore, it is no surprise that the food industry has recognised that fact. In a time of plenty, it is well placed to offer us whatever our genes have told us to desire. Furthermore, in recent decades, there has been a significant change towards more sedentary lifestyles, and there is a real issue with changes to our built environment not only in Northern Ireland but elsewhere.
108. No doubt Committee members have had an opportunity to read the Department’s written submission, and I do not propose to repeat it. Instead, I shall mention some of the key issues.
109. It is important to articulate that tackling obesity is one of the most important public health issues with which the Department is dealing. The ‘Northern Ireland Health and Social Wellbeing Survey 2005/06’ indicates that 59% of adults surveyed were either overweight or obese. The figures for children were lower, but they are still extremely worrying and are on the rise: 5% of five-year-olds are already obese, and 22% are overweight. The fact that the trend is rising gives enormous cause for concern, although the most recent figures indicate a little easement. We can return to that point.
110. It is important to note that the figures that I have quoted are similar to those found in Europe and North America, so we are all facing a similar problem. Therefore, a component part of the Department’s work will be to monitor interventions elsewhere closely, particularly if they are found to be effective.
111. The twin problems of too much energy in and not enough energy out — in other words, the lack of a healthy diet and an inadequate amount of physical activity — have long been recognised as risk factors for coronary heart disease. That fact was recognised here in the late 1980s, and those factors became the two essential targets in the Change of Heart programme, which some members may remember.
112. Throughout the 1990s and the early part of this decade, resources were directed towards promoting healthy eating and increasing physical activity, and those measures continue to form part of the Department’s work. In 2002, the Department launched its acclaimed Investing for Health public health strategy, which was important because it picked up on many factors relating to health determinants and wider issues.
113. At that time, there was a key change in strategic thinking, resulting in the Department identifying the need to focus on childhood obesity. It is not just an issue for the Department of Health, Social Services and Public Safety but one for cross-Government action, which is why the Fit Futures task force emerged in order to put in place an action plan aimed at preventing children and young people being overweight or obese. It contained recommendations for integrated cross-departmental action. That was made manifest by the development of a joint target among the Department of Health, Social Services and Public Safety, the Department of Education and the Department of Culture, Arts and Leisure to halt the rise in obesity in children by 2010. The final report of the Fit Futures task force was published in 2006, which identified a number of priority approaches: over 70 recommendations for action were made.
114. The Department’s current position on prevention is to build on Fit Futures, but to move to a position founded on recognition of the importance of addressing obesity across the entire life course. The vast bulk of our present work on obesity is founded on that principle of aiming at the whole life cycle. We remain committed to a cross-departmental and cross-sectoral approach. We recognise that, as well as the Department of Education and the Department of Culture, Arts and Leisure, other Departments also have a vital role to play. We will continue to press for a greater use of health impact assessments by Departments with responsibility for the built environment and for regulation of the food industry.
115. Our written evidence shows that we committed to developing an obesity prevention strategic framework by spring 2010. In the meantime, actions and initiatives that address childhood obesity in support of Fit Futures will continue. The new framework will not be a panacea. Challenges remain, particularly those related to what is known as the obesogenic environment, an environment in which it is more difficult for people not to become overweight. We are trying to tackle a long-term lifestyle issue in a world where the emphasis is often placed on short-termism. Our obesity prevention strategic framework must address those kinds of challenges and turn that trend around. That will not be easy, and it will not be possible for my Department to achieve that on its own.
116. I hope that we will have a chance to pick up on those issues in more detail during questions. I ask Dr Chada to make a few introductory remarks about the health and wealth impacts of obesity.
117. Dr Naresh Chada (Department of Health, Social Services and Public Safety): Thank you very much for outlining the key issues, Andrew. I speak as a doctor and a public health specialist; I am extremely concerned about obesity, as are other colleagues in the Department of Health, Social Services and Public Safety, particularly the Chief Medical Officer.
118. I will give the Committee a quick overview of some of the health impacts associated with obesity. We are all aware that heart disease and strokes continue to be among the biggest killers in Northern Ireland, and smoking causes much of that. However, obesity is an important risk factor for those conditions. If someone is under the age of 50 and happens to be obese, he or she is twice as likely to suffer a heart attack or have a stroke.
119. We are all aware of the many people in Northern Ireland who have diabetes: 65,000 to 70,000 people suffer type 2 diabetes. If one happens to be obese, one is 20 times more likely to suffer from that condition. The Institute of Public Health in Ireland has done much detailed modelling, particularly with respect to the way in which type 2 diabetes is likely to increase over the next five to 10 years. If we do not halt the year-on-year increase in obesity, we could have another 10,000 to 15,000 people with diabetes in Northern Ireland by the early to middle part of the next decade. That is also a matter of particular concern.
120. Other health issues are not as intuitively obvious. Cancer — particularly gynaecological cancers — are also associated with obesity. I refer to cancer of the uterus, cervix and ovary. Men may be affected by bowel and prostate cancer. A certain proportion of cancers can be attributed to obesity. Conditions of the respiratory system are also associated with obesity, including sleep apnoea and associated breathing problems.
121. We are all aware of the problems that orthopaedic conditions cause, both with regard to pressures on the Health Service and the wider workforce. Lower back pain, hip and knee issues are also associated with being overweight and obese.
122. That is a range of the issues that are associated with obesity and the public health impact that are important to everyone. I am sure that the Committee will consider those as serious issues.
123. I want to talk about health economics issues. Health economics is an inexact science, but I will quote some facts and figures associated with the costs of obesity. The 2003-04 House of Commons Select Committee on Health Third Report estimated that the cost of obesity was £3·7 billion per annum, which is a considerable resource.
124. The ‘Foresight: Tackling Obesities: Future Choices’ project report — to which we will refer throughout the evidence session and which forms a large part of the evidence base and policy behind current thinking on obesity — suggests that, by 2050, at current prices, we will be spending £10 billion a year across the country on direct Health Service costs associated with obesity. There will also be costs of around £50 billion a year associated with the loss of productivity and workforce issues. Huge resources are involved if we do not tackle the issue of obesity.
125. There are other estimates relating to Northern Ireland. It has been estimated that 260,000 working days are lost each year because of obesity-related conditions, costing the economy approximately £500 million. A recent Northern Ireland Audit Office report, ‘Obesity and Type 2 Diabetes in Northern Ireland’, states that, throughout the UK, diabetes is thought to cost the Health Service around £1 million an hour. In Northern Ireland, that translates into around £1 million a day. Type 2 diabetes is closely related to obesity and has a huge economic impact.
126. Mr David Galloway (Department of Health, Social Services and Public Safety): Generally, people present in the health system through morbidities other than their weight. That is recognised in the general medical services contract through the use of quality and outcomes framework (QOF) points and directed enhanced services (DES) for long-term conditions management. Some £800,000 has gone into supporting those DES directions, and 90% of GP practices have signed up to them. We have very high rates of achievement in the DES points, and high scores against QOF points.
127. Currently, we do not have any clear data to show the difference that primary care activity has made for those people. When they come into the secondary care system — Naresh has already outlined the impact of obesity on the health of those individuals — there is a significant knock-on effect for the secondary care sector.
128. There are services that are more specifically directed toward treating obesity and overweight people. We can refer people to a dietetic service, which can examine their diets. People who present for surgery will undertake preoperative assessments that offer them advice about managing their body weight, lifestyle, nutrition, exercise, and so on.
129. At the far end of that spectrum of activity is the possibility of surgery for those who are extremely obese. In the past, the National Institute for Health and Clinical Excellence (NICE) has issued guidance on access to bariatric surgery, and the Department has endorsed a clinical guideline for Northern Ireland. As such, it remains an aspirational programme.
130. Bariatric surgery is not currently commissioned by the health boards in Northern Ireland, although, last year, £1·5 million was made available to ensure that some 120 people had access to bariatric surgery from providers in Great Britain. The boards are currently discussing how they might progress that issue in 2009-2010 to ensure that that service is provided to the people who are most likely to benefit from it.
131. The Deputy Chairperson: Obesity is a cross-departmental issue, although the Department of Health, Social Services and Public Safety will carry the brunt of the cost of providing treatment and helping people. The steering group has been going for almost a year. Is there a good level of engagement by the other Departments that are represented on the steering group?
132. Mr Rob Phipps (Department of Health, Social Services and Public Safety): The short answer is yes. We mentioned the public service agreement (PSA) target for childhood obesity in our written submission. It is shared among the Department of Health, Social Services and Public Safety, the Department of Education and the Department of Culture, Arts and Leisure. There has been a strong partnership since 2004, but the steering group has invited other Departments to become involved. When we start to develop the framework, we will go back to those Departments to ask for outcomes; it is not enough simply to attend the meetings. I assume and expect that further discussions will take place.
133. The Deputy Chairperson: As you develop your framework, this inquiry will feed into it.
134. Mr Phipps: The timing is brilliant.
135. The Deputy Chairperson: It has worked out well.
136. Dr Deeny: I also have an interest in this subject. I see that three Departments are involved.
137. We all know about diet and exercise. There is a strong focus on diet, which is as it should be. However, there is a lot of talk about exercise but, perhaps, not enough action. Families and schools are important. I said last week that I believe that some schools have placed too much importance on academic achievement as opposed to exercise. Those of us who are privileged and lucky enough to have children have a responsibility to see that they get good exercise. I have two sons who are heavily involved in sport, but I have a daughter who is not getting enough exercise. In this electronic age in which there are so many interesting things to do on a computer, for example, I wonder what we should do as a Committee.
138. Should it not be mandatory for schools to provide at least two to three hours of exercise a week for our young people? I have seen what is happening in general practice. I have been a GP for many years, and I am now seeing young girls who tell me that they are smoking. When I ask them why — because we have to record information about their smoking — they tell me that it curbs their appetite. That is a worrying development, not to mention the fact that they are not getting enough exercise. We are too focused on what young people should not eat, but they are doing something that is harmful to their health in order to curb their appetite. We should focus on getting young people to take more exercise. Is the Department of Education thinking along those lines? I think that it should be. Should we be saying that the Department of Education should play a role and act quickly? It is just not good enough that schools concentrate on getting top marks at the expense of ensuring that young people get enough exercise.
139. Mr A Elliott: The support of the Committee on issues such as this is important. Each Department has its own challenges to face and has a lot to deal with. It is also important to say that, when it comes to the capability to learn, the mental health and well-being of children are paramount, and sport and activity can contribute to that. There is a double benefit in tackling obesity in that it helps to improve mental health and well-being.
140. Mr Phipps: Will you invite the Department of Education to this Committee?
141. The Deputy Chairperson: We have not decided that yet.
142. Mr Phipps: Physical education is a compulsory part of the curriculum for children in years 1 to 12.
143. It is up to each school, but Department of Education guidance states that they should do at least two hours’ exercise a week. In 2007, the Minister of Education launched the Curriculum Sports programme for primary schools, which aims to develop physical literacy skills. Therefore, schools are putting an emphasis on physical activity.
144. There is also the Health Promoting Schools programme, which addresses all areas. Therefore, although there is an emphasis on food and healthy eating, there is also an emphasis on physical activity. There are local activities and initiatives that involve young people of school age in physical activities, which are possible because of the Fit Futures funding that we provide to the health boards.
145. You may wish to ask the Department of Education about its guidance, but our view is that it recognises the importance of physical activity.
146. Dr Deeny: Is guidance good enough? Certain schools do not seem to be following the guidance. Is there no way to pull those schools up on that?
147. Mr Gallagher: The Department of Education will say one thing on guidance but then say that there must be 27 curriculum choices delivered at post-primary level. The Department is defeating its own guidance on exercise, because PE, games and sport are squeezed because of pressure from the other curriculum choices. Therefore, there is a bit of a problem.
148. Mr A Elliott: Schools will only ever be one component in tackling obesity — it will never be enough to rely on schools to solve the problem on their own. I can remember a piece of correspondence that our Minister received in which a doctor wrote that there was a school on the outskirts of a Fermanagh village that had no pavement for, perhaps, 100 yards from the school gate. If the authorities had designed the pavement in a different way, many more children could have been walking to school instead of being driven, because their parents were worried about them being knocked down.
149. There are many issues about how the Government and their agencies think about health and creating opportunities for movement and activity, even short of the formal sports curriculum. It is important for politicians, Ministers and Departments to begin to tackle and wrestle with those issues if we are to succeed in reducing the obesity problem.
150. The Deputy Chairperson: We must work together rather than in silos.
151. Mr Gardiner: Prevention is better than cure. Rather than nine of us on the Committee for Health, Social Services and Public Safety sitting around and listening, we must put our hand to the plough and see the work through. Along with the Departments, I hope that we can launch a publicity campaign by engaging with the ‘Belfast Telegraph’ and booking a page in all the local papers and the better-selling papers to get the message across.
152. Mr Buchanan: That will cost.
153. Mr Gardiner: It will cost more to treat a patient than to advertise to the public what they can do to prevent some of the illnesses associated with obesity. That can even be done at school level. We must work on getting that message to the public — we will not be able to get the message out as things stand, and people will continue to die. We must get the message across, come hell or high water.
154. The Deputy Chairperson: Are you talking about a Committee initiative?
155. Mr Gardiner: The Committee can push the initiative and push the Department to act. There could be a joint effort. I do not care who is involved, as long as we get the message to the public.
156. The Deputy Chairperson: We can explore that further.
157. Mr Phipps: Some of the funding that we have given to the Health Promotion Agency has been to promote physical activity through campaigns.
158. Mr Buchanan: It is not working.
159. Mr Phipps: As Andrew said, one of the key issues and difficulties is sustainability. The same applies to climate change — you have to keep going.
160. One of the difficulties that we have had in the past, because of the nature of the funding, is that one cannot get that degree of sustainability. I totally agree that we need to engage the population. It is a kind of social marketing. A number of countries are developing a social-marketing approach, which includes campaign work and getting the support of environmentalists. If there is to be a physical activity campaign, it is essential that the infrastructure is in place.
161. Schools were mentioned. Everyone should be on board, otherwise the campaign will sit by itself. The Foresight report states that there cannot be a series of one-offs; it must all be brought together. A campaign is absolutely right, but it must form part of the whole picture, and it must bring other Departments on board and get them involved. We must get the other bits together.
162. Mr Gardiner: We must start to get it right. There is not much point in sitting here talking about it. We want action.
163. Mr Phipps: I agree totally; we need action, and we also need other people on board.
164. Mr A Elliott: There is also a health inequality dimension, which is important to articulate. If a child happens to be lucky enough to be in a wealthier household, that child’s parents may drive him or her around from one interesting activity to the next on many evenings each week. If a child comes from a home without that luxury, he or she may be considerably disadvantaged as regards the risk of obesity. Therefore, we must see what we can do. For example, there is a beautiful natural environment around Belfast, but how accessible is it, how much is it used, and how safe do people feel when they use it? There is a whole host of issues that must be played into this discussion to get people moving and to get them out into the natural environment. I am thinking of Black Mountain, for example.
165. Mr Buchanan: No doubt, this is a huge concern right across Northern Ireland, when one considers the amount of working days that are lost and what that costs the economy and the Health Service. It is a big issue that must be tackled.
166. I was going to ask a question about education programmes, but that has already been answered. Schools used to buy into them. Programmes are in place in schools, and perhaps they could be widened in order to make sport or some such activity more creative for the children. Some children do not like sport as much as others. We must open it up and make it more creative to get them involved in some other type of physical activity. However, it goes wider than that.
167. What initiatives are available at GP surgeries or in local health centres, so that patients who attend those centres are made aware that there is an obesity problem that must be dealt with? Those patients need to take on the responsibility to deal with their situation. District councils provide parks and leisure facilities. However, we must get the message across to people to use those facilities, which will help them to tackle their obesity problems.
168. There is another element. Some people are on the edge of obesity, and they do not realise it. They may be slightly overweight and think that their condition is not too bad. It does not register with them that they are in that situation — perhaps I am there myself. However, we need to consider that issue.
169. I listened to Sam’s suggestion, but the Committee do not have the finances available to do that campaign. However, the new public health agency has been set up specifically to deal with such issues. Perhaps the Committee should write to the agency and ask it what strategies it has in place and how it proposes to tackle the issue of obesity.
170. Members are well aware of the DUP stance on the public health agency. There is no point in setting up such a body only to find out that the Committee has to pick up on something that the agency was established to deal with. As a Committee, we have to hold that body to account and examine exactly what it is doing.
171. Another challenge is the modern world of technology. Everybody is sitting pressing buttons rather than being active. We must tackle that issue in order to overcome obesity.
172. Is obesity more prevalent in socially deprived areas?
173. The Deputy Chairperson: We received a submission from the current public health body, the Health Promotion Agency. When the new public health agency is formed on 1 April 2009, we intend to invite its representatives to a meeting to put that question to them. That will probably be after the Easter recess.
174. Mr Galloway: I will start by explaining the primary care end of things. Primary care has a vital role to play in communicating the right messages about obesity and how people could try to manage their own weight, diet and level of physical exercise. Material is available to assist general practices to do that. In my introductory remarks, I said that that has been recognised in the formal structures for the general medical services contract.
175. Other options are available. In some parts of Northern Ireland, GPs are able to refer people to physical activity programmes that are run in conjunction with local authorities. That is not universally available across the Province, but that is the sort of activity-driven solution that GPs can offer when they believe that the issue is about encouraging someone to take part in physical activity. Those are the major elements with which GPs will deal without going into other forms of treatments, such as drug therapies, to curb diet or deal with weight gain.
176. Mr Phipps: There is a gradient of social class. A smaller proportion of social class A or 1 is overweight or obese than social classes D, E or 5. There is a whole range of issues around inequalities and access, which is very difficult to untie. The facts are there, but people give various reasons to explain them. There are certainly issues around access to fresh food and the kind of pressures that people may or may not be under. It is a very complex issue.
177. Dr Chada: I reinforce Rob’s comments. For most diseases and illnesses, there is usually some sort of social class gradient, which is prevalent and ubiquitous in public health. As Rob said, it appears that that is the case for obesity. There is probably a great deal of regional variation, both at a micro level and nationally. Again, one could try to unpick what the reasons for that may be, but it is likely to be a number of factors.
