Northern Ireland Assembly Flax Flower Logo

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:

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

Executive Summary

Summary of Recommendations

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:

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]

Graph

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]

Graph

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:

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
Mr Andrew Elliott
Mr David Galloway
Mr Rob Phipps

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
Ms Geraldine Kerr
Ms Treasa Rice

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
Dr Colin Hamilton
Dr Theo Nugent
Mr Ivor Whitten

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
Professor Frank Kee
Dr Michelle McKinley

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 would consume. As part of the year 1 behavioural sciences programme, we give students an article from a popular magazine providing dietary advice. We then give the students a number of patient scenarios: in one, an affluent, well-educated family will probably understand a lot about nutrition and, in another, there is a family that has a single income that is below the basic minimum wage. We get the students to work out reasons why the families described in each case scenario are able to comply with the dietary advice in the magazine.

664. During tutorials, students often comment that they did not realise that X amount of salt or hidden fats are contained in the convenience foods that they eat. Therefore, medical students are being educated about the foods that they consume as well as about the foods that their patients will consume.

665. The Deputy Chairperson: There are no further questions. I thank you all for your informative presentation. We will certainly forward you a copy of the report that we produce at the end of our inquiry. Thank you very much.

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 Karen Smyth

Northern Ireland Local Government Association

Ms Katrina Morgan-Talbot

Belfast City Council

666. The Deputy Chairperson (Mrs O’Neill): The next item on the agenda is the evidence session with the Northern Ireland Local Government Association (NILGA). We have received submissions from NILGA as well as from several local councils.

667. I welcome Karen Smyth, who is head of policy at NILGA, and Katrina Morgan, who is leisure operations manager at Belfast City Council. I invite you to make your presentation, after which members may ask questions.

668. Ms Karen Smyth (Northern Ireland Local Government Association): Thank you, Chairperson, for inviting NILGA to give evidence to the Committee. We appreciate the opportunity. Unfortunately, I must apologise for the absence of elected members at the meeting. We would have liked to have brought along some of our elected members; however, several other meetings are taking place. The Committee will be aware that our members are busy with the review of public administration (RPA) and policy development panel meetings. Therefore, trying to get someone to attend has been problematic.

669. We intend to run through the NILGA submission that the Committee has already received. I will then bring Katrina Morgan in to discuss more fully the projects that Belfast City Council, in particular, is working on.

670. Preventive healthcare is a key issue for local government. It has a huge impact on communities; citizens’ well-being; and on the economy, which relies on people’s fitness for work. The integrated work of councils’ environmental health, community and leisure services officers currently provides demonstrable success at local level. It indicates that a more joined-up approach to the issue is key to a successful approach to tackle obesity. 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.

671. We have found that the best and most successful projects are often implemented in partnership with other agencies, such as the education and health boards, which provide a link to schools, as well as the Fit Futures teams and health-promotion teams. Often, councils assume the role of enabler in much of that work. They have a civic-leadership duty to ensure that citizens maintain a healthy lifestyle.

672. Councils have played a full role in Investing for Health partnerships. A number of examples show how councils have taken the lead on well-being. For example, in the Newry and Mourne District Council area, the council’s facilitation of the well-being action partnership has been an exemplar of how a partnership approach can improve health.

673. The Chief Environmental Health Officers’ Group is to convene a nutrition subgroup to look at how environmental health officers can best become involved in tackling obesity in the general population and also to share ideas and initiatives that might be happening elsewhere in Northern Ireland, the rest of the UK and the Republic of Ireland. That subgroup will also include members from the Food Standards Agency Northern Ireland (FSANI), and we will be working in partnership with them.

674. Local government environmental health officers have been involved in promoting schemes. For example, in conjunction with food manufacturers, they have been promoting the Food Standards Agency’s traffic-light scheme. We are willing to work with the agency on further emerging initiatives, such as its campaigns on saturated fat and salt. Other projects of that nature include the implementation of the Chartered Institute of Environmental Health’s awards for healthier foods and special diets.

675. Members will also be aware that councils are the foremost providers of leisure facilities in Northern Ireland. Their leisure services offer a wide range of physical activity programmes and facilities that target the entire community, often according to age. They encourage citizens to engage in sport and other physical activities.

676. Ms Katrina Morgan (Belfast City Council): Good afternoon, folks. I will cite some examples of the successful programmes that Belfast City Council has run over the past year for various age groups. Choose n Move is a programme that is targeted at children between the ages of four and 16. It was designed by our health development unit and contains two key messages: eat more fruit and vegetables and become more active. The programme consists of 11 activities, and children are referred to it and are tracked through leisure centres, and parents can also obtain information from our Choose n Move website.

677. Moving up through the age groups, the FRESH project is targeted at children between the ages of 11 and 13. FRESH stands for food, relaxation, exercise, self-esteem and health. It is partly funded by the Eastern Health and Social Services Board, and it is delivered in partnership with the Belfast Health and Social Care Trust, Belfast Community Sports Development Network (BCSDN) and other councils, such as Lisburn City Council, Down District Council and North Down Borough Council.

678. Belfast City Council has three programmes in place, and they are based at Shankill leisure centre, Avoniel leisure centre, Ballymacarrett recreation centre/Andersonstown leisure centre. We like to target families, as well as kids. One of our programmes is called Fit Families, and it is run in conjunction with the Maureen Sheehan Centre, which is part of the Belfast Trust. It is a pilot project, which involves five families in west Belfast. The programme includes activity books, education, physical activity opportunities and weekly review meetings. We hope to have the first evaluation of that project by June 2009.

679. Other projects that are targeted at families include the parent, toddlers and children programme, which is delivered with the help of the Healthy Living Centre Regional Alliance. In total, we have rolled out 13 programmes that are being delivered through 50 different educational workshops; their evaluation is due in May 2009.

680. We consider some of our other programmes to be innovative. For example, two Kidzfit gyms are based in Belfast: one is at the Shankill leisure centre, in the north, and one at the Falls leisure centre in the west. Figures show that, so far this year, more than 2,000 kids have participated in those programmes, which involve activities specifically for kids. We are trying to branch out beyond leisure centres, and the Greater Shankill Sports Committee and the Shankill Junior Football Club have become involved.

681. Finally, the Healthwise programme runs in many council areas across the North. It 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. Last year, more than 1,000 people participated in the programme through Belfast City Council. That is a little flavour of what Belfast City Council and some of its local partners do.

682. Ms Smyth: Members will be aware, and I have already referred to the fact, that NILGA works intensively on the review of public administration and local government reform. It is essential that local government grasps the opportunities, particularly those presented by the health and social care reforms. A local council plays a vital role as service provider, civic leader, partnership convener, community focus and advocate on health issues. We draw the Committee’s attention to the Lyons Review, which identified local government as a place-shaper and highlighted the need to take a wider view of health and wellbeing. In addition, a recent World Health Organization report refers to urban planning as a key aspect in the consideration of the wider elements of health provision.

683. Councils should be taking up opportunities in the new joint-working pilot schemes and local commissioning groups. In addition, following local government reform, community planning, the power of well-being and other powers will increase the ability of local government to influence the health of local communities.

684. We are keen to think differently and to innovate, focussing on outcomes and not on who does what, and we look forward to working with the new Public Health Agency at regional and local level on obesity issues. The new health structures will provide a greater role for local government through participation in the Public Health Agency and in local commissioning. The Minister has already invited expressions of interest from councils on the possibility of hosting joint pilot schemes to focus on addressing specific health and well-being inequalities. We will meet the Minister shortly to take that work forward.

685. The Minister’s letter indicated the possibility of collocating health and social care staff with local government staff to support councils in exercising their power in well-being and community planning and in inter-sectoral partnerships, and we will explore the way forward on that. Those staff could also assist in developing local health-improvement plans to reflect local needs with regard to issues such as obesity. We would also support the local commissioning group in developing commissioning plans to deal with Health Service provision and measures to prevent ill health. We want to develop and extend those arrangements post-2011.

686. NILGA makes a number of recommendations on taking forward work on obesity. It hopes that the ‘Fit Futures: Focus on Food, Activity and Young People’ report will be fully implemented. We believe that a comprehensive, cross-cutting, long-term Northern Ireland strategy to tackle obesity needs to be drafted and implemented as soon as possible, bringing together all major stakeholders. There should be a scoping exercise of existing good practice, to be shared with all relevant agencies and central and local government departments.

687. Central Government should fund the roll-out of known successful initiatives, such as the Cook it! programme, and develop a joined-up approach at regional level in order to ensure consistent messages on healthy eating. Cooking skills should be made a mandatory part of the school curriculum, and healthy food choices should be available in all schools. We want to continue to work in partnership with the Food Standards Agency and the food industry in order to improve the nutritional quality of the foods that are available for sale.

688. Healthy eating awards should be available to food-business operators in Northern Ireland, and social marketing tools should be used in a campaign directed at the parents of young children and at the general population to increase awareness of health-related issues that are caused by obesity, because the accessibility of young people to the wrong foods needs to be addressed at regional level. There should also be adequate opportunities for young people to participate in physical activity at school and in the wider community.

689. The Deputy Chairperson: Thank you for your presentations. Local government will play a key role in tackling obesity and a number of other issues. As we move forward with the RPA, the transfer of community planning powers to local councils will be crucial for tackling health inequalities, because, quite often, people from socially deprived areas are more likely to be obese or to have long-term illnesses. With regard to the way in which local government feeds into the cross-departmental obesity steering group, do NILGA representatives sit on that group?

690. Ms Smyth: As far as I know, there are links between that group and the Chief Environmental Health Officers’ Group. We have participated at officer level rather than at elected-member level, but I can check that.

691. The Deputy Chairperson: That is a key matter, because, every week since this inquiry began, we have been hearing about access to leisure services and about a lack of play facilities. Obviously, that is all part of the whole process.

692. Ms Smyth: Community planning will be crucial, and working things out in local area agreements in the community planning processes will be vital in sorting out the whole problem.

693. The Deputy Chairperson: Katrina, you spoke about people in the Healthwise programme being referred. Is that referral from a GP?

694. Ms Morgan-Talbot: Yes. It is commonly known as the GP referral programme, but, technically, it is called the Healthwise programme. An individual can be referred for anything, including obesity or obesity-related illnesses such as high blood pressure or heart disease. People do, therefore, pass through the programme, and it is open to all age groups.

695. The Deputy Chairperson: Does that happen only in Belfast City Council, or does it happen across the board?

696. Ms Morgan-Talbot: It happens in a majority of councils in Northern Ireland.

697. The Deputy Chairperson: This is the first time that I have heard of that programme. The Committee has previously teased out the issue of what a GP can do.

698. Ms Morgan-Talbot: We roll out the GP referral programme, and, in Belfast, we link up with GPs through the Eastern Health and Social Services Board. The GPs sign up to the programme, and there is a process through which individuals are referred and which involves indicators and suchlike. In the past, individuals have come into leisure centres to inquire about the programme. If their GP was not on the list, we would have gone back to our partners to try to encourage that GP to sign up to the programme and to come on board.

699. The Deputy Chairperson: OK. Is that programme free for the participants?

700. Ms Morgan-Talbot: Yes. It is a 12-week programme, and it is free for participants.

701. The Deputy Chairperson: That needs to be publicised to make more people more aware of it. That message is not currently out there.

702. Ms Morgan-Talbot: It is quite well known. Last year, more than 1,000 people participated in the programme, even though there was only enough funding for 800 people. However, we decided that, despite the fact that that funding ran out around November, we should continue to take people on the programme, because we did not want to stop it dead.

703. We find that the biggest hurdle for people is the fear factor of making that first appointment and coming to see us. People can be referred, but sometimes it takes about three months for them to visit us. Perhaps a little more awareness of the benefits of the programme would be helpful.

704. Mr McCallister: How many GPs are involved in the programme? Are all GPs aware of it?

705. The Deputy Chairperson: The Committee recently heard evidence from representatives of the British Medical Association (BMA) and they did not discuss the programme. That is why it seems to be new to us, and why I think that doctors are unaware that they can refer patients to it.