178. Mr Phipps: One of our responses to the board is to ensure that any initiatives are targeted at health inequalities so that localised targeting also occurs. There is a range of initiatives.
179. Ms S Ramsey: I think that I will be a fly in the ointment today. Before I do that, I declare an interest as somebody who is overweight.
180. You said that your Department, the Department of Culture, Arts and Leisure and the Department of Education have a shared commitment to tackling obesity, and thank you for providing the Committee with a good paper on the various steering groups and working groups. However, it strikes me is that, having seen some good advertising campaigns on television, there needs to be an overarching publicity angle. That follows on from earlier points: Samuel was right about the need for publicity and, as Thomas said, district councils also have a responsibility to publicise their leisure facilities. My district council, of which I was a member for several years, provides 26 play parks, but only one of them is in a nationalist area. We must consider the cost of entry to leisure facilities. You made a point about what is happening in Belfast, but there are other issues.
181. My concern is about overall responsibility: can the Department of Health, Social Services and Public Safety simply take the lead on tackling obesity? Departments are arguing about which of them should fund schemes such as Sure Start or after-school projects. Who intervenes to say that enough is enough and tell an individual Department that it must fund a particular project or scheme? Representatives from areas of social disadvantage are fighting with the Department for Social Development about neighbourhood renewal. Who intervenes to demand that it be funded? An overarching strategy exists to deal with obesity and associated illnesses. However, if one Department says, for example, that it will not fund Sure Start or an after-school project, or if a council refuses to set up particular play facilities, who intervenes to insist that the funding goes ahead? Each Department is fighting for its budget.
182. It takes me back to the Investing for Health strategy. It was a key document at the time and all Ministers signed up to it. We now need to put Ministers and the Executive behind the eight ball and tell them that it is one thing to agree to the strategy, but they must be aware of what is happening on the ground.
183. The other day, the Assembly debated the advertising of cigarettes. Where do the supermarkets and manufacturers sit on the issue of obesity? Sometimes it is cheaper to buy frozen and convenience foods than fresh food. Who is responsible for improving that situation? I mean no disrespect to you or the Department, and I am not saying that a commissioner is needed, but whatever you do will be a drop in the ocean until someone says that enough is enough. If the Department for Social Development, the Department of Education, the Department of Culture, Arts and Leisure or the councils cut funding or do not go down the line that we want them to, can the Minister of Health, Social Services and Public Safety go to them and say that enough is enough and outline what they need to do?
184. Mr A Elliott: I will respond briefly on a couple of those points. There is no doubt that, in identifying the early-years issue, you highlighted an important component of a range of public health issues that we are trying to tackle. The parts of the developed world that will be quickest and most successful in addressing obesity and noticing a real change will be those that are best at joined-up government. Their Ministers will be able to sit down and work closely together to determine what each of them needs to do to contribute to the overall package. The challenge for all of us is to try to ensure that, by working cross-departmentally, we achieve the most bang for the buck.
185. There are some positive elements to what is happening in healthcare. In setting up the public health agency, the Minister made it clear that he wants close linkages with local government. He wants the public health agency to be central to community planning and to all the activities that we expect to see local government doing more of in the future, particularly after the review of public administration is complete. That is encouraging and has the potential to tackle not only obesity but a range of other determinants of health.
186. Mr Phipps: One of the ironies of obesity is that most of the work upstream is, arguably, conducted outside the Health Service. You put your finger on an extremely challenging issue: for the strategy to work, we must negotiate with all the other Departments, because they each have a role to play. The next year will be interesting as those discussions develop, because we are adopting the approach of asking Departments where they want to be in 10 years’ time. The questions we will ask are: how do we get there and what are the barriers?
187. Ms S Ramsey: How do we enforce that? Kieran mentioned guidelines. For whatever reason, Belfast City Council or Omagh District Council may decide not to invest more money into play and leisure facilities. However, a key factor in tackling obesity is ensuring that people exercise. Who makes the councils accountable for making that happen? The steering group includes a representative from the Northern Ireland Local Government Association (NILGA). However, no representatives on the steering group have the authority to say to Lisburn City Council that of the 26 play parks under its control only one is in a nationalist area and that issues of ill health must be tackled, especially in socially deprived areas. However, it seems that no one on the steering group can do that.
188. Mr A Elliott: Are you suggesting that we introduce a mechanism to reach all the councils?
189. Ms S Ramsey: Yes I am, and I also want the Department’s strategy to be enforced. It is positive that some Ministers have adopted a joined-up approach, but other Ministers need to come into play. Local government is the key to all this, because it provides the leisure centres, the parks, and so forth.
190. Dr Chada: That is a very important point. You mentioned the Northern Ireland Local Government Association and its representation on the steering group. Certainly, involving local government is one element. Eventually, we will have to move towards mechanisms through which local people can influence what is happening. Such mechanisms will ensure that local players who are interested in public health can influence decisions locally, which is what you want to see ideally.
191. We are trying to put some of the building blocks for that in place by encouraging local government, as well as the regional and local elements of the new public health agency once it comes into play, to take a greater interest in public health.
192. Mr Phipps: Perhaps one of the ways forward is through PSA targets. One approach could be to have more shared targets. What you spoke about is what we will be grappling with over the next 12 months. Ms Ramsey’s point about securing buy-in is, to a certain extent, one of the challenges that we will have to address.
193. Mr A Elliott: We need to think about your point. Essentially, the issue is about how to engage effectively with the local councils and capture their attention. We will take that thought away with us.
194. Mr Phipps: The world is changing slightly, and we have to work our way through those changes at the same time.
195. The Deputy Chairperson: Community planning will be the key to taking this forward. Therefore, you will need to get that right before anything can get up and running. It is hard to change something that has become embedded. Therefore, we need to tack health inequalities onto community planning from the start. A pilot might be run in one of the areas, so it would be good to monitor that and see how it plays out.
196. Mrs Hanna: I certainly agree with Sue; we are all looking forward to the new public health agency and to seeing how well it works across the sectors. In the Assembly, we have a responsibility to work together and to work cross-departmentally, but we do not do that. We do, however, pay lip service to that responsibility, and we know it.
197. The Committee agreed that it should set up a group on young people and mental health with the Committee for Education to examine school projects and ways of supporting young people, such as coping strategies. We need to do far more on that, and we need to do it formally. For example, what is the Department of Agriculture and Rural Development doing about food labelling? Food labelling might not be DARD’s responsibility entirely, but it is its responsibility to some extent.
198. What is the Department of the Environment doing about open spaces? In rural areas, there are lovely parks and some great facilities; however, those do not exist in built-up areas. When I was a child, I was chased out of the house to play; now, even my granddaughter and grandson, who are 18 months old, have their own DVDs. In fact, I have been given a DVD for them to watch when they are at my house so that there is no problem. We did not have DVDs when I was young so we had to go out to play. That is part of the problem; however, it is far more than that.
199. I was a midwife for many years, and I believe that the way to tackle obesity is to focus on prevention and early intervention. Much of that should start at the antenatal clinic, if not before. A mother should be supported and educated about diet and exercise, because, as Kieran said, obesity is certainly connected to lack of exercise.
200. There has been a cultural shift from simply going outside to play to watching DVDs and sitting around waiting to be entertained. Given that shift, as Sue said, we must involve local government, and I think that it wants to become involved. Councils have some good facilities, but they must engage with people.
201. I worked on the reception desk of a leisure centre for about a year, and I knew all the people who visited. However, although it was free to attend the leisure centre, the people whom we wanted to visit did not do so. How will we engage with those people and make them visit leisure centres? How do we prevent them becoming obese in the first place? Obesity is an addiction, and, at that stage, it is difficult for people to lose weight. It is not as easy as visiting the GP, asking for help, receiving diet sheets and going on a diet.
202. I wonder about psychological therapies, because losing weight is very much about people’s frame of mind. I keep mentioning the informal meeting that members had with Dr Michael Ryan, which I thought was fascinating. Those ideas should be incorporated into our strategy on obesity, because they are not currently. It is up to the Assembly and the Department to address that matter.
203. We all work in silos, and although we talk about the Executive’s poverty strategy, the issue of obesity is linked to poverty and to the widening gap between the haves and the have-nots. We still have the same poverty strategy. In fact, it is a read-across from Westminster, and there have been no changes to it. The Committee for Health, Social Services and Public Safety has a lead role but not a full role, and members cannot address the matter unless we work with other Departments and find the key and the secret to engaging the public and getting the message to the relevant people. That must be done through the community, because many people become engaged in that through peer pressure and peer support.
204. We have analysed all the issues and have reached certain conclusions. However, we must establish how those conclusions will make a difference. We have not unlocked that matter yet. The only way to engage everyone is through the new public health agency’s working with all Departments and all Assembly Committees. What is the Department of Health, Social Services and Public Safety doing with other Departments? Is it asking questions about green spaces, food labelling and exercise in schools? We must ensure that all Departments play their part.
205. Mr A Elliott: The Department has recently been involved with Sir Michael Marmot’s work with the World Health Organization. He also did some work in England to tackle health inequalities. At one of those events, someone told me that, in order to tackle health inequalities successfully, the most important factor is to examine the first four years of life up to the age of three. It is interesting to note that money invested in early years, and before birth, could bring a much greater return on health outcomes on a range of issues.
206. Mr Easton: In various ways, obesity costs £500 million a year. That amount of money would represent a good efficiency saving for the Minister, instead of the number of nurses being cut back. However, as Sue and, to a lesser extent, Carmel said, the Health Promotion Agency and sporting initiatives will not make a huge difference. Legislation needs to be changed.
207. No matter how much exercise schools offer, as soon as it is break time, children go to the tuck shop to buy crisps or Mars bars, which undoes all the good work. School meals are mainly junk food, and, unless we change the law, force schools to offer healthy meals, remove tuck shops, tackle retailers and monitor what ingredients the food producers are using, we will not be effective. In order to make any difference, we need extremely radical proposals.
208. Mr A Elliott: We cannot speak for the Department of Education, but that Department would probably say that it has put a lot of energy into the Health Promoting Schools approach and tackling the issue of tuck shops. There have been some real changes. No doubt there are still some examples of poor practice, and the Department has started to focus on that issue.
209. Mr Phipps: Schools have new nutritional standards, and changes have been made to make them more rigorous. Schools have also been able to increase the amount of money that they can spend. Work has been done.
210. Mr Gardiner: There are also breakfast clubs, which promote healthy eating.
211. Mr Easton: No one denies that, but I am suggesting that it does not go far enough. We need something totally radical in order to make a difference.
212. The Deputy Chairperson: We intend to invite officials from the Department of Education to discuss that further with the Committee.
213. Ms S Ramsey: I agree with Alex, and I know what Sam is talking about; it is about changing a mindset. Not so long ago, there was a row in the Assembly about whether the Department of Health, Social Services and Public Safety or the Department of Education was funding the breakfast clubs and after-school clubs. It is about changing Departments’ mindsets. The will is there, but we need to change the mindset of civil servants. Instead of cooking the books, we must ensure that we are cooking the right stuff.
214. Mrs McGill: I have a question about children and young people in relation to the graph and some of the figures that you have presented on pages 3 and 4 of your written submission. The figures date back to 1997 and 1998, and there are also some figures for 2004 and 2005. However, the rest of the graph relates to possible trajectories. There is a gap from 2005 until now.
215. Mr Phipps: Those figures need to be updated.
216. Mrs McGill: That is a bit out of date. The graph is an illustration of possible trajectories, but it would have been better to have a more up-to-date analysis of the situation in relation to children and young people.
217. As a personal observation, I do not see obesity in young children when I meet them. I read your figures, but I do not actually see evidence of obesity, although, obviously, what I see is limited.
218. Mr Phipps: That is interesting, because research has been carried out into parents’ views of their own children, and many parents cannot see that their children are overweight, although the figures suggest that they are; there is a perception that parents do not always recognise their children being overweight.
219. Adults and parents do not always see the link between being overweight and ill health, as Dr Chada pointed out. They think that a child may be overweight but that he or she is still healthy. People’s perceptions are an issue. Awareness must be raised of the health risks associated with obesity. Your point is absolutely valid.
220. Mrs McGill: That is not really my point. When I see groups of young people — and many visit this Building every day — I do not look out to see who is obese and who is not, but I do not see such levels of obesity.
221. Mr A Elliott: Only 5% of children are obese, but a higher percentage of children’s BMI is not at a healthy level. Perhaps that is not as obvious in a group of people wearing blazers.
222. Dr Chada: There are two issues here. First, as Rob and Andrew pointed out, the prevalence of children who are overweight or obese is much lower than it is in the adult population. Secondly, as Rob also said, it is a matter of perception and norms. Over time, people have been getting heavier, and there is a higher prevalence of people who are overweight or obese. Therefore, what we now consider to be normal might not have been considered to be normal 20 or 30 years ago. Therefore, there are many subtle issues that point to how we perceive matters.
223. The Deputy Chairperson: You said that the statistics here are not dissimilar to other areas. Have you examined how successful other countries have been in tackling the problem? Perhaps you could share with us success stories and good practice elsewhere?
224. Mr Phipps: I attended an EU meeting recently, and it was fascinating to hear about all the countries that we assumed would not have had an obesity problem. For example, Italy is very concerned about obesity, as are Spain, Portugal and the Czech Republic. Interestingly, the Czech Republic has great difficulty in getting young people to eat traditional Czech food. Therefore, it is the same issue — it is about the globalisation of food patterns.
225. Sweden has had some success, and it has seen a reduction in obesity among young people, but it has been honest in saying that it does not know the reason for that. Nevertheless, it has seen a slight decline.
226. A programme called Ensemble, Prévenons l’Obésité des Enfants (EPODE), which means “together, we can prevent obesity in children", has been implemented in France and Belgium, and it focuses on the local community. England is considering adopting a similar programme called Healthy Towns, which takes a community-driven approach to tackling the problem.
227. Therefore, there are some examples of good practice, but, interestingly, much of Europe is saying that there is a problem, and we are not too sure how to address it. People want to find the best way forward, and the approach that we propose to take is one that Holland and other countries are keen to follow. Therefore, other people are thinking of taking the approach that we are taking, so we are almost leading in the overarching obesity framework.
228. The Deputy Chairperson: Finally, the Health Promotion Agency’s submission to the Committee stated that its weight management clinics are not consistent across the North and that access varies depending on where people live. Do you have any comments on that?
229. Mr Galloway: That is the situation. In response to Mr Buchanan’s question, GPs can refer people to activity programmes, which are delivered in leisure centres. However, that is not universal. Therefore, there some work to be done to ensure that the services are available so that people can be referred and can receive advice and information about how they could better manage their weight.
230. The Deputy Chairperson: Obviously, consistency is important.
231. Mr Galloway: Consistency is the issue. Over time, the four boards have taken different approaches to issues in their own areas, so the situation has developed in slightly different ways in the four board areas.
232. Dr Deeny: What does PSA stand for?
233. Mr A Elliott: It stands for public service agreement.
234. The Deputy Chairperson: Thank you very much for coming along.
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
Witnesses:
Dr Caroline Hughes |
Action Cancer |
235. 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.
236. You are welcome to this afternoon’s Committee meeting. Geraldine Kerr will make a short presentation, and that will be followed by members’ questions.
237. 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.
238. 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.
239. 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.
240. 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.
241. 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.
242. 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.
243. 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.
244. Caroline will provide more detail on the evaluations, but there have been increased awareness and lifestyle changes as a result of that.
245. 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.
246. 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.
247. 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.
248. 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.
249. 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.
250. 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.
251. 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.
252. 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.
253. 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.
254. 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.
255. 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.
256. 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.
257. That is all that I have to say at present, but I can offer more information in answering your questions.
258. 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?
259. 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.
260. 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.
261. 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.
262. Dr Hughes: 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.
263. 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.
264. Dr Hughes: Yes, and that is one of the messages in our health action programme.
265. 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.
266. Mr Gallagher: 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.
267. 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.
268. Dr Hughes: 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.
269. 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.
270. 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.
271. 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.
272. 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.
273. Ms Rice: 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.
274. 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.
275. The Deputy Chairperson: Perhaps the Health Committee needs to hear that advice, too. [Laughter.] We were shocked there.
276. Ms Kerr: 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.
277. Ms Rice: 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.
278. Ms Kerr: 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.
279. Mr Gallagher: 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?
280. Ms Rice: 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.
281. Dr Hughes: 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.
282. Dr Deeny: 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.]
283. Ms S Ramsey: You are well paid.
284. Dr Deeny: 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.
285. 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.
286. 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?
287. Ms Rice: 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.
288. Dr Deeny: 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.
289. Dr Hughes: 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.
290. 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.
291. Ms Kerr: 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.
292. 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.
293. Dr Hughes: 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.
294. Mrs Hanna: 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.
295. 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.
296. 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.
297. 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?
298. Dr Hughes: 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.
299. Mrs Hanna: 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.
300. Dr Hughes: 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.
301. Mrs Hanna: 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.
302. Ms Kerr: 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.
303. Dr Hughes: 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.
304. Ms Kerr: 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.
305. 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.
306. 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.
307. Dr Hughes: 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.
308. Ms Rice: “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.
309. 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.
12 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 Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey
Witnesses:
Mr Nigel Gould |
British Medical Association Northern Ireland |
310. The Deputy Chairperson (Mrs O’Neill): We will now receive evidence from the British Medical Association (BMA). I welcome Dr Theo Nugent, who is a member of the general practitioners’ committee; Dr Colin Hamilton, who is the chairperson of the BMA committee for public health medicine and community health; Mr Nigel Gould, who is deputy secretary of the BMA; and Mr Ivor Whitten — whom we all know very well — is the BMA Assembly and research officer.
311. Dr Colin Hamilton (British Medical Association Northern Ireland): On behalf of the British Medical Association Northern Ireland, I thank the Committee for the opportunity to give evidence today. Obesity is a significant public-health problem in most of the western world, and there are particularly high levels in Northern Ireland.
312. Obesity is caused by an imbalance between energy input and energy expenditure, which basically means that if someone eats something and does not use the energy from it, it tends to stick; there is nothing magic about the science. The question is how to get the general public to accept what we all know has to be done so that we can try to turn back the tide of obesity.