706. Ms Morgan-Talbot: OK. I can double check that information. I know that information on the Healthwise programme is normally sent out to local GPs, but I do not know whether that is enough to entice them into the programme. I will check what mechanisms exist for informing people.

707. Mr Gardner: Has that trial programme dealt solely with GPs in Belfast?

708. Ms Morgan-Talbot: No. Several other councils are involved —

709. Mr Gardner: I have not heard anything about it. I represent the Upper Bann constituency, which includes Lurgan, Portadown and Banbridge, and I am not aware of any activities in those areas.

710. Ms Smyth: I will contact the councils to find out which ones are participating, and I will inform the Committee.

711. The Deputy Chairperson: The Committee would appreciate that. A GP sits on this Committee, and he is unaware of the programme, because he has talked about what he would do —

712. Ms Smyth: That may have something to do with the board area in which he works.

713. The Deputy Chairperson: It would be good if you could provide that information to the Committee.

714. Mrs Hanna: Good afternoon, you are very welcome. It all sounds so simple: eat more fruit and vegetables, get out more and, maybe, eat a bit less, but that seems to be very hard to do. The councils, more than any other bodies, are closest to those on the ground. Not only that, the councils operate the leisure centres and the playgrounds, and we must utilise those facilities better.

715. Ms Morgan-Talbot: We should not concentrate only on the leisure centres; we should also examine the role that our parks can play. We must try to make the parks more user-friendly to entice people into them, rather than just keeping them as green spaces. We want to work in partnership with the parks.

716. For example, we engage with schools. We run a very successful cross-country championship, during which we carry out awareness sessions that deal with nutrition and various other things. We try to include families. We see family engagement as crucial, because if families can be encouraged to adopt a healthy lifestyle, the children will naturally fall in to sync.

717. Mrs Hanna: It seems that much research and analysis has been carried out, yet the solution is so simple. It seems that attempts to motivate people to become more active are not working. Do you agree?

718. Ms Morgan-Talbot: Motivation plays a huge role, but culture is also very important. For example, there are areas in Belfast that suffer socio-economically and have higher rates of children not attending school or not finishing qualifications. In those areas, the level of parental participation in fitness sessions is also lower. Therefore, it is key that we reach those hard-to-reach communities.

719. The World Health Organisation’s Commission on Social Determinants of Health recently published a report that suggested that urban planning was a key to improving health. We very much agree with those sentiments and want to utilise things such as cycle schemes as a way of encouraging people to become socially involved in exercise rather than just visiting a leisure centre. Indeed, Belfast City Council is carrying out a strategic review of leisure this year, and we see that review not just as a way to examine our stock, but as a way to examine methods of improving community engagement and getting people from the wider community into our parks. We will seek to do that by joining up with other partners, clubs, groups and societies in an attempt to promote leisure, whether in participation or as recreation.

720. Mrs Hanna: You referred to schemes at the Shankill and Falls leisure centres, have you measured any outcomes of those?

721. Ms Morgan-Talbot: It can be hard to actually sit down and determine how to measure the outcomes, but, through the local schools, we have found that the children who participated in the programmes — those who possibly would have skipped PE classes in the past — have found that they have become interested in, and actually look forward to, exercise. As a result, those kids will come in at weekends with their parents.

722. The council operates a means-tested benefit pricing policy in all our leisure centres to attract folk who are on low incomes or unemployed. It runs month by month, depending on which schemes we run. If we run a successful scheme in an area, we discover that many more families join leisure centres. They become involved, and leisure centre usage increases. However, actual health outcomes are harder to determine.

723. Mrs Hanna: Those results are very powerful. You are saying that the people who are taking part in your initiatives are becoming more active and more involved, and that is what we want. If the simpler things, such as those initiatives, are working and are helping children to be more active, we should be doing more of that. We keep thinking of other things that we need to do, but maybe it is better to keep doing the simple things.

724. Ms Morgan-Talbot: When programmes such as the FRESH project, which is an 18-week course that is aimed at 13-year-olds, come to an end, we find that many of the kids come back to the leisure centres. We try to get funding to bring them back with their youth clubs, for instance. We incorporate various elements — not just leisure, but nutrition advice and other things — to make the programme interesting, and to make people see that a leisure centre is more than just a swimming pool and a main hall.

725. Mrs Hanna: If something like that is working we should be using it. We already have the leisure centres, the parks and the playgrounds.

726. Ms Morgan-Talbot: I am not sure whether members are aware of the Active Communities investment programme, which is open to all councils and is funded by Sport NI. Belfast City Council has received funding to employ coaches to deliver key health benefits to communities. We hope to have 17 coaches in place by October. In order to do that, we have linked up with local government bodies and local groups that have identified their key aims and sport-development programmes for increasing participation among hard-to-reach groups in communities, such as people with disabilities, children, young mothers and older folk. It is a three-year programme that will reach out into the community. We often find that people do not want to leave their community, and they want to go to classes in their local community centre or church hall. It is crucial to empower people to get involved.

727. Mrs Hanna: Although I appreciate that it is sometimes difficult to measure outcomes, I would welcome a report on such schemes that says what Ms Morgan-Talbot has been saying — that such programmes make a difference. Participation can be measured to some extent.

728. Ms Morgan-Talbot: Yes, it can.

729. Mrs Hanna: We need to know whether people are becoming more active and going back to the leisure centres or participating more in schools. That is the natural way to get children to be more active, and if it is working, that is good.

730. Mr Gardiner: Do you have any direct link with Craigavon Borough Council? Lurgan Park, which is the largest park in Northern Ireland won the green flag award. The next largest park is Phoenix Park in Dublin.

731. Mrs Hanna: It must be big.

732. Mr Gardiner: It is. Well, you can do a one-mile walk around the lake, or a two-mile walk, if you want to get young people involved in exercise and keeping fit. There is fishing, and new stands have been put up for people who want to fish.

733. Ms Morgan-Talbot: I am not sure if we have any direct links. I know that —

734. Mr Gardiner: That is why I am pushing this. You represent NILGA, which covers all local council areas. Craigavon Borough Council is involved; it has to be a two-way process.

735. Ms Morgan-Talbot: That is great; thank you very much.

736. The Deputy Chairperson: Katrina is speaking from Belfast City Council’s perspective. Karen is the representative from NILGA.

737. Ms Smyth: When I was researching our report, I was inundated with examples of good practice from different council areas. It was my understanding that those examples had already been fed to the Committee, and I did not want to repeat information that members had already received. I will forward that to you.

738. Mr Gardiner: OK.

739. The Deputy Chairperson: NILGA recommended a scoping exercise on existing good practice; that is exactly what we are talking about. Have you done that work?

740. Ms Smyth: Yes. We have done a partial scoping exercise of what already exists. When we ask councils for information, we do not get 26 replies very often. The work is under way, and we could take that forward for the Committee if it wants us to do so.

741. The Deputy Chairperson: It would be very helpful to have that information.

742. Mrs McGill: I would expect there to be particular focus on neighbourhood renewal areas because of deprivation and, by extension, poor diet. How is that addressed by Belfast City Council?

743. Ms Morgan-Talbot: The council has a strategic neighbourhood action programme (SNAP), which has developed action plans for 11 or 12 areas. The action plans address key themes from the environment to health. Each individual area, through a specific working group and various partners, has identified key actions that we will deliver.

744. Mrs McGill: Do those actions link to exercise and issues around obesity in particular?

745. Ms Morgan-Talbot: Yes.

746. Mrs McGill: I think that that would be fundamental, given that there are links.

747. Ms Morgan-Talbot: The council’s leisure services division had an input into how it would help to deliver all the action plans. I cannot tell you, off the top of my head, whether those plans are directly related to obesity, but I would be very surprised if they did not link into it in some way. I can look into our plans and come back to the Committee.

748. The Deputy Chairperson: There are no other questions. Thank you very much for coming along and giving your presentations today.

30 April 2009

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mrs Claire McGill
Ms Sue Ramsey

Witnesses:

Professor Eamonn McCartan
Mr John News

Sport Northern Ireland

749. The Deputy Chairperson (Mrs O’Neill): I welcome Professor Eamonn McCartan, the chief executive of Sport NI, and Mr John News, the participation manager of Sport NI.

750. Professor Eamonn McCartan (Sport Northern Ireland): It is an honour and a privilege to be invited to the Committee. It is the second time that we have attended. When we were last here, the subject matter was the Committee’s inquiry into the prevention of suicide and self-harm. Today’s subject is obesity, the tackling of which has an important role in society. John News is one of our senior managers, and, in collaboration with officials from the Department of Culture, Arts and Leisure (DCAL), officially has been responsible for Sport Matters, which is the strategy for sport and physical recreation in Northern Ireland. Members will know that the comprehensive definition of sport requires physical activity and physical recreation.

751. We hope that, as we become more experienced in presentations to the Committee, we will become more interactive. We have provided the Committee with a copy of our information, and one could build another Assembly with the amount of research on obesity that has been carried out around the world. I am content that you are familiar with the research findings and with the tsunami of obesity that has engulfed the developed world and the western world.

752. With your permission, I shall provide an overview of how we intend to make our presentation. The purpose of the presentation is to provide a brief introduction to the role of Sport Northern Ireland. You have all the research, and you know the basic energy equation. If a person takes in more energy than they expire, the energy has to stay somewhere, and, in the case of middle-aged men such as me, it generally goes on the tummy, and we get a little bit heavier. Nonetheless, it is a huge problem for an individual’s health and for the health of society. The problem must be tackled if we are to have fit and healthy individuals and, therefore, a fit and healthy society.

753. I wish to talk about how, and explore the ways in which, sport and physical activity can help. I ask you to park some of your traditional views on sport. 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. One need only go to Shaw’s Bridge on a summer’s evening to see people walking for two or three miles out to the Drum Bridge and back. People walk through Barnett Demesne. There are various forms of physical activity, and it is that element of sport on which I shall focus.

754. Towards the end of the presentation, I shall repeat the evidence that you have already received from other people about how obesity levels are increasing in young people, middle-aged people and old people and how that impacts on their quality of life and on the cost of health provision, which eats into limited resources.

755. Central to the vision of sport for Northern Ireland is the aspiration to have fit and healthy people who are capable and competent and enjoying a high quality of life, therefore contributing to, and not being a burden on, society. It aims to promote a culture of lifelong enjoyment and success in sport and physical activity that contributes to a peaceful, fair and prosperous society.

756. We have several important strategic objectives. We aim to increase participation in sport, physical activity and physical recreation. We aim to improve performance in sport, and we aim to do so through a managerial style that is effective and efficient. Through sport and physical activity, we are trying to improve the quality of life of individuals in Northern Ireland so that they have a better physical and emotional quality of life and so that, as a better person, they are more capable of contributing to a healthier and more positive society in which individuals are fit, confident and competent people. Many factors contribute to that fit, competent and healthy individual, one of which is physical activity. I will hand over to my colleague to answer this question: why should Government act?

757. Mr John News (Sport Northern Ireland): The answer to that is contained in the quotations that we have highlighted in our written submission. The first is from the World Health Organization (WHO) in 1996, and the second is a more recent statement by England’s Chief Medical Officer in 2005. It is not our intention today, as Eamonn said, to go over all the evidence. We can see the evidence on the streets, in the schools and in the shopping centres. It is all around us; we can see that people are increasingly overweight or obese.

758. We believe, as the Committee does, that it is not just a problem for the Department of Health, Social Services and Public Safety. The fact that representatives from Sport NI are here today and that we are increasing our investment in physical activity programmes underscores our belief that we have a role to play in finding a solution. 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. We are working on the basis of the adage that prevention is better than cure.

759. The Committee’s time is limited, so we will not retrace the history of obesity in the public-sector policymaking processes. In our submission, we show how, even in the past six or seven years, the challenge of obesity for public-sector policymakers has become embedded in the process. It is about bringing the 2002 Investing for Health strategy up to date with the obesity prevention steering group, which the Department of Health, Social Services and Public Safety convened in 2008. There is a consensus among policymakers that we all must act.