313. As a screening tool, obesity is measured by body mass index (BMI). A score of between 20 and 25 is considered normal, but there are people in the Province who have a body mass index of 60 or higher. There are not many people in that category, but anyone who scores over 40 would be considered morbidly obese, and many of the recommendations for dealing medically with obesity are for such people.
314. Obesity affects people of all ages, and there is a mission statement in our submission about dealing with children. That is where addressing obesity becomes important; it is not necessarily an individual issue, particularly since it starts in childhood; it is a family and wider societal issue. Therefore, many of our recommendations are not purely for those in the medical profession, like us, or those in the health services that the Committee monitors. The problem has to be dealt with on a wide basis and include education, the provision of opportunities for exercise and many other issues.
315. The BMA scientific committee in England has produced many reports, all of which can be made available for perusal to Committee members. Those reports address obesity at a variety of levels, such as childhood and adolescence.
316. My specialty is public health, so I will concentrate on the statistics. Since 1997, measurements have shown a 26% increase in adult obesity. That is a very significant increase; I cannot think of any other population index that has shown that sort of growth. Currently, 59% of adults and 26% of children in Northern Ireland are overweight or obese. Those children will probably grow up and develop to a higher percentage of adults because of the nature of obesity. It has been said that obesity alone is a population time bomb that will, perhaps, cause the generation that is growing up to have a shorter lifespan than their parents. Whether that does or does not happen is in our own hands to a large extent. There is nothing about this problem that is inevitable; much of it is to do with lifestyles and the environment in which people live.
317. Obesity causes 450 deaths a year in Northern Ireland at a cost of £500 million to the economy. The savings that are possible are mentioned in our written submission. I will not describe all the diseases that are associated with obesity; most members will know about those already and will have heard about them in other presentations. However, we know about the growth in heart disease and in type 2 diabetes, which is closely associated with obesity. There are many others, including some cancers.
318. What is it about the foods that we eat that are causing the problem? It is about fats and sugars; I do not claim to be an expert on physiological science, but if people’s diets concentrate on saturated fats and sugar, it is almost certain to result in obesity. If that is associated with lack of exercise, a cycle will build up. A problem with childhood obesity is that the next phase of life in the female population tends to be pregnancy. If a woman is obese by the time she becomes pregnant, a range of complications can occur that will affect the next generation. I will not go into all the potential medical effects; they are listed in our submission. At the end of this litany, the BMA believes that action must be taken to encourage people to make better dietary choices and to engage in a more active life. As I said at the beginning, this is not rocket science.
319. There has been a lot of coverage on the radio today about the suggestion of a tax on chocolate as an approach to the problem. The BMA does not believe that that is the way to go; to focus on one foodstuff does not seem to be very sensible. That proposal came from someone in Scotland; I would point out that a deep-fried pizza contains no chocolate and would be much worse than the occasional chocolate bar. To focus on individual foodstuffs on the basis of a parallel to smoking cigarettes is not the way to go. We all need to eat; none of us need to smoke, so there is a totally different dynamic at work.
320. The BMA will start to work with Northern Ireland’s new regional public health agency in a couple of weeks’ time, on 1 April. I do not want to speak for Dr Rooney or Dr Harper, but as we will be joining the new organisation soon, there is no question that obesity will be a top priority. Since this is not purely a health problem, however, there are other parts of the public service, including the Committee, that can concentrate on the issue. One is the interdepartmental public health committee, which has been in existence for many years and has achieved some good results. Obesity is an ideal subject for that committee to consider. The promotion of healthy eating habits in the school curriculum — I do not know whether schools still call it home economics — lends itself to education for life about what is healthy and what is not. That would be a matter for the Department of Education.
321. The provision of cycleways and walkways in new housing estates would, presumably, be a matter for the Housing Executive, Roads Service and other bodies about which members know more than I do. We envisage a multi-agency approach to tackling obesity, and we also want to encourage the private sector. It is important not to assume that education stops at school.
322. Over the past couple of years, the failure of some major supermarkets to adhere to a simple method of outlining whether the food that people buy from the shelves is healthy has been slightly disappointing. Those members who do the shopping will be aware of the simple red, amber and green traffic-light systems that anyone can understand. In some supermarkets, products are described as containing so many kilojoules of such and such per kilogramme. I cannot understand that, so how on earth anyone doing the shopping is meant to scan a product with that sort of overload of information and be able to buy healthy food, I do not know. Any pressure that could be brought to bear on private industry, particularly the food and retail food industries, would be extremely valuable, because people need not only to know what is healthy but to be able to access it.
323. I do not want to go into too much detail, because my colleague, as a GP, works more closely with the people affected. He will detail some aspects of dealing with the problem as it affects the population.
324. Dr Theo Nugent (British Medical Association Northern Ireland Northern Ireland): GPs are well placed to spot folks who appear either to have problems with obesity or to be heading in that direction. We are reasonably well placed to detect and manage some of the problems that arise, or the medical fallout, from obesity, such as osteoarthritis, raised blood pressure, heart disease and diabetes.
325. However, GPs are not terribly well placed to give people good advice on how to control their obesity. If, for example, a patient arrives at my surgery with a body mass index of over 30, that is a starting point and gives a rough estimate, or indication, of a weight problem. That individual might be tremendously fit and the extra weight might be all muscle, but, from my experience in east Tyrone, that is not always the case.
326. What does a GP do when patients seek help and to where does he refer them? More to the point, patients may have been motivated to seek help to produce a real change in their health profile years down the line, but where can GPs seek help based on evidence of a reasonable chance that patients will stick with the programme to which they sign up?
327. As Colin said, GPs are also faced with the broader issue of two or three generations of the same family presenting with similar health problems that stem from obesity. As GPs, face to face with patients and trying to help and advise them, where do we start? The main plea from GPs in the BMA is for an answer to that question. We know that the problem is increasing, and public-health colleagues are able to keep us well apprised of the demographic time bomb, but what can we do that will be effective in helping our patients to tackle the problem?
328. Dr C Hamilton: Members will see a few bullet points on pages 4 and 5 of our paper. In my panic to get through my presentation, I missed a couple of those, one of which concerns the role of employers. At lunchtime, I heard for the first time that the BMA has a good programme of yearly checks for its staff, including blood pressure, weight, and so forth. I am slightly envious of Mr Gould and Mr Whitten who are BMA staff, because the NHS is a poor employer in that respect, and, as one of
329. There are some good employers in the Province and others that are not so good. During a credit crunch, the temptation is probably to run down, rather than improve, such services. We would like to see employers being encouraged as well.
330. We have also suggested that the public health agency should research what works and what does not work, because that is a difficult area. Many people have been working hard in health action zones, and so forth, in communities. To date — and, in part, because of the four-board system — the best practices have not been spread throughout the Province. However, I think that that will happen quickly when we move to the new system. We have to find out what works.
331. It is not a counsel of despair. I know that I sounded pessimistic at the beginning of my presentation, but there are other parts of the world, such as Finland and parts of the United States, in which major results have been achieved. People have said that it is not easy to achieve a lifestyle change in Northern Ireland, but I argue against that. Our population is as ready for a lifestyle change as any other. In Finland, for instance, success was achieved because the wives and mothers were informed that, if they wanted their husbands and children to live longer, changes would have to be made. That has made a significant impact over the past 20 years or more.
332. Northern Ireland is not that different. Scotland is similar to here, and I know that there are programmes available there that are beginning to achieve results. Therefore, I am not as pessimistic as, perhaps, I sounded at the beginning.
333. The Deputy Chairperson: Thank you for your presentation. A research paper on how programmes in Norway have been taken forward, and their success, is being developed. I share your hopes for the role of the public health agency. We can see the importance of the role that it will play in tackling obesity, and, as part of the inquiry, we have invited representatives to attend the Committee after Easter.
334. Theo said that GPs are well placed to detect obesity. We have already heard about the lack of places or services, such as dieticians, to which individuals can be referred. Will you provide some information on follow-through services that are available and the problems that GPs are encountering? Detection is well and good, but it will be difficult to do anything about it if support and assistance are not available.
335. Dr Nugent: There is little problem when someone turns up with a fallout from his or her obesity, such as diabetes. There are services available to help them to deal with that. However, a colossal workload is required when an individual is referred with what the dietetic service term “simple obesity". That is, usually, a complicated obesity, and, to be fair, it does not test the motivation of the patient. I end up suggesting that they go to Weight Watchers. That is not a flippant comment; it tends to work. The Weight Watchers programme is based on healthy eating and the type of eating pattern that can be sustained lifelong. It does not recommend that individuals eat food that tastes like cardboard or that is made up in a milkshake, or any other gimmick.
336. I am also aware of exercise programmes. My practice does not have access to any, but I know a few practices that do. The consensus is that patients enjoy taking part in exercise programmes. They are motivated to go, and they ask to be signed up to them. They complete their 12-week programme, but I am not certain whether there is a longer-term follow-up. I do not know whether patients stick with it; they probably do not. However, it is worth trying. If those people do not try the exercise programmes, it reinforces the idea that leisure centres are only for the Lycra battalion who work on the treadmills for an hour or two at a time. They are for people who want to establish a healthy lifestyle.
337. There is a limit to where we can send people before they develop problems, and it is difficult for GPs to see how they can motivate individuals or encourage self-motivation in families. We are talking about families.
338. The Deputy Chairperson: Therefore, exercise should be available on prescription. When the Committee considered the issue of mental health as part of our inquiry into the prevention of suicide, GPs said that they suggested to people who were feeling down that they joined an exercise class but that those people could not afford to do so. We considered that joining a class would be beneficial. I know that exercise cannot be prescribed to everyone as it would be costly, but perhaps some aspects of that idea could be looked at.
339. Dr Nugent: It can be quite simple. The idea must be put into the public mindset that exercise does not have to be complicated. If people can do a 20-minute walk three or four times a week, that is brilliant. People should start with the simple stuff. Media programmes look for complicated answers to the problem and show intensive training regimes. That is all very well, but simple lifestyle changes can include, for example, cutting down on butter. That is not rocket science stuff to mystify the issue, but it makes it simple and relevant to the vast majority of people.
340. Dr Deeny: You more or less hit on what I was going to say. As a GP, it seems to me that, every time a societal problem arises, it is left to GPs to sort out. I could not agree more with Theo that GPs can deal with the consequences of obesity but that prevention is another matter.
341. Last week, the Committee heard evidence from departmental officials, and, as I said previously, too much emphasis is placed on diet as opposed to exercise. It is a two-way process, and it also includes parents and schools, the Department of Health, Social Services and Public Safety, the Department of Education and, perhaps, other Departments. I am aware of schools that place too much emphasis on academic achievement as opposed to exercise. Last week, departmental officials told the Committee that each school is given guidance that they should devote at least two hours a week to exercise but that they are not required to do so by the Department of Education.
342. I am sure that you will agree that that should be considered, because, when one drives through any large town, one can see that young people have become heavier. As I mentioned last week, I have come across girls who smoke to control their weight, and that is a shocking and frightening situation.
343. I have never been keen on the use of drugs to treat people who are overweight. I know that such drugs exist and that GPs sometimes have no choice but to prescribe them because a person’s health — or, indeed, life — may be at serious risk. However, those drugs create a mindset in which people think that all they have to do to lose weight is to take a drug.
344. I also agree with Theo’s point that people’s mindset about places such as leisure centres is that they are only for really fit people and for athletes, who seem to take over the treadmills for a long time. Those places should be for people who want to become healthy.
345. The Deputy Chairperson and the Chairperson have previously said that exercise is good for mental health. We know that endorphins make people feel good after exercise. It would be a good idea for GPs to select patients who could benefit from exercise programmes and to work alongside local government agencies or councils. In the long term, that would save the Health Service a lot of money. I would like to hear practical ideas about how that could be done. I know that that has been piloted in certain practices, but I would like to be able to prescribe some of my patients to take exercise, rather than writing out a prescription for drugs to try to curb their appetite.
346. Dr Nugent: The medication that supposedly controls obesity medicalises the condition and presents it purely as a medical problem for which there is a tablet. To an extent, human nature means that people will see obesity as not being their problem and that they simply need their tablets. My simplistic view is that such medication falls into two basic categories. The first type of medication stops people absorbing fat from their bloodstream, and it causes dreadful side effects in people who take the medication but do not follow a low-fat diet. The second type of medication is designed to do different things to the body, and it can do much nastier permanent damage to the circulation and elsewhere.
347. I agree that, in attempting to prescribe exercise and changing people’s mindsets, it is important to demystify leisure centres and turn them into places that are for people. Probably the original concept behind leisure centres was to have a community resource to which people could have access, and — I mean no harm to those who are addicted to exercise — it needs to be accessible to others. How do we go about that? I have found that word of mouth is a tremendous piece of machinery. If a programme were up and running where people could go along, where family groups could be encouraged to go, and it was no longer seen as a bit odd for families to exercise in a group in a low-key way — they do not have to be elite sports persons, and they do not have to be into one particular sport — it is bound to be an enormously powerful tool. It would also send out the right message.
348. I am happy that I am a GP in an era in which the old paternalistic mindset has long gone and that one of mutual respect exists. Without mutual respect, our profession could not function. That is also a useful tool. I hope that doctors are perceived by patients as being equal. Doctors have knowledge — and patients have different skills — but we are equals, and we are there simply as advisers and guides. However, there must be something out there that demystifies exercise.
349. Cycling is another classic form of exercise, as Colin said. When one wanders around Amsterdam, there is a fear of being clobbered by a bicycle every two seconds, because people forget that bicycles still exist. I cannot remember the last time that I saw an entire bicycle; they are usually chained frames attached to a lamp post because they have been vandalised.
350. It is simple, uncomplicated stuff: The BMA and GPs would welcome any move towards a public mindset of encouraging exercise at a simple level.
351. The Deputy Chairperson: Dungannon District Council took the decision recently to close the leisure centre so that it could be used solely by the XXL club, which some people might not even want to go to. When the local councils give evidence to the Committee, we can discuss further making leisure services more available and ask about the possibility of having private sessions in order to get people interested and moving without feeling intimidated.
352. Mr Gardiner: Dr Deeny has covered the issue of GPs, and GPs are the first port of call when a person has a problem. Dr Hamilton said that the hospitals were about the biggest offenders. Have you seen some hospital menus? If not, the Committee can ask for them, to see what is going wrong.
353. Dr C Hamilton: I have not seen any menus recently. I have paid attention to —
354. Mr Gardiner: You made a statement to the fact that they were the biggest offenders.
355. Dr C Hamilton: No; I said that they certainly were the biggest offenders as regards employment. Staff canteens always have a “healthy option" that I would not call healthy. We are suggesting that schools should no longer have only one healthy option, and that, for several days at least, there should be healthy food only so that pupils do not have the option of chips. In most staff canteens in Health Service hospitals, people will veer towards the chips and not the unfamiliar food, because they are consistent.
356. Mr Gardiner: Are you saying that healthy food is not based on five portions a day of fresh fruit and vegetables, and so forth?
357. Dr C Hamilton: Dieticians preach about five portions a day, and people need to have a certain amount of fruit and vegetables. However, that does not mean that people must spend their lives eating like a primate that eats only fruit. I will, occasionally, treat myself to fish and chips — about once a month — or chocolate once a week.
358. Mr Gardiner: Confession is good for the soul.
359. Dr C Hamilton: Absolutely. However, there are some people who eat nothing but fruit and vegetables, which is fine for them, but it is not really practical for most people’s lifestyles nowadays. However, a reasonable balance is required, and that is where education comes in. It is harder to teach a reasonable balance than an absolute.
360. Mr Gardiner: I thought that the BMA would have had an opportunity to look at the menus of the hospital authorities before it came to the Committee. Madam Deputy Chairperson, may I move that the Committee asks for different hospital menus to be provided in order to see what food is being served?
361. The Deputy Chairperson: We can do that.
362. Mr Gardiner: If the Committee can take any action, it will.
363. Mrs Hanna: Eating is pleasurable and fun, and we do not want to remove the fun entirely. However, as you said, people should enjoy fish and chips occasionally or, as I do, eat two or three chips from other people’s plates.
364. Although you are not specifically responsible for the problem, you are in an ideal position to know your patients’ backgrounds and the challenges that they face. Poverty and a lack of choice are the origins of much of the problem, and the figures continue to support that assertion. I understand how that happens, because less-well-off people cannot buy nice berries, and so on, from Marks and Spencer. Perhaps they do not have much choice, and the chippy is nearby.
365. Schools no longer teach much home economics. There is less emphasis on budget and managing a household than there was traditionally. Many people do not cook any more, do not know how to cook and do not eat meals at the table. There is a culture of TV dinners, and supermarkets are full of ready meals at bargain prices. Those ready meals are not fresh and contain many additives, and, as you said, one could not begin to analyse what is in those products.
366. People have huge challenges to overcome. Once somebody is overweight, it is difficult to lose weight, because, at that stage, eating is an addiction, and it is difficult to find motivation. Some sort of a partnership is required, and you said that you work with the health action zones. We must get closer to communities and try to encourage people to use leisure centres — which should be free of charge — for fun exercise classes for the entire family. Leisure centres could also put two healthy options on restaurant menus rather than one healthy and one unhealthy option. It can sometimes be difficult to make healthy food attractive, but it can be done.
367. Our approach must be based on practical solutions. We have analysed the situation, and we know the issues and the diseases that obesity is causing. We need to prevent obesity in people who are not overweight by offering better education and more exercise in school. We must practically support people who are overweight or obese in their communities and work with personnel in health action zones and other health groups. GPs should probably be part of that partnership, because they know the people, the background and the dangers.
368. Some sort of practical partnership will start to make a difference. That is easier said than done, but we have discussed the matter with some groups and will discuss it with many more. However, we need to be able to measure any difference. We should be able to return a year later to some groups in the community to see whether people are eating a healthier diet or whether they are feeling better. We could conduct some practical pilot schemes and measure the outcomes in order to determine what works and what does not work. Several groups need to work together practically on that matter.
369. Dr C Hamilton: Mrs Hanna makes some good points, a couple of which are reflected in our recommendations. I participated in a radio programme on U105 this morning. The caller on air before me was a father called Dave. He complained that he visited his local Spar in order to buy oranges for his child to take to school instead of sweets. He discovered that the price of oranges had increased hugely whereas the price of chocolate had decreased hugely. I understand his frustration. He tried to do something but the retail industry made it difficult for him.
370. Mrs Hanna mentioned ready meals. We all eat ready meals; they are a natural part of life. One thing that always bugs me is: why do beans with less salt and less sugar cost more? The same principle applies to other items. What is the justification for that? I do not know if the Committee will take evidence from the retail trade or the food industry, but it would be interesting to hear an answer to that question. Many food companies offer healthy alternatives, but why is there a premium on those healthy alternatives?
371. Mrs Hanna: The companies say that it is more work to remove the salt, in which case I suggest that they remove the salt from all products.
372. Dr C Hamilton: Precisely. Salt does not occur naturally in many basic foodstuffs. Therefore, it must be added somehow or other.
373. Dr Nugent: I also take your point that it is desperately important to look at outcomes and to see what actually works. Nothing is more demotivating than to launch a series of initiatives that roll on, year after year, and do not produce results. We cannot stand over them and have confidence in them; nor, indeed, can the public have confidence in them. That is an important point.
374. Mrs McGill: Having listened to today’s and last week’s evidence, I am beginning to think that, although this Committee is conducting the inquiry into obesity, perhaps the Committee for Education or the Committee for Culture, Arts and Leisure should be doing it. I have read Dr Domhnall MacAuley’s editorial, which is among our papers. You may not have seen it, but it is a good piece. The editorial is entitled: “Physical activity may be good for you but we are not the key players".
375. It finishes:
“Let us not be foolish enough to accept responsibility for a task we cannot deliver. There are many aspects of practice where we can make a difference. This is not one."
376. We are the Committee for Health, Social Services and Public Safety. You are the BMA. I have listened to what Theo said in response to our comments. I have also considered your submission. Much of it relates to what is, and what should be, happening in education.
377. Last week, I made the point to the departmental officials that I do not see the 26% of young people who are physically obese. That may be an indictment of what I see when I look at young people. There are many young people around the Building.
378. According to your paper, the figure for 2005, which is probably the most recent that is available, is 26%. We also have figures for 2003 and 2002. There does not seem to be an up-to-date figure for childhood obesity. That may be an issue. I do not dispute that there is a problem; however, is there any danger that the problem could be exaggerated in the first instance?
379. Dr C Hamilton: One of the problems of obesity, particularly in children, is that it is, to an extent, invisible. I am no expert on children. However, if a child is overweight compared with his or her peers, he or she is not going to be standing around on street corners or going places with the school team. That boy or girl is a lot more likely to be shut indoors and involved in solitary activities. That is part of, and reinforces, the problem. He or she will be using the computer as opposed to taking part in healthy sports, simply because he or she feels different and separated from other children.
380. Although that is a trite explanation for the issue that you have raised, there is a certain degree of truth in it. That problem can be tackled only through engagement with schools: it goes into areas that are beyond the Health Service, such as bullying, and so forth. That is a significant issue, which is why, when people get to the stage when they need to attend dietary clinics, psychologists are available. When people have spent years in that cycle, it can produce significant problems. However, is it one of compulsion; has the person learned the habit that food is his or her only comfort, and that has become that person’s lifestyle? It is not a purely physical problem; it has a mental overlay.
381. Mrs McGill: I understand that, but I want to know about the figure of 26%, which represents one quarter of young people. I know that these are 2005 figures, but still —
382. Dr C Hamilton: That figure does not mean that 26% of young people are morbidly obese, but rather overweight or obese. It is a question of thresholds. Like everything else — blood pressure or cholesterol — it is a continuum. If you find out what the figure was 50 years ago, you will discover that it was a lot less, and today’s figure is a lot less than in some other countries. I am afraid that we get used to the average in Northern Ireland.
383. Mrs McGill: I repeat: we need up-to-date figures rather than figures from 2003 or 2002.
384. Dr C Hamilton: I have no problem with that.
385. Mrs McGill: I think that those figures come from the Department.
386. I concur with what Carmel said about the situation in schools. There was a drive some time ago to have healthy eating in schools — Jamie Oliver’s campaign. To avoid eating a healthy lunch, the young people used to take lunches with them — crisps, and so on. As you have said, this is a major challenge.
387. Ms S Ramsey: I will not declare an interest here; I would have to declare an interest at every Health Committee meeting that I attend.
388. I wish to support Claire’s point, because this is not solely a health issue. Last week’s discussion with officials brought out that point. Has the BMA contacted other Departments on this issue? We say that it is not a health issue, but as a health professional organisation, the Committee compounds the problem when it adopts the issue. The BMA has a duty to talk to other Departments.
389. We need an update from the Department of Education. I have heard that there is a problem over the budget for extended schools. We aim to promote prevention, and we need to be proactive. As was said earlier, we need to get the message over at an early age. The prospect of extended schools was welcomed by everyone: it is not a health issue. However, we should try to get information on this issue because I am sure that this Committee would be genuinely concerned if the budget for extended schools were in jeopardy.
390. Dr C Hamilton: I agree completely with that. I am a governor of a couple of schools in Derry — one is primary, the other secondary. Both run the extended schools programme. They are excellent in teaching people to choose the healthy breakfast option, and so on. However, it is a vulnerable budget that may or may not be continued. We would like to encourage policies like this — policies that achieve results. This may not be a purely educational issue, but it certainly works for those who attend it. It must be encouraged.
391. The Deputy Chairperson: The Minister of Education does not want that budget jeopardised in any way. In this inquiry, we can urge the Department of Finance and Personnel to ensure that there is money for extended schools.
392. Mr McCallister: The Department of Health, Social Services and Public Safety has to pick up the cost of obesity, but its involvement comes too late. Other Departments should be involved beforehand. Probably, in an ideal world, all those other policies would be pursued, and obesity would not trouble GPs too much.
393. Your presentation is interesting in that the solutions to this problem are amazingly simple, but the problem is hugely complex. For Committee members, as policy-makers, it is difficult to take simple solutions and put them in place in every community.
394. Colleagues have raised interesting aspects. Carmel spoke of the huge inequalities in health. In the more deprived communities, not only are opportunities to exercise limited but healthier food options are also much more restricted. My background is in the agrifood sector, and I have visited the premises of food processors. I have seen the variations in quality, and the only factor that identifies the better-quality product is the price.
395. One can understand how easy it is for families on lower incomes to be drawn towards unhealthy food, and all of the problems that that brings, so it will be interesting to see how perfectly simple, everyday solutions to building a healthier lifestyle and diet — such as taking 20- to 30-walks or replacing the school car run with a walk to school — might be implemented. Simple solutions can address what has become a complex and costly societal problem.
396. Dr C Hamilton: Getting exercise need not be complicated; one does not have to go to the gym. Looking back 50 or 60 years, one discovers that obesity was not a working-class problem, but, rather, one of the middle and other classes — the people who had money to spend on food. Nowadays, the situation has totally reversed.
397. One reason for that is that much more exercise used to be taken during people’s normal day-to-day lives. For instance, there was not the same level of public transport; people tended to walk to the shops and carry their shopping home. It is not for me to tell people never to take a bus; however, one might suggest that they walk to the shops and, having finished their shopping, take a bus or a black taxi home. For many people, that would involve a 15- or 20-minute walk, and if such behaviour were to become the norm, in itself, it would achieve many of the results about which we have been talking.
398. One could easily suggest the same thing to middle-class people with four-by-fours. If someone lives a quarter of a mile from their children’s school, there is no need to ferry them there in the Chelsea tractor. I am not suggesting that people should send small children to school alone; they should walk with them, and establish the habit early. Walking is by far the best exercise; it is natural, one does not have to learn how to do it, and one can do it more or less anywhere.
399. Changing the types of food that people eat is a little more complicated, because many factors must be considered, such as pricing. Nevertheless, the simple foods that our ancestors ate — such as porridge — are perfect health foods. Nowadays, porridge has been replaced with sugary breakfast snacks, because they are fractionally easier to prepare in the morning. However, nearly everyone has a microwave, so it should not be difficult to make porridge instead of having cornflakes. Simple measures can work.
400. Mr Buchanan: There is no doubt that the increased level of obesity in today’s society is a worrying factor. Obviously, we all agree that prevention is better than cure, but, in order to prevent obesity, we must begin by getting our message through to very young people.
401. Although we talk a lot about taking a multi-agency approach, in my experience, it is difficult to co-ordinate such a united approach and to action it on the ground. Local councils provide leisure facilities and parks, but the problem is with connecting with people in order to encourage them to use those facilities. Similarly with schools; we can introduce all the programmes we want, but, once again, the problem lies with encouraging children to make use of them.
402. All those problems can be traced back to a lack of discipline in homes and families. Discipline in families, especially with respect to children, is the key to preventing obesity. Therefore, we must consider how best to connect with families in order to embed a culture of discipline, because no matter what sphere of life one cares to mention, the results of a lack of discipline at home are apparent throughout society. We must get back to that key component: discipline in the home.
403. What are we doing to educate families about the need to have that element of discipline in the home in order to prevent obesity? What has the BMA done to date? What meetings has it had with other Departments such as the Department of Education or the Department of Culture, Arts and Leisure about this problem?
404. Dr C Hamilton: Theo will answer on the primary care side, which includes family health issues.
405. The BMA is a national organisation, so much of our work and research has been undertaken nationally. Much of our scientific wing’s research has been done with English Departments, including some of the research and the booklets that we have already mentioned. I am not sure, Ivor, whether there has been any direct work with, for example, the Committee for Education. I do not think that we have received any invitations from that Committee.
406. Mr Ivor Whitten (British Medical Association Northern Ireland): No, we have not. Mr Buchanan made a valid point, which has been made before. What work is the BMA doing with other Committees if it is saying that the problem is societal and not purely medical? The BMA can take on that kind of work, although our members work at different levels with different Departments because of the existing co-ordination with the Department of Education at board level. Many of our members are already involved at that level. The BMA would, perhaps, wish to examine more strategic issues rather than day-to-day matters. However, I take the point; it is a cross-departmental issue, and it can affect the whole gamut of society in Northern Ireland. DETI and DEL are involved in creating employment and encouraging innovation.
407. As a BMA staff member, I can have a simple health check every year, which records my body mass index, my cholesterol and my blood sugar levels. I do not normally visit my GP except with my kids, and that private-sector health check immediately expands the cohort. Such a simple health check could easily pick up on busy working people who perhaps look after their kids or even their parents, or carers who look after everyone else but do not look after themselves. They are generally being missed because they do not present to their GP for a check-up. If check-ups are done in a simple manner through private-sector industries and organisations, that will immediately expand the cohort of people who are being tested and told that they should see their GP. Perhaps their BMI is a little higher than it should be, and they need to go to their GP just to be on the safe side. It encourages people to think about themselves and to ensure that, if something is picked up, they go to their GP. GPs can deal only with the people who present themselves. The responsibility to act goes across all Departments.
408. Food and nutrition are also important factors, with which DARD can become involved. Northern Ireland has excellent food standards; how can we improve nutrition throughout society? Healthy options in school meals were mentioned, but why cannot all food be healthy? We should try to make healthy food look a more attractive and easier option. It is easy to discuss those options, but incredibly difficult to implement them. The Committee is making a start, but the message must be spread further. It should co-ordinate its discussions with other Committees on how to make the issue cross-departmental.
409. We all have a responsibility, which we accept. It could be said that this Committee is making a start in its inquiry into obesity in Northern Ireland. Action to address obesity is currently very patchwork in that there are many pilots but very little co-ordination. The public health agency could be a major stakeholder, at least in a co-ordinating role, in ensuring that good pilots are rolled out across Northern Ireland and that they are properly monitored so that we can get as much information as possible. That is required, because we have very little information on how obesity is being tackled in Northern Ireland.
410. Dr C Hamilton: The important points about the role of the family should not go unheard.
411. Dr Nugent: Mr Buchanan, your point is very important. As a parent, until recently I thought that discipline was something that parents imposed on their children. Fortunately, my children are now at an age to disabuse me of that notion — I am now incorrect on most issues, and they are there to keep me right.
412. In my experience as a GP, most parents become bashful and annoyed about their smoking habits, not because members of their peer group are criticising them but because their kids come home from school and give them an earful about it. My youngest fellow is the only one of my three kids to do home economics at school, and it is amazing what he is aware of, what he knows and the issues on which he is prepared to pontificate. Obesity will never be one of his problems, because he is built like a racing snake, and he is the only one of my three children who will not get scurvy.
413. The education of kids, and boys in particular, is an interesting matter. Until recently, in many schools — although not all schools — home economics was almost a taboo subject. By giving boys more encouragement and access to that subject, they can gain an incredible amount of knowledge. That is also an important motivator for parents, because, when they are in Tesco, their children now question what they are buying. There are wider issues with regard to the economics of food pricing, but education and discipline from the kids upwards are the way to go.
414. The Deputy Chairperson: I could not agree more with you, because my kids are also like that. For example, yesterday was No Smoking Day, and my wee boy had my husband tortured all day by asking if he had smoked yet. Therefore, kids are important in tackling obesity.
415. Reference was made to Weight Watchers, but I do not want to pick on that programme in particular, because there are others such as Unislim. Do such programmes have a role to play in tackling obesity? I do not think that they are regulated. Do have any feelings on whether they should or could be regulated?
416. Dr Nugent: For a start, those programmes are accessible; they do not cost a packet, and they offer peer support. I also do not want to single out Weight Watchers, but it is the only programme in our area of which I am aware. There is a Weight Watchers “lite" in our area, which is typically for males who do not want to take part in a programme with a group of females of a certain age. Without being sexist or ageist, many males will not go to such groups, but they can access information online or in paper format, which gives them education about healthy eating with tasty food.
417. As an ordinary GP who works in an ordinary practice, that is the only thing that seems to make a difference: people sign up to a weight-loss programme and come back lighter, happier and, more to the point, are no longer eating food that is wildly expensive or that tastes of cardboard, as food from a zero-fat diet would. Those people are eating food that is spicy, tasty and interesting. I do not know about regulation, but the programmes seem to be well organised and well run.
418. The Deputy Chairperson: I thank you all for your contributions, which have been very helpful to members as we progress our inquiry. We will forward you a copy of our report when it is published.
26 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
Mr John McCallister
Ms Sue Ramsey
Witness:
Dr Michael Ryan |
Northern Health and Social Care Trust |
419. The Deputy Chairperson (Mrs O’Neill): I welcome Dr Michael Ryan from the Northern Health and Social Care Trust. Members will recall that we met Michael at one of our informal discussions. A copy of his submission and other relevant papers are in Members’ papers.420. Dr Ryan, thank you for sitting through our long business session. I invite you to lead off and members will ask questions when you have finished.
421. Dr Michael Ryan (Northern Health and Social Care Trust): Thank you very much for your invitation to come back to the Committee. I will talk to my written submission. I have also submitted supplementary information. I emphasise that I am speaking as clinician in the front line: I am not an academic clinician. I see patients who are at a very high risk of cardiovascular disease, particularly diabetes and high cholesterol. My motivation to get involved in this topic is due to the fact that 90% of the patients that I see are either overweight or obese, and there is no specific service for them to avail of.
422. Although the Department has made many efforts in the community, there is a significant shortfall in the care offered to patients — unless they are children, which is laudable — in the primary or secondary health-care arena. That is my motivation for coming here today.
423. There is no comprehensive, strategically planned, service for dealing with overweight and obese adults, in particular. There is also no seamless stream of care packages available for those who suffer from overweight and obesity. According to the World Health Organization, about 7% of all disease, about one third of all coronary heart disease and stroke, and almost 60% of hypertension disease are secondary to overweight and obesity.
424. As I mentioned, 90% of the patients I see for diabetes; about 80% who attend cardiac clinics; 70% who attend our gastrointestinal clinics, and about 60% who attend respiratory clinics have significant co-morbidity that is linked to weight and obesity. The difficulty is that there is no service for those patients. A large proportion of the population needs professional help.
425. I have appended a table to my submission that puts the issue of weight and obesity in context by ranking its health-risk factor against the risk factors of other conditions that have considerable resources invested in them. For example, smoking will roughly quadruple a male or female’s risk of diabetes, which accounts for approximately 12% of total health-care costs. Some patients who have hypertension — for which treatment is expensive — take three or four hypertension agents on a regular basis.
426. Abdominal obesity is on a par with those risk factors as regards the risk of cardiac disease. However, as a proportion of that risk, the resources put in to deal with the problem are miniscule. The problem is that, unlike other issues, there is no “plug-and-play" approach to tackling obesity. No tablets or agents, such as those used to control cholesterol or deal with hypertension respectively, can be used to tackle obesity. A fundamentally different approach is needed to tackle obesity than those that are being used to address conventional risk factors.
427. Secondly, much of the morbidity and premature mortality linked to hypertension, diabetes and cardiac disease is underpinned by the co-existence of overweight and obesity among those patients. At a whole range of clinics, obesity is the common denominator in a high proportion of patients’ conditions. My contention is that a vast range of clinical services is being “silted up" with patients who attend with obesity-related co-morbidity, but who have nowhere to go.
428. A doctor might pick up on the fact that a patient has diabetes, hypertension, a respiratory problem or heart disease and send him or her to a specialist in the respective field. However, the patient’s fundamental problem will not go away until the obesity issue is addressed, because it underpins the primary presenting complaint. In the current structure, adults with a weight-related problem are being squeezed into other clinics.
429. As I said, about 90% of the patients that attend my diabetes clinic have weight-related issues. It is well established that more than 90% of diabetes is caused by overweight — too many calories in, too few calories out.
430. Fundamentally, the current approach lacks cohesion and an overarching strategy. It fails to produce objective and quantifiable outcome measures, such as the assessment of value for money and clinical effectiveness. I suggest that the current approach is inadequate; we see the evidence for that in that the obesity and overweight epidemic is now described in the medical literature as having reached a crisis point.
431. I suggest that we adopt best practice: the Counterweight programme in Scotland, for example, has been shown to be very successful in primary care and we can use that as a model framework for an obesity service in the Province. The interesting outcome of that is that for every unit of weight lost, the drug costs — the treatment of hypertension, diabetes, heart failure and cardiac disease — drops by 6%. Therefore, there is a cost-effective aspect to this proposal.