760. The challenge, as we see it, is that partnership working will be crucial to that action and its implementation. Partnership is an easy word to articulate. It is easy for us to represent partnerships on organisational charts, but the real challenge is to make partnerships happen. It is about how people make decisions and investments that complement one another. That is the biggest challenge. It is not about convincing people of the need to act but making sure that we all act in concert towards the same set of objectives.

761. Eamonn mentioned Sport Matters, the draft strategy for sport and physical recreation. That document attempts to move away from strategy to implementation. The challenge is to take the actions off the paper and put them into practice. Sport NI suggests that there are two different settings for priority action. The first is about policy, and Eamonn will cover some of those points.

762. Professor McCartan: Undoubtedly, members, it is an a priori fact that obesity exists in the western world and here in Northern Ireland. All empirical evidence shows that it is on the rise. If we all accept that fact, it is time that we began to prioritise some actions. At a policy level, Sport NI advocates the formation of a clear, accountable, physical strategy by the Northern Ireland Executive, which would sign it off and set targets and tasks for Departments.

763. Mr News: We are conscious that we need to give the Committee examples. We do not want to leave members with words on a page. One in four children is overweight or obese. Although the inquiry into obesity is being held by the Committee for Health, Social Services and Public Safety, why, when we talk about translating departmental targets into action, do we not set targets for schools to reduce the percentage of children and young people who are overweight or obese? Schools can measure, monitor and act on that. We can suggest to them how to go about that.

764. It could be: two hours of PE for every child; two hours of extra-curricular physical activity for every child; ensuring that there is community access to school facilities in the evening; and GPs prescribing physical activity rather than expecting people to make that choice for themselves. The Government must work to ensure that there is a culture of physical activity and that it is accessible and a default position.

765. Professor McCartan: You will have heard that we argued that all Departments, in a cross-departmental fashion, should take responsibility for that. In doing so, we contest that that would promote not only a cultural change but a societal, structural and organisational change at a societal level and an individual level.

766. The policies and the evidence are there. Where in the world have other people got on with it? We are advocating that we in Northern Ireland get on with tackling the problem of obesity. There are policy examples from other countries, one of which is very close. The Scottish Government recognised that obesity in Scotland was rising at a disproportionately higher rate than the rest of the United Kingdom, so they developed a physical activity strategy on a cross-departmental basis and set aside £24 million over three years.

767. One of the big difficulties that we associate with partnerships is: who will take the lead? Quite often, people are content to sit around the table in partnership as long as nobody is leading. The Scottish Government said that they needed a leadership group, so they appointed sportscotland to work in an Active Schools network and to be responsible for increasing physical activity among young people in schools in Scotland. The Government held sportscotland responsible, gave it a level of resources and tasked it to undertake the work over three years.

768. There is the capacity in Northern Ireland. The problem is the same, but we now need to move from policy to practice and from policy to implementation. A lead group should be identified — whatever it may be — and it should take responsibility for addressing obesity in various categories — for example, young people, teenagers, people in their 20s, 30s and 40s, and so forth.

769. Mr News: If we are to address the problem, all those sectors must sing from the same hymn sheet. District councils have responsibility for the community planning process, and they have a power of well-being and a responsibility to ensure the health and well-being of ratepayers in district council areas. The education sector is developing area-based plans and considering synergies between the schools estate and access to the schools estate by local communities. The health sector is seeking to develop health-based plans.

770. Why cannot physical activity be a common theme that will run through each of those area plans? The last thing that we need is three sets of plans pulling in three separate directions. We need to ensure that sectors work together to organise physical activities to combat the rise in obesity. We must ensure that sports coaches can work in schools and that teachers understand what GP referral schemes are doing. Our health professionals must understand what is happening in the sports sector and the education sector. As Eamonn said, that means that we must have one organisation — a group of people — coming together to share that information and make the investment decisions together.

771. Professor McCartan: We are in a fortunate position in Northern Ireland, because Sport NI and others have developed programmes that clearly address the issue of obesity through the principle of increased physical activity. Obesity occurs when the energy taken in is in excess to the energy going out. Over the past few years, we have identified programmes to cater for various sectors. We have several target group areas, which include: activities in relation to play; people who drop out of participation in physical activity and physical recreation; the more traditional sedentary population; and, as I get older myself, older people. We have had considerable success in those target groups.

772. Mr News: Departments are sometimes averse to investing in high-risk projects. Sport Northern Ireland is a development agency, and we see it as part of our remit to take those risks and to invest in areas in which there has, perhaps, not been a track record of investment. Many of our investments in recent years have been evidence-inspired, because we can see that there is a problem, and we believe that we can make a difference.

773. More adults need to be involved in physical activity. However, the way to achieve that is to take a long-term view, so we need to make sure that children and young people have the skills and competencies to be able to be involved in sport and physical activity. Young people need to be physically active and to go on the family weekend cycle ride. Young people learn those skills in a family setting and in a school setting, where all children spend the first 16 years of their lives, and, importantly, in a preschool setting.

774. That is why we recognise the importance of play. Over the past four years, we have invested a significant amount of our resources in PlayBoard, and together we have involved 4,000 children and young people under the age of eight in the physical activity programmes. Much more importantly in our view with regard to sustainability, 332 play workers are now trained and competent in using physical activity programmes. That is the legacy.

775. Play workers are not the only people who have an influence on children and young people. The single most important influence on children is, perhaps, their role models and those they see around them. Those are their peers and their parents. That is why one of the dropout points that we identified in much of our research has been among post-natal mothers and young mothers in particular.

776. We invested in a project in the upper Springfield area of west Belfast and into parts of north Belfast in which, through 10 community centres, 100 young mothers aged 16 to 35 have been involved in post-natal physical activity programmes. Crèches are provided so that mothers and their children are not separated. Although one might think that those are just babies, toddlers also go along to those classes. They watch their mothers being active and enjoying physical activity and see that as a positive and enriching experience.

777. We have investments in Derry City Council in partnership with health action zones in the north-west, where we have engaged with more than 100 GP referrals. Rather than prescribing very expensive obesity drugs, the GP sector in the north-west is prescribing exercise in local leisure centres. We have produced several publications in recent years that highlight those developments in non-traditional settings.