432. The managed clinical network model of service delivery is now well established and has been shown to be an effective means of delivering targeted services for specific reasons. The approach to weight management at all levels of intervention should be supported by the managed clinical network. Much of the cost of such a programme is already embedded in the system because we are already dealing with the consequences of overweight and obesity on people’s health, but it is unrecognised and unquantified because there is no specific weight-related programme targeted at the problem. Considerable resources have already been invested in tackling weight-related problems but, as a practising clinician at the front line, I see no evidence of their effectiveness. A managed clinical network model, specifically for obesity, would be able to evaluate programmes of care and produce solid evidence or otherwise of cost-effectiveness and clinical effectiveness.
433. I have submitted some slides as evidence to back up some of what I am saying. I am conscious of time. On the first slide, to which I have already referred, you can see that eating fruit and vegetables reduces risk, particularly in women, and that exercise will halve the risk, particularly in women. Cholesterol is very important and very expensive to tackle, but its threat to health is on a par with overweight and obesity. Obesity is, literally, the elephant in the living room.
434. I hope that the slides complement what I have said. I apologise for the small size of the writing, but otherwise it would run to 10 pages.
435. Obesity is reckoned to cost the Health Service £120 million per annum in Northern Ireland. We are already expending resources on the consequences of obesity: I propose that we invest in preventing that outlay on patient care. The impact of obesity on an adolescent or a young adult is equivalent to that of smoking and there has been a tremendous effort put into smoking as regards awareness and prevention. There are smoking cessation clinics and smoking cessation nurses: we do not have the equivalent for obesity and yet it poses the same threat to health. As we gain from the use of cholesterol drugs and blood-pressure drugs, and as the death rates from cardiovascular disease fall, the death rate from diabetes increases. A report in January 2009 showed that 55 patients died from diabetes 10 years ago in Northern Ireland. The figures from last year show 188 patients having died from diabetes.
436. Diabetes is an inevitable consequence of weight gain: our submission contains slides showing obesity as a risk factor for type 2 diabetes in women and men. For those of you who are not familiar with body mass index (BMI), I will give an example. A person who is 5 ft 6 in tall and weighs nine and a half stone would have a body-mass index of 25, which is fine. A person who was 5 ft 6 in tall and weighed around 12 and a half stone would have a body-mass index of 30. I see patients who weigh twice that, as does every doctor in the Province. It is a useful benchmark to know when a person is clinically obese.
437. When people develop diabetes, they may say that they have a mild form of diabetes. That is like saying that you have a slight touch of pregnancy. It is a serious and significant health threat. We can see mortality and glucose as a continuum. I draw your attention to mortality, as it is such a “hard" end point, and there is no coming back from it.
438. The tragedy of the shortfall in healthcare provision is that much of the diabetes cases can be prevented. There are three trials to show that, within three years, intervention can prevent about 60% of diabetes from occurring. I present a summary of those trials in the submission. Exercise and weight control can prevent at least that amount of diabetes, which is costing the healthcare system dearly. Once a person is diagnosed with diabetes, his or her life expectancy is reduced by approximately 10 to 15 years.
439. If we invest in weight loss and obesity, there are a number of benefits that will arise from a 10% loss in body weight — those benefits are detailed in the slides. Again, I draw your attention to mortality, because it is so dear to my heart. One can see that obesity-related cancer deaths will drop by 40%. Some cancers, particularly in women, are linked; about half of certain cancers in post-menopausal women are related to obesity, according to a recent report.
440. There is no drug or combination of drug therapies that would achieve those gains across the board globally. The absence of such an approach to weight and obesity is a serious shortcoming in healthcare provision. The fact that there is not a “plug and play" technology makes it a difficult area, and one that doctors conventionally tend to avoid, because it requires a different approach; repeated intervention and support at psychological, social, or physical levels.
441. I have provided a hypothetical example in the submission, which details the years of life lost for someone aged 40, who is 5 ft 6 in tall and weighs 12 and a half stone, with a body-mass index of 30. At age 40 they would lose approximately seven years of life. There are very few medical illnesses that, globally, across the population, achieve that level of compromise in relation to life expectancy.
442. The impact of obesity and overweight is worse than all the cancers put together, on an epidemiological basis, and yet we can intervene, and it can be prevented if caught early enough. If there were a structured programme that would involve as many impact points as possible, we could prevent very significant premature mortality and morbidity in the population.
443. In summary, I support the proposal for significant investment; from my perspective as a practising clinician, the research has gone on long enough. There is very good evidence that weight can be controlled, that weight gain can be mitigated, and that the consequences of weight loss are well established. We have effective means of intervening, with motivational analysis, behavioural modification from the Scottish Counterweight programme to show that such intervention is cost effective. However, political will is needed to make it happen, and that is why I am here today. Thank you very much.
444. The Deputy Chairperson: Thank you for your presentation. It will be valuable to the Committee as it carries out its inquiry.
445. You talked about a managed clinical network, and the staff and training required for that. Will you give the Committee more information on the nature and extent of the specific training needed for staff to deliver such a programme, and how that programme would be delivered?
446. Dr Ryan: A managed clinical network is a well-established model of healthcare delivery, and there are several in the Province. Fundamentally, it is protected time for a range of interventions under a structured programme. It has terms of reference, a management board, specific goals, and an audit programme to quantify its outcomes.
447. I do not feel that training is the problem. For example, in my job plan I have no time to deal with obesity. The scale of the problem lies mainly in the community — in schools, play areas, secondary schools, universities, etc — and that would be a major plank of a network. The difficulty is that the effort that we are putting into schools is not part of a strategic system: we are not measuring the outcomes. For example, there are many community groups — such as WeightWatchers — and there are many facilities for exercise. We are not harnessing those resources in a structured and managed way.
448. I cannot say how much I would need specifically. Many trusts have a managed network for diabetes. The expertise probably exists already, and much of the effort and expenditure exists. However, it must be released specifically for obesity. I cannot quantify that at this stage. The cost of not doing it now will be much higher five years down the line.
449. Mr Gardiner: When I was reading your submission last night, the economy, the efficiency and the effectiveness jumped out at me, and you have referred to some of them. Do GPs need training in obesity? Can health visitors deliver information? How can we improve the system? You have talked about a programme, and getting it across to schools and various organisations. Please elaborate on that?
450. Dr Ryan: The problem as I see it — from my perspective as a clinician with nowhere to send my patients — is that knowledge is not the problem. We are all aware of the need for reducing calories, and we are all aware of the need to exercise. The difficulty is the patient’s relationship with calories and food. It is a complicated issue: it is fundamental to a patient’s sense of well-being. Some specific training is required, and the most effective strategy used in Scotland and Wales contains motivational analysis and behaviour modification techniques, which is a branch of psychology — it is not knowledge. Patients know that they should not eat cream buns or whatever it may be.
451. Mr Gardiner: I am not so sure that patients do know, and it would be better for them if their GPs told them so.
452. Dr Ryan: You are absolutely correct.
453. Mr Gardiner: Should someone in authority not get that message across?
454. Dr Ryan: Yes; but the message must be approved and standardised. GPs seem to be delivering a slightly different message depending on the biases, their expertise, or the level of interest that they or their staff have. Some of those messages are neither appropriate nor effective, and that is where the managed network approach comes in. There would be a single message, approved and evidence-based. It is not a group hug.
455. Weight and obesity are well-established causal factors, in the same way as blood pressure and cholesterol. We need to become more scientific and rigorous in how we deal with weight issues. Having a group hug is not acceptable; we can no longer depend on well-meaning individuals doing their best. There is evidence that there are effective strategies, and, for the health of our population, we must implement them with a sense of urgency. We all need to be retrained.
456. Mr Easton: It is good that you are enthusiastic. My feeling is that we force food retailers and producers to reduce the amount of fat, sugar and salt that goes into food, any measures that we put in place will not help much. I would appreciate hearing your comments on what we might do about that problem.
457. You touched on the subject of diabetic clinics. Do you think that a clinic should be developed specifically for obese people?
458. Finally, what is your opinion of the Norwegian nutrition policy and healthy-eating campaigns, which seem quite good?
459. Dr Ryan: My answer is yes to all of the above. We do need to engage with the food industry, but only up to a point, because it will be led by market forces. Educated people make different choices than uneducated people. In our efforts to improve the health of the community, although it is important to engage with the food industry concerning salt, fat and sugar, the question is what can we do with a 35-year-old person who weighs 26 stone and cannot walk because he or she is so heavy? The cost of dealing with the health problems associated with such a patient is enormous; whereas, the cost of dealing with that person’s diet and getting him or her back to work is relatively small.
460. Two weeks ago, I saw a patient in my clinic — I am the only clinician who accepts obesity referrals — who carried her tummy in a modified shopping trolley. That lady cannot work because of her weight: her mobility and her social interaction are compromised — she is 52 years old. We need specialist clinics and services for such people — their lives are blighted. Suggesting that we ignore the problem, or just treat people’s blood pressure, is not dealing with the fundamental morbidity of what is an enormous social and personal problem. We must tackle it at a social, educational and individual level.
461. There should be adult obesity clinics to specifically target patients who fall through the community-level and primary-care-level filters, because cases involving overweight or obese people are silting up the vast majority of clinics in hospitals and GP practices. We need somewhere for those patients to go, so that they can receive the expert treatment and intervention that they require. The cost of not doing that will eventually be much greater than the cost of doing it.
462. The Surgeon General of the United States commented that this is the first generation of Americans whose life expectancy is less than that of their parents, specifically because of the obesity problem. An obese teenager is likely to be a cardio-vascular invalid in his or her 40s. We must do something about that problem as a matter of urgency, and that tone is reflected in the literature, which describes a tsunami of obesity.
463. When I was training, type 2 diabetes was called “maturity-onset diabetes". Nowadays, I see 18 and 19-year-old people with that condition, and paediatricians are seeing it in the under 16s. That was unheard of. All I can say is that in my view, it is the single biggest health problem facing our community.
464. Dr Deeny: Thank you, Michael. I am sorry that I missed the start of your presentation. As a GP, I am very concerned about obesity. I have two quick questions about the problem. First, I have my doubts about the BMI. One of the measurements is a waist-to-hip ratio. Last week, we saw the wonderful victory in Cardiff. Many of the guys who played in that rugby team would certainly have a BMI that, according to the charts in a GP’s surgery, would be classed as obese, yet they are big, strong and physical guys. I wonder whether the BMI needs to be discounted and replaced with a better measure of obesity. Some of those rugby guys are 18 stone and are built like the side of a house — they could run through you.
465. Secondly, as a doctor, I too think that it is our duty to get the message out and make it clear that this is a major epidemic that will have serious health consequences for the next generation, and those that follow, if it is not addressed.
466. As I said before, I am worried that we are perhaps going to extremes in being too alarmist. I say that for two reasons. You mentioned that, for about half of certain cancers in post-menopausal women, there is a link between obesity and cancer, and that is what made me ask the question. I was delayed because I had a surgery this morning. I called with a patient who is worried about cancer. Unless a statement such as yours is made more accurate — explaining how great the link is, as opposed to simply saying that there is a link — we are in danger of worrying a significant section of the population who are already starting to worry about cancer, particularly if there is a family history of it.
467. I will give you another example, which I mentioned a few weeks ago. There is an advertisement on the radio and on television, which is perhaps another example of going a little bit too far and almost terrifying people to force them to live a certain way. The advertisement is to do with breast cancer and drinking, and there is no doubt that there is a link there. However, that advertisement worries me. It shows a lady drinking and the drink going down the oesophagus, which is fair enough. It then states that drinking within the normal limits can reduce the risk of cancer. To me, listening to that, it sends out the message that even drinking sensibly and normally is associated with a link to breast cancer. On the one hand, people are being told that if they stick to the normal weekly units of alcohol — 14 units for women, 21 units for men — that that can have beneficial effects on health. Now we are hearing that if you stick within those limits, it will not get rid of you chances of breast cancer, it will only reduce them.
468. I am talking as someone who has been in general practice for some years. For doctors, and all medical people, getting the message out there to the community, strong and clear, is of absolute importance. However, I fear that we are going to extremes and terrifying people. Perhaps sometimes we get the wrong message across. Can you quantify the link between post-menopausal women who are obese and cancer?
469. Dr Ryan: There was a recent editorial in the ‘British Medical Journal’ (BMJ) on that very topic, which stated that: “Among postmenopausal women in the UK, 5% of all cancers (about 6,000 annually) are attributable to being overweight or obese. For endometrial cancer and adenocarcinoma of the oesophagus...half of all cases in postmenopausal women are attributable to overweight and obesity."
470. I did not make that up. That is from the ‘BMJ’.
471. I accept that the BMI is an imperfect measure. I have been waiting for 20 years for the perfect measure. The difficulty is that meanwhile, patients are dying. We cannot wait for the perfect measure; however, I accept that the body mass index is not the ideal. You are quite right; it is a different kettle of fish if muscle weight is a contributory factor. However, at least it would sift out, on an epidemiological or population basis, those patients who might be targeted for lifestyle intervention.
472. In the literature on the issue, there is absolutely no doubt that the lighter that a person is — within reason — the longer he or she will live. I am convinced of that connection, and there is vast evidence to support it. Actuarial statistics from insurance companies will bear that out forcibly.
473. I have presented one or two of the best slides to show that even being moderately overweight will compromise life expectancy. I stand by that assertion. I accept that patients may not worry about losing two or three years from their lives, but that has the same effect on mortality of the whole population as all the cancers put together. To get the weight message into context, the Americans have a great phrase — “the soft stuff is the hard stuff". Blood pressure is a plug and play; someone takes the tablets, and it goes away. Cholesterol is also easy to address. However, obesity is a much more tenacious and difficult problem. I can understand why we do not have a simple solution to obesity, but that does not mean that we can afford to ignore the problem — the cost of ignoring the problem will be enormous.
474. Dr Deeny: I do not want to ignore the problem, but we must get across a message that is as accurate as possible. For example, I am concerned that the message about menopausal women will worry people more and affect their mental health. People who are obese and post-menopausal will read that message and think that they have a 50% chance of getting cancer. That is my concern.
475. Dr Ryan: Knowledge is power. In my clinical practice, I use that type of knowledge all the time — the more that a patient knows about his or her condition, the more he or she is empowered to deal with it. In no situation is that more important than in a lifestyle-related problem. If a lady is obese and concerned about her cancer risk, perhaps she will be motivated to do something about it. There are very few cancers that people can address by changing their lifestyles. If a lady loses 10% of her weight, she will reduce her risk of obesity-related cancers by 40%. That is the epidemiological return on weight loss, which is well worth it. There are some serious threats to health, and putting the minds of patients at ease is important. However, it is equally important to give patients the hard and cold facts, and the literature on the issue supports that.
476. Ms S Ramsey: I do not know whether I should thank you for your presentation. I am sitting here thinking that maybe I should just go home, go to bed and give up the ghost, because what I have heard is depressing. I agree that knowledge is power, but responsibility comes with that power.
477. In your presentation, you mentioned the importance of mindsets and attitudes in how we deal with the problem. Some people say that a sizeable percentage of those who suffer from obesity, some forms of cancer and diabetes come from socially deprived areas. That is an issue that we need to talk about. We also need to address the problem early, which means that we need to invest in schools.
478. Alex Easton said that food producers and manufacturers need to examine their ingredients, but we are not investing in school meals. A large percentage of the children who receive school meals come from socially deprived areas, and they are getting food that will create problems for them later in life. If we are going to be honest, we need to be brutally honest and admit that we — as a society and as the people who are supposed to be in charge — are feeding the problem; pardon the pun.
479. We also need to invest more in after-schools programmes, whether those are for recreation or study. The Assembly has debated the issue of whose responsibility it is to fund after-schools programmes. One Minister and Department are fighting with another Minister and Department, and the issue of neighbourhood renewal is getting lost because of that. Therefore, we need to be brutally honest about that.
480. Education is the key. We need to be honest about the advertisement and sponsorship of big events. A number of years ago, cigarette companies advertised at events, then it was the alcohol companies, and now it is either big fast-food companies or soft-drinks companies. We need to be clear about that.
481. Do you believe that other Departments and Ministers are playing an active role in trying to deal with and tackle this issue? A number of weeks ago, officials from the Department of Health, Social Services and Public Safety told us what they will do. However, we, as a Committee, have no control over the Department of Education, the Department for Social Development (DSD), or the Office of the First Minister and deputy First Minister (OFMDFM). I want you to be honest, because we need to tackle this issue as a collective problem. Do the Executive have a collective responsibility and mindset to deal with the issue of obesity?
482. Dr Ryan: That is a difficult question for me to answer. I do not know what is going on in the Executive. I am simply addressing the issue from my perspective as a practising clinician. I see more and more patients with a primary problem that I have no authority to help them with; I have no means to help them. Obesity is a problem that I should and could help them with if I had the time. In running a diabetes clinic, I have an obligation to my employer to see diabetes as the primary focus. Although I do address all the other issues as best I can, obesity is such an intractable and deep-rooted problem that it needs specific, targeted intervention.
483. Obesity is a health issue; an education issue; a social policy issue; and a public transport issue. I agree with you, I do not know who should pay for this. All I know is that there are consequences that have yet to be realised. The difficulty is that I do not see the evidence to suggest that the provision of school meals produces fitter, lighter, healthier, smarter children with a longer life expectancy.
484. My primary measurement is death. If I intervene to help patients, I must be satisfied that there is evidence to show that they will live longer. That is my only justification for adding chemicals to their mix or for instructing, advising or guiding them to change their lifestyle. My concern is that resources are being expended and that there is no overarching infrastructure to weigh those in the balance in order to ascertain whether they are producing value for money.
485. Ms S Ramsey: First, forget about the evidence about the value of schools meals. School meals are being provided, so we should ensure that those are of the highest standard. Secondly, I know loads of people who would love to be able to afford to buy free-range chicken. I use this example to show why people get caught in the trap. A free-range chicken can cost £8, £9 or £10; whereas a processed chicken costs approximately £2. Although we need to change the people’s attitude to food and lifestyle, we also need to ensure that they are able access healthier produce.
486. Dr Ryan: I agree, but I do not know of any evidence to show that free-range chickens are any more nutritionally beneficial than processed chickens.
487. Ms S Ramsey: We are led to believe that they are.
488. Dr Ryan: If I were selling free-range chickens, I would lead you to believe that, too.
489. Mr Buchanan: In your opening remarks, you mentioned the Counterweight programme in Scotland. How long has that been in operation, and how has it been evaluated? How much would it cost to set up a similar programme in Northern Ireland? Finally, how long would it take to roll out such a programme across all the health board areas?
490. Dr Ryan: The Counterweight programme in Scotland is primary-care based and provides specifically trained staff to deal with obesity. It is rigorously evaluated by the University of York and the University of Aberdeen. Counterweight has produced credible evidence of the cost-effectiveness of that type of programme.
491. To implement a similar programme region-wide would require a significant amount of priming money, but that would be recouped through a reduction in drug costs, reduced levels of diabetes, fewer hospital admissions, and so forth. I can only hazard a guess that to roll out such a programme across the Province may cost approximately £500,000 a year for the first two or three years.
492. The Deputy Chairperson: Dr Ryan, thank you for coming today. Your evidence has been most helpful to the Committee, and I will ensure that you receive a copy of the final report.
2 April 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
Ms Claire McGill
Witnesses:
Ms Tracy Gibbs |
College of Occupational Therapists |
|
Ms Pauline Mulholland |
British Dietetic Association |
|
Ms Teresa Ross |
Chartered Society of Physiotherapy |
493. The Deputy Chairperson (Mrs O’Neill): I welcome Ms Pauline Mulholland, a board member of the British Dietetic Association (BDA); Ms Tracey Gibbs, chairperson of the College of Occupational Therapists (COT); and Ms Teresa Ross from the Chartered Society of Physiotherapy (CSP). I invite you to make your presentation, after which members will have an opportunity to ask questions.
494. Ms Pauline Mulholland (British Dietetic Association): I thank the Committee for giving us the opportunity to present allied health professionals’ views on tackling obesity.
495. The Committee’s inquiry is timely, given the new healthcare arrangements and organisations that came into being yesterday. It also gives allied health professionals the opportunity to make a more co-ordinated and robust contribution, not only to tackling obesity, but to addressing a range of related long-term conditions.
496. On behalf of the British Dietetic Association, I alert the Committee to the fact that dieticians are uniquely qualified health professionals, which is demonstrated in the way in which they assess, diagnose and treat individuals and the wider public with problems that are related to diet and nutrition. Dieticians make a singular contribution to the prevention and management of obesity at all levels.
497. At regional level, we feel that we can contribute by working with strategic groups in overseeing the development and implementation of a policy on obesity. To date, we have not had the opportunity to do such work; we are involved only at the lower levels of strategy development and would therefore welcome the opportunity to contribute at a higher level. On the subject of commissioning, we can contribute to the design of services to meet patients’ dietary and nutritional needs. We lead on the implementation of obesity and food-guidance policies in local trusts and in education. We support individual patients in the management of clinical obesity, and we also work with communities and voluntary groups on prevention. That is where local people can make the changes necessary that are to tackle the issue.
498. In our written submission we provided the Committee with a range of examples of preventative measures. We also provided to the Committee a recent British Dietetic Association leaflet outlining the contribution that dieticians can make. Some examples in Northern Ireland are the Cook It! programmes, which are run throughout the Province, the FRESH programme, which is for young adolescents with obesity in north and west Belfast, and Bank Your Smile, which is an oral health project in the west. Those initiatives are designed to deliver the Investing for Health strategy and the Fit Futures strategy in the Province.
499. The British Dietetic Association considers that the new Regional Agency for Public Health and Social Well-being provides the opportunity to evaluate such schemes across Northern Ireland and to decide which of them to commission to create the best outcomes for the public. For maximum impact, we would like those schemes to be embedded in core services across Northern Ireland.
500. We are engaged in joined-up working with many other agencies. That is because people other than dieticians have a role to play. We work with education providers, local councils and environmental health officers. We also work with local leisure centres and other bodies that provide physical activity programmes in support of tackling obesity. We established a range of schemes in schools, but given the fact that one meal a day is eaten at school, we must build on those. We must ask what happens with parents and children beyond the school hours.
501. One of our key roles is the management of clinical obesity, which is a challenge for individuals and professionals. People aspire to lose a significant amount of weight over a short period, and sometimes that puts them off accessing our services. We need to manage such expectations and promote the message that if individuals can be encouraged to lose 10% of their weight and to maintain that weight loss, they can achieve significant health benefits. The evidence shows that a 10% weight loss will reduce blood pressure and cholesterol, improve the control of blood sugar for people with diabetes, and reduce the death rates for a number of conditions. As a result, we may be able to reduce the number of drugs that such patients have to take, thereby reducing public expenditure.
502. The outcomes from intensive weight-management programmes across Northern Ireland have been well recorded, and we have several examples. Those outcomes are achieved through a combination of dietary advice, exercise and techniques to change behaviour. Thus we aim to alter an individual’s entire lifestyle and to maintain that change in the long term. We do so using supportive practical approaches, such as cookery demonstrations and supermarket tours. That is because people need to get not only advice, but the skills to put that advice into practice.
503. In order to deliver on the significant agenda of challenging obesity in Northern Ireland, we would like it to be recognised as a disease in its own right. We would also like a regional obesity framework to be established to support the delivery of the agenda across the Province. The Department of Health, Social Services and Public Safety and other Departments can lead by example by implementing schemes that teach people about healthy nutrition in the workplace, for instance. There are many examples of that type of scheme across the UK. Of particular note is a scheme in Wales, through which the Minister of Health and Social Care implemented a charter for vending in healthcare facilities. Our challenge is to extend that throughout the public sector in Northern Ireland, thereby improving individuals’ workplace choices.
504. Ms Tracey Gibbs (College of Occupational Therapists): Thank you very much. I am delighted to be able to speak to the Committee on behalf of the College of Occupational Therapists.
505. I will discuss a number of the key areas that we identified in our document. Obesity is a significant issue for the many different groups of people with which we work. That includes people of all age ranges in acute-hospital settings and in their community environments and people who suffer from chronic conditions and other co-morbidities that are often associated with obesity. Other groups of people with which we deal include those with mental-health problems and learning disabilities. We also work with wheelchair users, particularly children and younger people.
506. Occupational therapists (OTs) in Northern Ireland have identified an increased need for specialised bariatric equipment, and we outlined some implications of that need in our written submission. Bariatrics is the science of providing healthcare for our heavier population. On a day-to-day basis, that has major implications for transporting patients in hospital beds, the use of hoists and porters’ chairs, and for the use of seating in hospitals and in the patient’s home. Addressing the need for specialised equipment for that client group is a major challenge that faces therapists.
507. Although there is a lot of emphasis on the global epidemic of obesity, it is also important to consider the needs of the obese person. It must be ensured that they are treated with respect and dignity and that stigma and discrimination are avoided. A person who is overweight may feel socially isolated or excluded. Their role as a caregiver, as a spouse or as a child, for example, may be affected. As a result, occupational therapists consider the ability of the overweight person to look after themselves and their ability to function in their own environment. Very often, activities of daily life may be affected.
508. Occupational therapists feel that it is important to address this issue from a preventative, health-promoting perspective. It is also important to help people cope with the symptoms or results of their condition and to prevent further problems. Investment should be provided so that preventative programmes that incorporate health-promotion and lifestyle-management strategies can be delivered to address the broad spectrum of issues among all clients across all age ranges.
509. A co-ordinated, all-systems approach to tackling the issue is necessary. There should be a national service framework for the treatment of obesity. Meaningful activities could be used as intervention. For example, people should be encouraged to become involved in activities that they enjoy, such as gardening or dancing, so that their mind and interests can be engaged. Ultimately, exercise on prescription should be broadened to include activity on prescription.
510. It is important that the home and general environment is accessible to people who are overweight or obese so that their problems are not compounded by being housebound, which can lead to further inactivity. Community integration should be encouraged to increase self-esteem. People will be motivated to maintain and improve their functional independence. That is particularly important for schoolchildren; it must be ensured that their schools, respite facilities and day-care facilities have the appropriate environmental design.
511. Occupational therapists endorse the concept of inclusive environmental design that considers the needs of all users, including those with obesity. We can provide expert opinion for that client group on equipment, environmental housing design, caregivers’ needs, lifestyle management and mental-health issues.
512. Overall, we recognise the challenges of our increasing obese population in Northern Ireland. However, we feel that further investment is essential across all our allied health professions so that equity for all can be delivered.
513. Ms Teresa Ross (Chartered Society of Physiotherapy): I want to highlight the role that physiotherapy, along with the other allied health professions, plays in the management and prevention of obesity. The Clinical Resource Efficiency Support Team (CREST) guidelines point towards secondary care, but the management of obesity involves primary care and secondary care. It is a healthcare issue that concerns the whole population, not just one element of it.
514. Physiotherapists have the skills and expertise to assess and allow people to take part in exercise programmes and to undertake exercise prescription. Some of our work involves people with type 2 diabetes and people with musculoskeletal disorders, such as people with muscular sclerosis or neurological conditions that mean that they may be confined to a wheelchair. That means that one must look at other ways of allowing them to exercise, because they will not be able to go to a gym or take part in group exercise. Exercises must be modified to allow those people to have some kind of physical activity that will help to prevent secondary ill-health problems that can result from poor fitness levels. Such conditions include cardiovascular disease and stroke, and there are others.
515. From a physiotherapy point of view, exercise is important for a person’s well-being and self-esteem because the whole person is being treated. It is important to improve a person’s self-belief and self-esteem and allow them to have the confidence to take part in exercise. Exercise programmes have moved into leisure centres across the region. Those programmes are not just for people receiving primary care; they are for children and for those with an adult learning disability or a physical disability. People can go along and get introduced to exercise, take part, and then start doing those exercises themselves. However, some people are afraid to go into an environment where there are machines and equipment. The physiotherapist helps them to become accommodated safely into that environment, and our Over to You scheme allows people to take control of their own health and well-being. That is an important part of a physiotherapist’s role. Exercise is not something that physiotherapists can do to people; they must take control of it themselves.
516. Part of our job is to introduce patients to other environments. Obesity is a community issue and a population issue. It is not a health issue alone. It is a full-partnership issue; therefore, it is important to use all the partnerships that we can to help us to deal with obesity.
517. We must look at other ways of exercising. My colleagues mentioned dancing, walking, running, boccia and bowls. There are all kinds of exercises, and it is a matter of introducing people to them.
518. We take a person-centred approach. Although people may be referred with a sore back or a broken leg, ultimately, the whole person has to be managed. They may become inactive as a result of their condition, which may cause them to become overweight. That, in turn, may cause them to lose their self-esteem and their feelings of self-worth. It is important that behaviour be modified and that the person be built up in such care settings as successfully as possible.
519. Through the projects that we have run in primary and secondary prevention, we have found that the partnership that is involved is huge and that it must be developed. One cannot just treat the individual in question; everyone, including family, friends and neighbours must also become involved to allow for the peer support that people need to allow them to manage their problem.
520. Ms Gibbs mentioned manual handling. The Chartered Society of Physiotherapy leads a lot of the manual handling training for Health Service staff, including nurses, medics, allied health professionals and social workers. People are trained in how to manage obese patients safely, and that training then allows them to have the equipment and techniques in place.
521. Whenever obese patients are admitted to hospital, the theatres or X-ray departments may not be designed properly to deal with them. Physiotherapists advise on how to set up a department and manage the equipment and to have the necessary equipment in place or contracts available for bariatric patients to be well looked after.
522. The CREST guidelines of 2005 refer to the role of physiotherapy and the advice on exercise to enable people to manage obesity and to become fit. Of the people who present at physiotherapy departments, 20% do so for reasons other than being obese. However, that leaves us in a prime position to educate, train, advise and empower those people to look after their own lifestyles. Ultimately, a lot of the issue concerns a change in lifestyle and thinking.
523. A lot of schemes that have been run from a physiotherapy, allied health professional and multidisciplinary point of view have been funded by the Big Lottery Fund or by some other short-term grant. That has been a difficulty, because although the scheme may run for three years and be proven, it may then not get permanent funding. It is important that we influence that.
524. The incidence of falls is another factor that has an impact. I know that a lot of work is being done on falls, osteoporosis and other conditions. However, an obese person’s muscles become weaker — their muscle tone lessens and their balance reduces; therefore, the risk of falls or of osteoporosis from not doing weight-bearing exercises is increased. It is important that people’s lifestyles incorporate physical activity. That involves the entire community and every possible partner having an educational role.
525. Under the old arrangements, physical-activity forums considered the health and well-being of the population. They looked at deprivation and other issues and encouraged a multidisciplinary or multi-agency approach to the management of obesity. Allied health professionals are well placed to help and to influence that work in the future.
526. Ms Mulholland: In summary, we hope that the examples that we provided help the Committee to recognise the significant contribution that allied health professions can make to the prevention and management of obesity. We look forward to working with many groups and agencies to deliver on that significant task. Again, we thank the Committee for giving us the opportunity to present our evidence.
527. The Deputy Chairperson: Thank you very much Pauline, and thank you all for your contributions. The Committee recognises the key role that you play.
528. With the launch of the new Regional Agency for Public Health and Social Well-being yesterday, what do you consider to be the potential role that local commissioning groups (LCGs) and the agency itself can have in addressing health inequalities in general, but, in this case, obesity in particular? Obviously, that agency now has a key role in health prevention, promotion and education. Do you have any views on that?
529. Ms T Ross: We welcome as really important the involvement of the new authority, the LCGs and the membership of the local government agencies in the new structure. As a chair of the local health and social care group (LHSCG) in the Southern Trust, I know that the relationship with local councils and other local partnerships was key to our being able to commission services that helped meet population needs — it allowed us to make decisions on the most focused investment that would achieve the best impact on a population.
530. Therefore, the new agencies provide a positive forum for us to build upon. Their involvement in local communities will be a good influence, and the involvement of local council representatives will help to build a better future.
531. The Deputy Chairperson: There will be an increase in leisure opportunities, which comes back to that multi-agency approach.
532. Ms Mulholland: The point is to combine the best examples of what has worked across the region and to roll them out in the mainstream. At the same time, we must consider what has been tried and tested and what fits with a particular local community, because all communities are different. It is about what the people in those communities and voluntary groups think will work and what they are happy to engage with so that the desired outcomes can be achieved.
533. Ms T Ross: The other point to make about leisure opportunities is that it is really important that the rules, and an open approach, are standardised. Some of our examples show that a partnership with the providers of leisure facilities on issues of costs and other matters can be built more easily in some places than in others. A common approach would be good, because it would to allow for healthy activities to move into other arenas.
534. Mr Gardiner: Tracey, as a representative of occupational therapists, how do you deal with obese people who have a mental illness or a learning difficulty?
535. Ms Gibbs: That is certainly a challenge for those therapists who work in front line services. For example, patients with mental-health difficulties have usually been attending occupational-therapy services for a number of years, and it is important to engage them in a specific, tailored and therapeutic activity programme to gradually reintegrate them into the community. That is done by identifying their hobbies and interests, trying to regenerate their ability to become involved in leisure activities and, ultimately, participation in the recently established condition-management programmes, through which occupational therapists try to enable people to get back into work through vocational rehabilitation.
536. Therefore, we deal with such patients through a range of programmes that involve both individual and group work. Occupational therapists have been working with folk who have mental-health disorders and have been trying to overcome the issue of obesity and the problems that it causes.
537. In addition, from a learning-disability viewpoint, an increasing problem for occupational therapists is the use of equipment, and wheelchair sizes in particular reflect that. Our population is possibly getting more overweight — obese — which results in challenges in sourcing the most suitable wheelchair for a patient to ensure that it fits into his or her day-care centre, respite facility and home environment. Along with our physiotherapy and dietetic colleagues, we try to address the huge implications of obesity and to ensure that the home life, work life or school life of a patient is as manageable and independent as possible. That is achieved through individually tailored activity-based programmes, correct supply and prescription of equipment, close monitoring of a patient at home, and very close liaison with teachers, care givers and the whole carers’ network.
538. Mr Gardiner: What percentage of the patients that you treat have a mental illness or a learning difficulty?
539. Ms Gibbs: I work in an acute hospital and deal with physical disabilities, so I cannot give you the exact percentage offhand. However, I can source that information for you.
540. Ms Mulholland: Allied health professionals know that occupational therapy is the most recognised therapy for mental-health and adult disability. Therefore, a much higher proportion of occupational therapists work with clients who have mental-health problems.
541. The Deputy Chairperson: Can I clarify whether allied health professionals are represented on the obesity steering group?
542. Ms Mulholland: No, they are not. One of our recommendations is that allied health professionals should contribute to that group’s work. We are involved, but not directly; one of our colleagues managed to be nominated by her trust to one of the subcommittees and has introduced the idea that it is important to have dieticians represented on the group. We have managed to get a dietician on the food and nutrition subgroup; the British Dietetic Association was not invited to sit on the food and nutrition subgroup, even though such matters are our core business and we are the only professionals in the healthcare system who are regulated to act on those issues. We have a role to play on the obesity prevention steering group.
543. The Deputy Chairperson: I think that Committee members would agree with that point; I certainly do. As I said at the start of the meeting, you have a key role to play. That might feed into our recommendations.
544. Ms Mulholland: I plan to send a letter to the chairperson of the subgroup asking whether they would like us to contribute.
545. Dr Deeny: Ladies, I thank you for appearing before the Committee. As a doctor, I think that it is vital that you should be a representative of allied health professionals on the steering group. I should know this, but could you remind me of whether there will be two allied health professionals on each local commissioning group?
546. Ms Mulholland: As far as I know, there will be only one representative for a minimal amount of time — approximately one or two days a month.
547. Dr Deeny: I want to focus on the prevention of illness through exercise. Everybody is talking about that, and it is a multi-agency, cross-departmental issue. As a community physician and a GP, I want the education sector to be involved, and I am glad that councils are involved. Tracey mentioned environmental design. As an OT, what practical measures do you think could be taken to help facilitate people’s exercising in their own homes? How can we facilitate that environmental design in order to tackle the epidemic of obesity?