778. Professor McCartan: The last time that we appeared before the Committee, we briefed you on the benefits of physical exercise and activity for mild depression. 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. No one in their right mind who falls into that state wants to go to an aerobics class where they will stick out among people who are neat, trim and fit. Therefore, that one interaction with a GP, who sends patients to a sports hall or leisure centre where they are mentored, encouraged and can see direct progress, provides them with a pathway to health and fitness. We believe that that approach will become more widespread in the next five to 10 years.

779. We all know that we have leisure centres, and we all know that they are open and that people can go to them. However, that of itself is not the answer. 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.

780. Mr News: There are projects for older people, which we describe as nifty-fifty projects. I must say that that uses the World Health Organization’s definition of older people rather than our own.

781. Professor McCartan: When John briefed me this morning, I reminded him that I am over 50 years of age. [Laughter.]

782. Mr News: I am treading on thin ice.

783. Rates of physical activity participation show a big drop-off among older people. One way to improve the quality of life of older people is to increase their social networks. We should give older people more opportunities to interact with their peers and prevent them from being alienated from society.

784. We have an investment with Craigavon Borough Council, which runs physical activity programmes across three leisure centres in Lurgan, Portadown and Craigavon. We have heard stories that that project has engaged older men and given them more opportunities to meet their peers. As a result, they have discussed other health problems such as prostate cancer and subjects that they would not otherwise have ever discussed in their social groupings. There are also opportunities for women to be involved in physical activity programmes, and there are 220 participants in the project in the Craigavon area.

785. The way forward is to make isolated examples of good practice more mainstream, and we must find a way to meet that challenge. How do we make examples of good practice the norm? How do we create the culture of enjoyment that is envisaged in the strategy?

786. Professor McCartan: It is a question of what we do next: how do we turn the evidence-inspired policy into practice? We want people to be more physically active as individuals, with their families, in school, in work and in communities; thereby, we will get an active and healthy society. The Committee should have cognisance of the need for the physical activity strategy to be promoted, developed, encouraged and implemented by a lead agency.

787. There is empirical evidence that obesity is on the rise and that it is a major cost to our health and our health provision. The UK Government’s Foresight programme predicts that nearly 60% of the UK population will be obese by 2050, and the direct cost of obesity is £10 billion a year. Only 32% of the UK population meet the Chief Medical Officer’s recommended levels of physical activity; therefore, almost 70% do not meet those levels.

788. Mr News: One in four children in Northern Ireland is overweight or obese. It is a startling figure that 70% of us are not physically active enough. There is talk of swine flu and pandemics, but more than 2,000 people in Northern Ireland will die this year as a result of physical inactivity.

789. Professor McCartan: There is resounding empirical scientific evidence that obesity is on the rise, and the variables that contribute to obesity are well known. The policy has been developed in places such as America, Scotland and Finland, and it could be developed quite speedily in Northern Ireland. The next trick is the move from policy to practical action. A delivery agency needs to provide single leadership. We cited the example of the Scottish Government granting £24 million over three years to sportscotland to address obesity in school. Such measures need to be implemented in Northern Ireland.

790. The Deputy Chairperson: Thank you for your presentation. You talked about a lead agency, and there is no doubt that sport improves the quality of life for everyone and that early intervention is vital in creating a culture of active participation in sport and leisure. You also talked about physical education and targeting young people in school, but physical education is often pushed to one side by an emphasis on literacy and numeracy strategies and other educational strategies. There is a great deal of work to be done on that issue. The Committee intends to discuss physical education with the Department of Education (DE) next week.

791. I know that Sport NI was to have been the lead organisation in rolling out the DCAL strategy for sport and physical recreation. The strategy was put out for consultation last year, but it has still not been implemented. What effect will the strategy have when it is finally introduced?

792. Professor McCartan: The strategy 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, it will not of itself address the problem of obesity, as resources will be spread among other issues. Responsibility for publishing the strategy lies with others, not with us.

793. The Deputy Chairperson: Do you know why it has been delayed?

794. Professor McCartan: That is a matter for the Committee.

795. Dr Deeny: I could not agree with the witnesses more. The Committee has discussed obesity many times; it is a societal problem. The danger with societal problems is that they become medicalised and are attributed to problems with health. I enjoyed your proactive and enthusiastic presentation. I am a GP. If we are serious about tackling obesity, we must increase our activity rates. I was interested to hear you talk about what you are doing in Derry city; I was aware of GPs prescribing exercise programmes for appropriate patients in Belfast but nowhere else. Therefore, it is good to hear that similar programmes are being carried out in Derry. I hope — indeed expect — that such GP prescription will be the future for all medical practices. That is what must be done.

796. I wanted to ask you about the extent of your involvement with the Northern Ireland Local Government Association (NILGA) and the various local authorities. I would like what is being done in Derry city to be replicated in Omagh or in Fermanagh and elsewhere in the North.

797. You said that some people are so conscious of their body image that they are reluctant to go into leisure centres. However, do you see a role for private health clubs, for example, in working with statutory bodies to address the problem of obesity?

798. Last week, on the radio and in the media, there was talk about the £8 million that has been spent over the past three years on drugs that doctors prescribed for those who are morbidly obese. We have to prescribe such drugs to people whose obesity places their lives in danger. I heard an individual on the radio say — quite disgracefully — that obesity drugs should not be funded at all, even though people’s lives are at risk.

799. However, prescribing drugs for obesity is a short-term solution; we need a long-sighted approach, which is where the prescribing of exercise comes in. I held a surgery this morning, although no one attended who was obese; they were all asking about swine flu. There are times when one would like to be able to prescribe exercise.

800. You talked about the lead group, which was interesting. A similar scheme has been established in Scotland. Who do you think should be the lead group? It will obviously have to be a group with a bit of clout that will be able to enforce certain measures. I am pretty certain that it is only a recommendation that schools should provide two hours of PE each week. I do not think that that is being carried out in many schools because they are placing too much emphasis on other subjects. That should become law, no matter what schools’ priorities may be as regards academic achievement. They must make sure that their population take exercise, particularly as they spend so much time in front of computers. It should not be simply recommended; it should be compulsory.