548. Last week, the Committee Clerk gave me a document that shows that GPs in the Belfast Health and Social Care Trust can prescribe leisure centre activity to patients. Although there was an arrangement in the west at one stage, GPs in the Western Board and other areas cannot prescribe in that way, and we must address that matter. Rather than wait until people get sick, if we are serious about real health promotion and disease prevention in the future, it is important that we establish a facility whereby GPs can use methods other than prescribing drugs in order to help people to lose weight.
549. As a GP, I want to be able to access patients whom I consider to be morbidly obese and whose health is threatened. Why should I be unable to prescribe physical activity as opposed to drugs, which are much more expensive? That is how we should progress. I was shocked by the document that the Committee Clerk gave me last week. I was pleasantly surprised to find that GPs in some parts of Northern Ireland refer patients to leisure centres. However, that does not happen in other parts.
550. Ms T Ross: I know that GPs in the Southern Trust prescribe exercise. They refer patients directly to leisure centres. Thereafter, the fitness instructor and the physiotherapist in a leisure centre work in partnership to assess the patient and set up an individual programme for them. The fitness instructor then takes control of the exercise programme. However, the fitness instructors require some training.
551. That would definitely be a positive way to progress and would allow the health system to target people who are at risk of ill health, as opposed to those who are actually ill. Therefore, it is important to develop the idea of prescribing exercise, and it should be rolled out.
552. Dr Deeny: The Committee Clerk has just handed me a document about the pre-fitness GP referral scheme. It is 12-week scheme that is similar to other UK schemes, and it operates in conjunction with the Eastern Health and Social Services Board’s Healthwise scheme. It is co-ordinated by the GP referral officer at a fitness centre. I think that such schemes are part of the future of healthcare and the prevention of illness.
553. Pauline is correct: such schemes will identify people who are perhaps a year or two away from a major health event or illness. Diabetes is already visible in young people in primary care. It used to be called maturity onset diabetes, but it can occur at any age, so it is now known as type 2 diabetes. Given that, such schemes must be a major part of our health strategy for the future, and we need to push access to them. We perhaps need to reach a point at which nurses can prescribe exercise, after having consulted with GPs and identified those patients that should be referred to leisure centres.
554. Ms Mulholland: That is one opportunity that the new Regional Agency for Public Health and Social Well-being will create. For example, how do we find out what is going on in different parts of the Province? Many schemes have been introduced in patches, and the Healthwise scheme in the Eastern Board area — where I am from — has been running for some time. I think that it was, perhaps, established on the back of Big Lottery funding. Several health-prevention schemes have received Big Lottery funding, but they did not receive the mainstream funding that would have enabled their benefits to be rolled out.
555. The Cook It! programmes, which promote healthy cooking, are one example of an environmental scheme. They are funded by the Big Lottery Fund across the Province and have received mainstream funding in two trust areas. However, in others trust areas, they have not received such funding. Therefore, some of our population has access to absolutely fabulous programmes that work and that have been evaluated, but those programmes do not exist in other areas. That inequity must be addressed, and the introduction of our new structures and way of doing business will provide an opportunity of which we must take advantage.
556. Ms Gibbs: With respect to environmental issues, our colleague Padraig O’Brien is working with the Housing Executive. However, occupational therapy needs more resources and more specialist knowledge of housing issues. In Northern Ireland, there is just one occupational therapist who is a clinical specialist in housing. Presently, he happens to work in the Northern Trust.
557. With such a person in place, specific research can be carried out in, for example, evidence-based practice, enabling us to prove which equipment is the most effective and efficient by trying out various devices in peoples’ homes. In different trusts, various waiting lists exist, and an assortment of equipment is being issued. Therefore, the range of equipment that is fit for purpose, research based and most efficiently costed must be streamlined.
558. Another way to move forward would be to have dedicated occupational therapists working specifically in housing. Other essential groups with which we must work and have closer links include housing authorities, the Housing Executive, the private sector, local schools and special schools. In addition, we must consider the whole area of risk management and become more environmentally efficient by devising practice standards in communities that ensure that any equipment that is to be recommended and prescribed is the best that we can deliver.
559. Dr Deeny: My question could apply equally to physiotherapists. There are not enough occupational therapists, who play a vital role in health and community care. Will you provide the Committee with statistics outlining how many OTs are in each of the five trust areas?
560. Ms Gibbs: Yes.
561. Dr Deeny: Could you also provide the Committee with the college’s estimate of how many OTs each trust should have? Most of us would agree that —
562. Ms Gibbs: There are 770 qualified professional occupational therapists in Northern Ireland, and the College of Occupational Therapists has 27,000 to 28,000 members. There are probably more than 200 occupational therapists in the Belfast Trust, approximately 120 in the Western Trust, and the remainder are dispersed among the other trusts. However, I can submit precise and up-to-date figures.
563. Dr Deeny: I would appreciate that. How many OTs does the college suggest that there should be in Northern Ireland?
564. Ms Gibbs: We have just submitted a response to workforce planning in the College of Occupational Therapists. The recommended numbers for each person in the population is much higher than the present numbers, but I can get the specific figures from our policy officer for Northern Ireland and forward them to you.
565. Mr Gallagher: I am glad to hear that there are so many OTs in the west of the Province; however, there appear to be few in places such as Fermanagh. That is an ongoing problem, but it is not for you to deal with today. Nevertheless, it will be interesting to see the figures when they come through.
566. You talked about the important role that dieticians must play. In addition, the British Dietetic Association mentions both the importance of having highly trained professionals and the need for support — including financial support — for them. Given that we must pay more attention to the problem of obesity, can you give us some idea of the position with respect to the population of Northern Ireland? Do you feel that we have enough well-trained professionals to work in that sphere?
567. Ms Mulholland: All the areas of work in which we are involved are regulated professions, and we are all regulated by the Health Professions Council.
568. Mr Gallagher: Does that include experts in diet?
569. Ms Mulholland: Yes, dieticians are regulated by the Health Professions Council. We are all graduates who have had to go through a training programme. We face challenges, in that others who are not regulated and trained in that way provide dietary messages that are not consistent with evidence-based practice. Being called a dietician is a protected title for all those who work in that area. Therefore, if you call yourself a dietician, you have to be regulated by Health Professions Council.
570. We recognise that there are limits to the number of dieticians in the Province. We are in a difficult position in healthcare, and we are all aware of the budgets. We recognise that we need more dieticians. We are working with the Department of Health’s service delivery unit to look at new access criteria with regard to waiting-list management. One criterion that we have set is that we would accept referrals from any health professional for a patient who has a body mass index that is greater than 30, which is clinically obese. The capacity is not there for us to deliver on that, so that is a challenge, and we would like to raise that issue with health commissioners and have that criterion accepted.
571. However, we have to be honest and say that dieticians are not the only ones who work in that way; our nursing and medical colleagues, GPs and practice nurses are all key and have their own messages to give. As a profession, we also work with commercial slimming companies. With regard to Dr Deeny’s point about exercise on prescription, there are examples in England of people’s being given access to weight loss on prescription. There needs to be a way to validate and ensure that commercial companies are reputable and that they follow evidence-based work.
572. To answer the question, we would honestly have to say that we do not have enough dieticians. We would want to have more highly specialised dieticians to look at prevention strategies. We can lead on those strategies and work with others to deliver them, because our expertise is in setting up the mechanisms. We work with community groups to deliver those strategies, and we do so very much on the clinical specialist side
573. One of our big challenges is that the majority of people who come to dieticians with clinical problems of obesity come with other medical conditions that need to be considered, such as diabetes and heart disease. The issue is not necessarily about just healthy eating; other dietary complications need to be managed.
574. The Deputy Chairperson: Your paper refers to the role of a consultant dietician and support workers.
575. Ms Mulholland: There are a number of consultant dieticians working on obesity in England. That is a new role, and those consultants are highly specialised. They exist for all the allied health professions. It is a growing area. However, we do not have any consultant dieticians leading on obesity in Northern Ireland. Their roles are split 50/50 between research and practice, and they are very much looking at undertaking research in the population and providing advice on strategy, development and clinical practice for all dieticians — potentially across the Province, if such a post existed.
576. On the other side of the scale — which fits in with the recommendations in the priorities for action to look at the distribution of unqualified healthcare workers to qualified colleagues — we have dietetic assistants, and the other professions have comparable assistants.
577. That is a new and growing role in dietetics in Northern Ireland, and the key things that dietetic assistants can do for we dieticians is to translate the messages that we give to patients into real-life actions for them and to support them to understand those messages. For example, we have looked at providing dietary advice on obesity to individuals or groups. A dietetic assistant could then take a group of patients to a supermarket and show them how to read labels, which they might have done in practice. They can take a product off the shelf — for example, margarines and spreads — and point out the differences between them.
578. Therefore, the point is to translate the message into practice, because so many messages are very confusing. When you go to the supermarket, you need to know which is the low-fat product and which has sugar and which does not. Are low-sugar biscuits OK? No, they are not, because the sugar has been taken out and fat has been added, making them worse than the standard product. That is the role of the dietetic assistant — they take those messages, translate them and make them live for individuals.
579. Mr Buchanan: Thank you for appearing before the Committee today. No doubt, if we want to tackle obesity, a multi-agency approach has to be taken in order to take it on and do something about it.
580. Throughout your presentation, you talked about the issues that are key to tackling obesity. Exercise and education are crucial, as are education and peer support for people who participate in some of those activities. How do you encourage people to participate in exercise, leisure, or in the programmes that you talked about that are being put in place? How do you encourage people who are in the obese category to participate in exercise to seek to reduce their weight and to make themselves healthier?
581. What work do you do with young people in schools or colleges to seek to get the message across that obesity is a serious problem and is something that everyone has to consider? How do you measure the results? I am sure that in your profession you deal regularly with many obese people. How do you measure the results of the programmes that you have in place to ensure that they are having an effect on the people with whom you are dealing?
582. Ms T Ross: From a physiotherapy point of view, we work across all the programmes of care, which means that we work with adults with learning disabilities, with children, with people who have physical disabilities, and with people in primary-care settings. Therefore, in all those fields, there is an opportunity to influence those people to take part in exercise.
583. For some people, it is about looking at what they can do in their own environment. A lot of it is to do with motivation, with trying to get people to change their mindsets and getting them interested in exercise, as well as trying to talk to them to find out what they like to do. We can prescribe exercise, but unless it links to people’s lifestyles, their family environments, or getting support from their families, they may not continue with it.
584. In mainstream schools, we have a programme for obese children, and the biggest success was when the parents, children and their siblings came to the programme together, took part in exercise and got advice on diet and exercise. It was a learning curve, and at the end of the 12 weeks — and even when we reviewed it a year later — they were sustaining the programme because they were supporting one another.
585. The change in the individual family’s self-esteem and confidence has been really evident with some of the schemes that we have run for adults with learning disabilities. There are issues around obesity and being overweight and accessing leisure and community groups and sporting teams. However, through physical-activity forums, we work in partnership with education providers, local football clubs, hockey clubs, and so on. Therefore, we are taking a community-based approach to the issue.
586. We assess people’s ability to take part in exercise or fitness regimes. We assess the risks that are involved and devise a programme that fits in with those and with their lifestyle. Therefore, it is important to know what someone is interested in and to find out where they can avail themselves of that activity. We can widen the whole partnership to include community development, local councils, and sports organisations. The impact that it has is very good.
587. We can weigh people, test their blood pressure and cholesterol and monitor all those things, but the greatest effect is on people’s confidence, well-being and self-esteem. If people go for a walk, join a walking club, go dancing, or even go out, their whole body image improves greatly and they feel so good that their ability to meet other people and to converse with them also improves. Therefore, such programmes have very beneficial effects on quality of life. People get all the health benefits from having their blood pressure, cholesterol and similar physical elements tested, but they also get improved quality of life and well-being, and their mental health improves. Therefore, the whole family unit and community benefit.
588. Ms Mulholland: There has been a huge campaign to improve nutrition in schools. Standards for the provision of food in schools have been set that have been implemented. One of the most recent developments has been the employment of a dietician in the Health Promotion Agency as a schools’ co-ordinator. Under the aegis of the new regional health agency, she will have a key role across the Province in evaluating how nutritional standards are implemented in schools. Nutrition advisers assess those standards regularly in schools to determine how they are progressing against their targeted tasks. They also give feedback and provide timescales for progress.
589. Ms Gibbs: When it come to measuring the effectiveness of our service, I should point out that occupational therapists cannot always pick up on patients in a physical setting until they present to an acute medical ward with, perhaps, a diabetes-related, arthritic or chest disorder. Those people come in with chronic conditions, and although they happen to be obese, we are unable to intervene — or to know anything about that client group — unless they are given a bed in a medical ward. Very often, we are dealing with compensation and addressing secondary problems. In future, hopefully, with more representation at departmental level and with more strategic guidance, we can employ ways to intervene at an earlier stage and work collaboratively to address the problem upstream rather than downstream, which lessens the effect of intervention.
590. The Deputy Chairperson: That concludes our question-and-answer session. Thank you for your presentation and your submissions to the Committee; they have been very helpful to our inquiry.
23 April 2009
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Witnesses:
Ms Mairead Boohan |
Queen’s University Belfast |
591. The Deputy Chairperson (Mrs O’Neill): Our first evidence session is with Queen’s University Belfast as part of our inquiry into obesity. A submission has been circulated to members, as well as a suggested issues paper.
592. I welcome Professor Frank Kee, the director of the UKCRC Centre of Excellence for Public Health, Dr Michelle McKinley, the principal investigator at the Centre for Public Health; and Ms Mairead Boohan, the deputy director of the Centre for Medical Education. I invite you to make a brief presentation, after which members may have some questions.
593. Professor Frank Kee (Queen’s University Belfast): I have provided Committee members with copies of a PowerPoint presentation, to which I will speak. I want to highlight some areas that the Centre for Public Health is emphasising in its current research strategy on obesity. The strategy focuses on causes, interventions and the way in which we believe that future policy scenarios and their consequences should be monitored, and why we see opportunities opening up that give researchers such as us greater traction with policy-makers and practitioners in the future. I know that the Committee has already taken evidence from a range of bodies, and I appreciate that this problem stretches over the life course and concerns how we live and where we live.
594. Although our own behaviour and the behaviour of cells may ultimately be the final mediator of how fat we become, the challenge for us, as epidemiologists and public health specialists, is to distinguish those proximal causes from the distal causes and work out the best way to improve on prevention of the problem.
595. There is often a needless and contrived tension between two ways to approach this issue: either chasing the tail of the distribution of people who are worst off; or shifting the mean of the distribution. As public health specialists, we usually prefer to try to shift the mean of the entire distribution of risk in the population.
596. In our handout, I point out a strategy that the Department of Health in England launched on 11 February 2009 — ‘Putting Prevention First: Vascular Checks: Risk Assessment and Management Strategy’. The strategy outlines attempts to pick up those most at risk, and the Department of Health is trying to chase those with the heaviest body mass index (BMI).
597. The object is to find the people who are at highest risk and then act to mitigate that risk. That is one method. Before the Department of Health supported that policy, it did some detailed health-economic modelling to ensure that the effort would be justified. At the Northern Ireland Centre of Excellence for Public Health at Queen’s University, and in the UK Clinical Research Network (UKCRN), we are trying to build up the expertise to carry out that type of modelling.
598. I am sure that members have already heard about the Foresight report, which examines the problem of obesity at a societal level. In my PowerPoint presentation, I refer to the futility of isolated initiatives; one might say that that describes the recent document that was produced by the Department of Health. To chase only the people at the tail of the distribution, or other isolated initiatives, will not tackle the problem, and that is not the way that we approach our research into obesity.
599. We have to take account of elements that affect the mean of the distribution and those that affect the worst-off people. The nature of individual behaviours is one way to examine obesity; they are extremely important. Dr McKinley will give members a flavour of a couple of studies that are under way that examine individual behaviours, after which I will make a few comments about the broader societal research that we are undertaking.
600. Dr Michelle McKinley (Queen’s University Belfast): I thank the Committee for the opportunity to present this evidence. I work in the nutrition and metabolism group at Queen’s University, which is directed by Professor Ian Young. I will summarise some of the research that Professor Patrick Johnston mentioned in his letter of 13 March 2009 to the Committee.
601. The nutrition and metabolism group runs several dietary intervention studies, in which we ask people to change one aspect of their diet. We monitor the effect of that change on a variety of factors that are related to risk of disease. I will explain some examples that will give members an idea of the types of studies that we run.
602. The first study examines the effect that increasing the intake of fruit and vegetable has on insulin resistance in people who are overweight or obese. Being overweight is associated with insulin resistance, which means that the body does not respond well to the insulin that it produces. Insulin resistance, in turn, is associated with an increased risk of heart disease and diabetes. It follows that interventions, dietary or otherwise, that may prevent or retard insulin resistance may help to reduce future risk of heart disease and diabetes. That is the reason that we have embarked on this study to examine the effect of increased fruit and vegetable intake on that health-related outcome.
603. We are also interested in the effects of different weight-loss diets, not only on weight loss but on insulin resistance and other risk factors for cardiovascular disease. We recently completed a study that compared the metabolic effects of a low-fat diet with a low-carbohydrate diet in people who are overweight. In addition to that metabolic research, we have an interest in the study of the management of obesity. There are many strategies to help people to lose weight, but it is equally important to help people to maintain weight loss.
604. Maintaining weight loss is extremely challenging, and only some 20% of overweight individuals who lose weight will actually keep that weight off in the longer term. Therefore, given the relapsing nature of weight loss, there is a need to identify novel ways to help people to maintain their weight loss and to test those approaches using robust methodologies. Internet-based programmes offer potential because they are interactive, readily accessible, relatively low cost compared with other interventions, and there is potential for widespread dissemination in the population. We have access to a unique Web-based behaviour change programme, which has been shown to help people to increase their activity levels and to lose weight. We will now test whether that Internet-based technology also has a role to play in helping people to maintain their weight loss.
605. We are happy to provide further details of any of our research programmes if desired by the Committee.
606. Professor Kee: Dr McKinley outlined one dimension of the research. In the PowerPoint presentation, I illustrate where consensus is emerging on both sides of the Atlantic about research priorities. It is being said that we need to take a broader view of research priorities, examining the environmental and societal forces that act on all of us and which regulate our intake and our energy expenditure. Therefore, individuals cannot simply be seen in isolation.
607. A sociologist in America produced a lovely piece of work, which hit the headlines and appeared in all major newspapers on both sides of the Atlantic. It is known as the Framingham heart study, and it examined a large group of people’s social networks over 30 years. The study found that the people who became fattest also had friends becoming fatter at the same time, and it posited that there were social network effects on how we regulate our energy intake and expenditure. It also suggested novel ways in which public health specialists could tackle that problem, harnessing the power of social networks. It underlined the need for longitudinal studies in populations, because we would not have found that without longitudinal studies in Framingham. As Michelle said, public health specialists are now starting to use new vehicles such as the Internet to transmit public health messages, and some of our work will harness a novel approach such as that.
608. The Department of Health in London recently issued a new social marketing campaign document, which focuses on how people make decisions. It uses the exchange concept, and perhaps, in our research, we should think about how to reward healthy choices. An innovative research scheme, Points4Life, has been launched in Manchester. It is based on loyalty cards for supermarkets, and people will be rewarded with more points if they buy healthy options or if they take more exercise. We are building that concept into a new research project. Before the scheme was launched, consumer market research was carried out in Manchester to find out what the voters wanted, so Points4Life is exactly what the community wants. That is one novel method to change the way in which we make our decisions.
609. We have tried to incorporate that concept into a research proposal, which has been shortlisted by the National Prevention Research Initiative. The proposal will study the impact of the Connswater Community Greenway in east Belfast, which was awarded funding from the Big Lottery Fund last year, on physical activity behaviours in the local area. We will build the idea of a loyalty card into that project, whereby people who use the Greenway can be rewarded with redeemable points in local retail outlets. It is an exciting new avenue of research for us, and it is one way to get the private sector interested in transmitting public health messages. One message emerging from that recent social marketing document from the Department of Health is that we need more public-private partnerships, as well as academic partnerships, to tackle the problem. In public health, translational research is about making a difference.
610. People talk about a bench-to-bedside model of transitional laboratory research. We talk about “bench to trench" — what really makes a difference to communities — and we will make a difference to communities only if we harness the power of those communities. That is what we are trying to do in the Connswater project.
611. My PowerPoint presentation refers to what we must do to capitalise on the available research opportunities. I know that this is the Committee for Health, Social Services and Public Safety, but obesity is not the Department of Health, Social Services and Public Safety’s problem: it is a societal problem. We will need all 10 or 11 Departments working together, whether on transport or urban design solutions, which will help to make a difference, or in ensuring that the right data is available for future planning, including data from the ‘Northern Ireland Health and Social Wellbeing Survey’, which is currently being reviewed by the Northern Ireland Statistics and Research Agency. We must continue to ensure that physical examination is an element of that survey.
612. I hope that researchers from Queen’s University and the University of Ulster can talk effectively to all 10 or 11 Departments that have an interest in solving the obesity problem, whether that be the Department for Regional Development, the Department for Social Development or the Department of Culture, Arts and Leisure. All those Departments are interested in our Connswater Community Greenway proposal.
613. My final PowerPoint slide refers to the UKCRC Centre of Excellence for Public Health, of which I am the director, being a partnership among Queen’s University, the new Public Health Agency, the Department of Health, Social Services and Public Safety, the Institute of Public Health in Ireland, the Community Development and Health Network, which allows our research to be more grounded and embedded to meet the needs of communities, and W5, which helps us to transmit our messages about new ways of tackling the obesity problem directly to schools. As researchers, we hope to have increased traction with the communities and with the policymakers. In fact, we had a wonderful seminar at W5 with policymakers and practitioners who helped us to engage with several schools from across the Province about obesity and obesity control.
614. That is the research that we are carrying out at Queen’s University.
615. Ms Mairead Boohan (Queen’s University Belfast): I will cover the undergraduate curriculum, and I thank the Committee for giving us the opportunity to make this presentation, which will build on the information given by Professor Johnston in his submission. I will explain the structure and the way in which we deliver the undergraduate curriculum at Queen’s University.
616. The curriculum is delivered using an integrated-systems-based approach. That means that, in years 1 and 2 of the curriculum, students work through each of the body’s systems. For example, when students are learning about the digestive system, they do not learn about only the anatomy; they learn about the physiology of the system. They also learn some of the basic clinical and physical examination skills that the clinician will use when examining that system. Given that it is an integrated course, they also cover epidemiology. When students are learning about the gastrointestinal system, they will consider the incidence and prevalence of diseases and illnesses associated with that system. They will also cover behavioural science — in other words, how the behaviour of the individual, and cultural and social factors, impact on health.
617. As the students are working through each of the body systems in years 1 and 2, information about obesity is included and integrated as appropriate. The students learn about the metabolic controls of the body system. When considering obesity and nutrition, the metabolic control covers the calorific and food intake and energy expenditure. The students learn about “normal" calorific intake — in other words, normal food consumption and what the body needs to function effectively and the energy that is expended from the body. They also learn about what happens when an individual over-consumes and ultimately becomes obese, and what may happen when an individual under-consumes food and suffers from malnutrition.
618. As part of the behavioural sciences element, we consider the modifiable and non-modifiable factors that may contribute to obesity. Modifiable factors include an increase in exercise and changes in patterns of eating and in eating behaviour. Non-modifiable factors include genetic predisposition to obesity and the conditions that can result from obesity — for example, diabetes and hypertension.
619. In years 3, 4 and 5, students begin their clinical rotations. During clinical attachments, when appropriate, they come into contact with patients who suffer from conditions directly resulting from obesity, metabolic disorders such as diabetes, thyroid problems and other conditions associated with diabetes — for example, hypertension and coronary heart disease, which are currently major problems for our population. In their surgical rotations, students learn about the diagnosis, treatment and management of those conditions and complications that can arise from them. Pre- and post-surgery complications for obese patients have implications for Health Service delivery, including extended stays in hospital.
620. Through orthopaedic and rheumatology courses, students also learn other health consequences of obesity — for example, damage to limbs and joints such as the hips and knees, which may result in surgical problems.
621. In year 4, the paediatrics course identifies and discusses obesity in childhood, which is a major health problem. During that course, students also learn how to measure body mass index and how to identify whether somebody is obese. The obstetrics and gynaecology course explores health and fertility problems — for example, polycystic ovaries, which can result from obesity.
622. In the general practice course in year 4, students revisit the health and behavioural science elements of managing and treating obesity, during which there is, again, much focus on dealing with the management of obesity and on eating patterns at a population level and, importantly, at the level of the individual. Students learn that mass-population education campaigns are often unsuccessful in managing conditions such as obesity. Individuals and barriers to complying with healthy eating — for example, budget and family finances — must be considered.
623. That covers what all students will learn about obesity in the core curriculum. In addition, the students have the opportunity to select components that are delivered from years 1 to 3. Each semester, students are given a range of about 25 modules from which they select those that they want to study in that semester. In year 2, two modules are delivered, providing students with much additional information about obesity. I have copies of the study guide for the module ‘Childhood Obesity: Understanding and Managing a Growing Problem’, if Committee members wish to take a copy. It contains information on current problems about managing obesity in our society.
624. Year 2 students also take a module entitled ‘Medics in Primary Schools’, which involves 55 primary schools in the greater Belfast area. Over 10 weeks, pupils visit the school of medicine for one afternoon a week to study a range of topics including a healthy living environment and healthy eating. That module teaches students that, quite often, children do not have much input or say in their diet. What primary-school children consume is decided by family members or by the content of school meals.
625. That is an overview of what is covered in the core curriculum and the student-selected components.
626. The Deputy Chairperson: Thank you very much for your presentation. We all agree that this is not just a health issue; it has to be tackled across the board on a cross-departmental basis. Professor Kee, you sit on the obesity prevention steering group. The Committee has received evidence from other interested parties. Dr Jane Wilde emphasised the need for more research to inform policy. Do you feel that there is currently a gap? Plenty of research is being done, but perhaps it is not feeding through to policy. There is a research element to the obesity steering group, but is it a strong element?
627. Professor Kee: The obesity task force has a data and research subgroup, which has met on about three occasions. I think that it is planning an event at the end of the summer. In the broader research community, people have recognised that working directly with policy-makers and practitioners must be the way forward. That will be beneficial because communities will co-design the research questions and come up with the solutions. That approach has been adopted on both sides of the Atlantic.
628. That is why I made a reference to “bench to trench". As public health specialists, we are more interested in what is effective rather than what is efficacious. There is a distinction in our mind about what is effective and works in real life rather than what works in a laboratory. Ultimately, the community will help us to design the best solutions.
629. The Deputy Chairperson: I like what Dr McKinley said about there being plenty of strategies to lose weight, but the problem is maintaining that weight loss. That is always the biggest challenge for anybody whom I know who has a weight problem. Anything that moves towards that type of project must be welcomed.
630. Mr McCallister: Following on from the Deputy Chairperson’s point about assessing how that is put into practice, what involvement will you have with the new Public Health Agency? Your point about schoolchildren visiting the school of medicine is interesting. Were those visits effective? Should we consider rolling out such schemes? As a pilot scheme, it has worked very well.
631. As the Deputy Chairperson said, we are mostly concerned with delivering the policy on the ground. Your point concerned making it easy for people, whether that be walking to school or through a person’s lifestyle choices or the built environment. All those elements should come together. I am keen to assess how we can intervene earlier and educate people at a younger age.
632. Ms Boohan: I will pick up on your comment about schools. That student-selected component has been running since 2000, and it started with 10 schools. It is confined to the greater Belfast area for timetabling reasons. In 2001, we did an evaluation with the 10 schools that had participated in the previous year. It was carried out by colleagues from the graduate school of education. They interviewed the school pupils who had taken the module during the previous academic year. The module covers a range of issues, and the one area that the pupils recalled most clearly concerned diet, food and nutrition. They talked to the researchers about how, when they were in a supermarket, they were able to inform their parents that certain foods were not a healthy choice, perhaps because of a high salt content.
633. Although that was a small evaluation, it definitely seems to have had an impact, probably because the pupils saw the medical students as role models. Although the medical students are at university, they are relatively close in age to the pupils and can, perhaps, identify more closely with them than an older or more experienced person can.
634. Professor Kee: Your question had two parts, one of which asked about schools and schoolchildren. We ran a debate day in W5, when sixth-formers from eight or nine schools across the Province debated the “nanny state". The way in which they interpreted both sides of the argument was marvellous. The chief executive of an advertising agency, the Chief Medical Officer and Basil McCrea, who spoke from the perspective of an MLA and legislator, attended the event. The sixth-formers quizzed the representatives with some smart questions. As Mairead mentioned, our schoolchildren are tuned into what drives societal behaviour and how to react to that. We did not come up with any new solutions that they had not thought of themselves.
635. The second part of your question relates to the new Public Health Agency. My contract is partly with Queen’s and partly with the agency. As a multidisciplinary centre, we received an award from the Department for Employment and Learning in summer 2008 to enable us to take the first steps towards creating an obesity observatory similar to that funded by the Department of Health in England. That will help us to communicate more effectively to various bodies, including health bodies and local councils, our knowledge of what works and what does not work. That must be multi-sectoral and multidisciplinary. It is important for the new agency, and for academics, to build capacity that will help us to model the consequences of different policies.
636. Mr Easton: Your research considers the body’s mechanisms and how much fat and sugar that it needs. If we are to reduce obesity levels, we must force food manufacturers to include the correct levels of fat and sugar in food. They tend to use too much sugar, because it is nice and everyone likes it. Through your research, what levels do you believe are required for the body to function, and what amounts should be contained in foodstuffs? Our inquiry should determine those levels to ensure that Departments are aware of safe levels and know how to force food companies to adhere to those levels.
637. Obesity is linked to diabetes. My father is diabetic, and, although he will kill me for saying so, he was quite a big man when he was younger. Therefore, I recognise the correlation between diabetes and obesity. Will eradicating obesity eradicate diabetes, or will some people contract that disease regardless of whether or not they are obese?
638. Professor Kee: I will answer the second question and ask Dr McKinley to answer the first one. Eradicating obesity will not eradicate diabetes, because there are two common types. Type 1 is, generally, contracted during childhood or as a young adult and is not associated with obesity to a great extent. Older, heavier people are more prone to type 2 diabetes. We must tackle obesity, because that will help to remove the factors that drive the diabetes epidemic. The rates of type 2 diabetes are increasing more quickly than those of type 1. Therefore, we must concentrate on solving the obesity problem to forestall the epidemic of type 2 diabetes. Dr McKinley will answer your question about food standards and the Food Standards Agency, because she has worked on both sides of the fence.
639. Dr McKinley: The Food Standards Agency has a wide communication strategy on that issue. It previously conducted a major campaign to try to reduce levels of salt in various foods, and it is now considering levels of saturated fat in food. Fat is energy dense and may be one of many factors that contribute to the obesity problem. The Food Standards Agency is the source of information on current dietary recommendations. The Department of Health issues recommendations on healthy diets, and the Food Standards Agency provides practical advice and information, which is communicated to consumers in a number of ways, including food labels.
640. Traffic-light labelling was a Food Standards Agency initiative. Communication strategies such as this have been designed to help the consumer to make healthier choices, and research now focuses on whether those strategies are helping the consumer effectively or whether other approaches should be considered.
641. For example, our research on comparing a low-fat diet with a low-carbohydrate diet for weight loss considered, where people were losing around the same amount of weight on those diets, whether one had a beneficial effect on areas such as cholesterol and blood pressure over another type of diet. There is much suspicion over whether low-carbohydrate diets have detrimental effects on health. The study revealed no major differences between the two types of diet.
642. More work must be done to find out what exactly are the best dietary approaches to offer to people who are trying to lose weight and to find dietary approaches that will not have any detrimental effects on the health of that person in the longer term. More research must be done, but the low-fat, high-fibre approach is still the standard weight-loss diet that is recommended and supported by health professionals.
643. Mr Easton: Unless the food companies are forced to do the right things with food, not much of a difference will be made. The inquiry does not have the powers to enforce that. We need to force the food manufacturers to make a difference to people’s lives.
644. Mr McCallister: There is a great deal of dissatisfaction, not only on the nutrition side but on the sourcing of food, including the definition of “fresh". The food-labelling agenda is huge, right up to European level.
645. The Deputy Chairperson: We will explore that further when the Food Standards Agency and the Food and Drink Association come before the Committee.
646. Mrs Hanna: Good afternoon; you are very welcome. Thank you for your presentation. The research is important in giving us a better understanding.
647. As many people know, it is hard to lose weight. For people who are significantly overweight, it can be a huge challenge just to start a diet. You mentioned healthy choices and the Points4Life initiative.
648. Dr McKinley talked about colour coding. That is done by Marks and Spencer, for people who can afford to shop there, but it is not done by Tesco, where the cheapest products are perhaps high-fat products. That is terrible, because some people are unable to afford that choice.
649. Another issue is better understanding of nutrition. The teaching of home economics at school used to cover a bit of budgeting and cooking, when people used to cook more and ate around the table. Many people now use ready meals, which are probably not as nutritional. They probably have a higher fat content, because they are tastier with additives and more salt. There are challenges with that.
650. Metabolic control was mentioned. We all blame a slow metabolic rate if we are not losing weight. What do you mean by that? I think Mairead spoke about that. Frank mentioned nutrition and metabolism. What impact does that have on losing weight?
651. Professor Kee: The questions so far have mentioned nutrition. The studies that have compared populations that have seemed to have become fatter over time have shown that the total calorific average intake has not been the significant variable. The expenditure of energy has been the significant variable. I can identify that trend towards sedentary living over my lifespan. We must not lose sight of that.
652. Mrs Hanna: You also said that one should look at the people one has been keeping company with over 20 or 30 years.
653. Professor Kee: As well as that, we can all look back on our primary-school years. I do not remember a single child who was overweight in the primary school that I attended.
654. Mrs Hanna: We walked to school.
655. Professor Kee: We did. I remember walking a couple of miles to school.
656. Mrs Hanna: We skipped, and we played rounders. We did not have computers or Game Boys.
657. Dr McKinley: In relation to losing weight, nutritionists are sometimes very black and white about energy balance: to stay the same weight, energy in must match energy out. Both sides of the equation are important: dietary intake and physical activity. Much research is under way, and I am not an expert in the genetic aspect of obesity or in whether some people are more prone to it than others.
658. The example that I am thinking of is the study that compared two weight-loss diets with different compositions. We provided people with their food and controlled their calorie intake. Both groups lost approximately the same amount of weight. Overall, it seems that, when people have a reduced calorie intake, they lose weight. In our sample, there may have been some people who were slightly more resistant to weight loss.
659. I referred to the “metabolic effects". We are trying to understand whether some diets are better for long-term health than others. Is a low-fat diet safer, in the long term, for someone who is overweight as opposed to a more fashionable low-carbohydrate diet? There are numerous books on low-carbohydrate diets but, at present, we do not know enough about their effects on health. However, some people find it easier to lose weight on low-carbohydrate diets, so we cannot be dismissive. We need to do the research and find out whether it is safe for health professionals to recommend such diets to people who are struggling to lose weight, who have tried the low-fat/high-fibre approach and for whom that has not worked. We need to explore different dietary approaches to suit the individual. Everyone is different when it comes to weight loss.
660. You referred to cooking. There has been an erosion of cooking skills. However, initiatives have been taken in Northern Ireland. There is a Cook It! programme, about which the Committee will hear more from others presenting evidence. Efforts are being made to rejuvenate those skills at all levels in the population. That is where home economics comes in. Uniquely, in Northern Ireland, home economics is still on the curriculum, and that might be crucial. It might be the only place where some children learn cooking skills because they may not learn them at home.
661. Mrs Hanna: School meals have been mentioned previously and whether chips could be removed from school menus to make meals healthier. Games should also be encouraged in school. Not everyone plays games — Gaelic, netball or whatever — but we must try to make sport fun. If children get used to activity, they crave it, whereas if they never do sport, they are more inclined to sit around.
662. The Deputy Chairperson: We need a cross-departmental approach, because that issue must be tackled by the Department of Education.
663. Ms Boohan: Several years ago, it became apparent that some medical students were unaware of the nutritional content and value of many of the foods that they were consuming and that, ultimately, their patients