801. You are involved at council level, and you are very enthusiastic, so do think that you should be the lead group? Who should be given the money and the clout to say to councils and schools — with the backup of this Committee and the Department of Health, Social Services and Public Safety — that that is what should happen with our young people?

802. Professor McCartan: You made four or five points, and we will try to address them all. If we miss any, you can come back to us.

803. I will begin with the issue of physical activity in schools and the amount of time that is set aside for it. There has been a fundamental change in our lifestyles: we have moved from being an active society to a sedentary society. That is fairly obvious to us all. We used to do things manually, but we now have machines, cars and buses. We tend to be less active than we were previously.

804. We have one of two options: either to take in fewer calories or to do more exercise. In the past, we exercised by playing in the street and going for walks, runs, and so forth. That is becoming increasingly difficult for young people. Schools are one place in which safe, structured and innovative physical activity can be delivered. You are quite right to identify two hours of PE each week being a guideline. Some schools do it very well, and others do not do it very well at all. There is also best practice in England, where there is a two-plus-two strategy. That is yet to be implemented in our schools. Our younger children are not getting that opportunity to participate.

805. We want our younger children to be literate in maths and English, but there is no mention of their being physically literate in relation to their lifelong skills and competencies of keeping themselves healthy and fit for purpose. What we are trying to advocate — particularly in our schools — is the concept of physical literacy. Although games may be involved, it is not about competitive games; it is about developing young people’s physically literate skills of running, jumping, throwing, landing, rolling and participation in fun physical activities that will encourage them and demonstrate to them the benefits of physical activity and exercise.

806. That is an issue that we have to address with those who are in charge of education. In our opinion, we have to increase the level and opportunities for our young people in schools through physical education. We have to improve the quality of the delivery of physical education.

807. Mr News: You asked about working with district councils and NILGA. In the past two or three years, our relationship, and the way in which we work, with district councils has been strengthened. In the past 12 months, we have been conscious of the changes that are on the horizon in relation to the restructuring of local government and the move to 11 district councils.

808. In October 2008, Sport NI announced a major investment to increase participation in physical activity programmes. Over the next five years, £15 million will be invested in the Active Communities programme, the purpose of which is to reduce some of the health inequalities that are the result of low rates of participation. Active Communities is not about traditional games or sporting activities. District councils will be given money to develop the appropriate partnerships in those consortia areas.

809. We have asked each of the 11 consortia to submit implementation plans to us. We are receiving some innovative plans in which district councils are working alongside education and library boards to develop physical literacy skills, play programmes, nifty-fifty programmes, targeting sedentary populations, health action zones and neighbourhood renewal partnership areas across Northern Ireland. There are some sport-specific ideas, but we are also receiving more enquiries about physical activity leaders.

810. 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. We are trying to encourage people to use the rich natural environment. We want more people walking along the towpath in Belfast or using our parks and the Northern Ireland countryside. Although the traffic on the roads is increasing, we still have a rich network of country roads and minor roads on which people can walk or cycle. We are trying to encourage greater use of the Mournes and the Fermanagh lakelands for non-traditional activities.

811. Professor McCartan: The review of public administration will provide new structures in Northern Ireland, particularly for our local authorities and district councils. A central tenet of the review is community planning. 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.

812. The Deputy Chairperson: I remind members that we have only 15 minutes left in this evidence session, and four members want to ask questions. Please keep your questions and answers succinct.

813. Ms S Ramsey: I have a load of questions, but I will go through them quickly.

814. The good thing about the Committee’s inquiry is that we can make recommendations to other Departments and Ministers. Some of the issues that have been raised are cross-departmental in nature. I am not as confident on the issue of local councils as they sit at the moment. I agree that change will occur as a result of the restructuring of the councils, but quality is the cornerstone. The provision of play areas is a big issue in my area, so I am conscious that, although Sport NI is giving them £15 million, the councils are off the hook when it comes to providing play facilities in some areas.

815. I agree with you; your written and oral presentations send out a clear message that Departments have not had a joined-up approach to the issue. We can see that in the conflicts about the extended schools programme and whether it is the responsibility of the Department of Health, Social Services and Public Safety, the Department of Education or the Department for Social Development. Addressing the lack of play spaces and leisure facilities will cost money. The issue of planning is missing, and it must play a key role. It seems to be easy to get planning permission for a fast-food outlet, a pub or a club in disadvantaged areas. We must also challenge the fast-food mindset and easy access to such outlets.

816. We can tie some of those issues into the cutbacks in DCAL’s budget — money that is being taken away because of the 2012 Olympics. That has a negative impact on communities here. Your submission states that people have easy access to the wrong food; what does that statement mean in the context of advertising at sporting events? How do you judge which companies advertise at sporting events? Fast-food outlets advertise prominently at some of those events. By the way, your presentation was useful.

817. Professor McCartan: I will try to address all those issues; however, if I do not, let me know.

818. You asked about planning and fast food. Although this is anecdotal, I saw a report on the news last week in which a local authority closed down a kebab shop because of its proximity to a post-primary school. That seemed an eminently sensible move, because, although the school was trying to provide high-quality low-fat food, the children were buying the fast food.

819. Ms S Ramsey: Will you provide details about that?

820. Professor McCartan: The shop was closed down. I will obtain the details; I do not have that with me. Planning is important and is addressed in Sport Matters.

821. Mr News: Sport Matters recognises the need to plan an environment that is conducive to physical activity. In many modern buildings, an escalator is the first mode of transport that greets people. Architects who design buildings should place stairs at the forefront rather than the escalator.

822. On a more serious note, when planning permission is issued for new housing developments, the situation should be avoided in which ball games are not allowed on green spaces. Play facilities should be placed on those green spaces at the heart of the community, where parents know that their children can play safely. We should build cycle paths to allow people to cycle, rather than take the car, into the town centre. We must ensure that we have a public transport infrastructure, through which people can take a bus to the train station and carry their bike on the train. In the long term, those decisions will create a situation whereby society, by default, encourages a culture of physical activity.

823. 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. If we bring that notion to the school setting, we need to ensure that, in planning our schools estate, school facilities are accessible to the community. We need to create an access point to the school — one that does not entail opening the whole facility — through which adults and children can use the school facilities. There are technical solutions to all those issues. However, we must step back and draw breath before we put pen to paper and realise our aims. We want to create one set of facilities on a shared estate that can be used by everybody and that encourages them to be more physically active.

824. Professor McCartan: The power of advertising is massive, particularly on young people. Ms Ramsey is correct; advertisers recognise the strength of sport and sporting events, and, therefore, they want to be associated with major events such as the FA Cup final, the All-Ireland Senior Football Championship final, the Heineken Cup, and so on.

825. The relationship among sponsors, advertisers, event organisers and governing bodies has been successful. For example, the Gaelic Athletic Association has a strong view on the advertising of alcohol and will move to alcohol-free sponsorship in the next couple of years. Sport NI has a direct relationship with the Belfast city marathon. Although Coca-Cola sponsors that event, all parties to it, including Belfast City Council, have encouraged the sponsor to use Deep RiverRock — which, as we know, is water — to promote the event, because we perceive the consumption of water to be more healthy than the over-consumption of fizzy drinks.

826. Sport will have to address that huge issue. The marketeers and advertisers see a direct connection between major sporting events and their target markets. They buy the events and the advertising, and they promote their products. Sport has become conscious of that, and it has become conscious of its own social responsibility. I hope that alternative ways will be found to do that in the years ahead.

827. There has been a reduction in lottery funding because of the 2012 Olympics, and that has affected funding for Sport Northern Ireland. The Northern Ireland Assembly has given £53 million for the creation of elite facilities. Although a reduction in funding is always sad, we are glad to have been given £53 million, which, we hope, will see much-needed facilities being built right around Northern Ireland to meet the sporting and local needs of the community.

828. Mr Gallagher: My points relate to physical education and the school curriculum, which we have touched on before. First, what is taught in PE lessons? It is not enough simply to provide football. When children leave school, about 10% or 15% of them will continue to play football. Children must be exposed to a range of activities in school so that, if they discover that they get enjoyment and satisfaction out of playing badminton, dancing, swimming or whatever, those experiences are provided at that stage.

829. Secondly, there is the issue of a minimum of two hours a week for PE. I agree that there should be an absolute minimum of two hours a week for physical activity for children because it will be an important aspect for the rest of their lives. There are 25 hours in the school week, and the Department of Education, or those who advise the Department, tell us that, at Key Stage 3, pupils must have access to 24 subject areas. Clearly, that has a negative effect on having two hours of physical education available for young people.

830. My views on that would take about three hours to explain, so I will condense them. It is nonsense to believe that we can educate children in 24 subjects over 25 hours a week. The end result is that they will have experienced a whole lot of everything but they will have learned very little about key areas. However, the report will be based on all our submissions and evidence sessions, which is why I return to those two areas — the minimum amount of time necessary for physical education and the quality of the physical education programme provided in schools.

831. Professor McCartan: Mr Gallagher’s comments are exceptionally consistent with our own. We believe that two issues must be addressed in relation to the quantity of physical education in schools. We are strong advocates for the provision of two hours during the curriculum time and two hours post-curriculum time. Above all, we are keen, and we are committed to the quality of physical education. It is incumbent on those who are tasked with, and have the privilege of, teaching physical education that they do so for all children, not just the talented. They must expose children to all the physically literate skills and competencies required not only to play sport but to carry out a worthwhile role in society. Dexterity and fitness are important for pupils who take up manual jobs.

832. Sport Northern Ireland strongly supports the concept that there must be an increase in the quantity of physical education. However, of itself, quantity will not be beneficial without an improvement in quality. We all know and can relay examples; for instance, my wife managed to avoid physical education for the bulk of her seven years at post-primary school. She proudly boasts that she did it only twice. [Laughter.] One must ask why that is the case. It can only be that sport was not presented to her in an attractive and inclusive manner. Therefore, if she did not like competitive games such as football or camogie, there were no alternatives. There is an absolute host of alternatives.

833. A prime example of how to succeed in a non-keen, non-competitive sport is Dawson Stelfox. He was a smallish build at school, and he did not play rugby, hockey or cricket. He merely went on to become the first Irishman to climb Mount Everest and the first British man to climb Everest by the east route. Sport is fortunate to have a range of physical activities that can attract and develop skills and competencies, wherever they lie, in individuals in our schools. Therefore, we support the provision of two hours of physical education every week.

834. Mr News: I will add to what Eamonn said in relation to two hours of PE. If we do not know how much PE every child receives, the adage that I heard recently applies: no data, no problem, no action. We must measure how much PE is taught in our schools. The evidence that we have seen recently leaves no doubt that, where the PE curriculum is delivered well, it is delivered exceptionally well. Primary-school teachers are some of the most resourceful people in this part of the world. Their integration of various subjects into a school day is one way in which we envisage achieving a culture of lifelong enjoyment of sport and physical activity.

835. Sport Northern Ireland recently did some work with education and library boards, during which a new resource called Activ8 was introduced, which members may have seen on television a few weeks ago. Activ8 gives teachers a resource that encourages children to be physically active for 60 minutes each day, in line with the Chief Medical Officer’s recommendations. However, it does so in a way that is part and parcel of the school day by providing examples of how to build sport and physical activity into numeracy lessons, how to encourage children to write about their weekend physical activity, thus helping the literacy curriculum, and how to encourage pupils to be aware of the world around them and to contribute as active citizens. There are innovative ways in which physical activity can be built into the curriculum. It does not have to be about two hours of ring-fenced PE each day. The key is 60 minutes’ physical activity every day, and two hours of physical education a week is part and parcel of that overall programme.

836. A challenge for us is to ensure that the message does not become too convoluted for those working in education, health or sports that they confuse 60 minutes, two hours, seven times a week, five times a week and five pieces of fruit a day. There must be a clear, simple, consistent message about how to make physical activity the default position.

837. Professor McCartan: What was your adage about a lack of data?

838. Mr News: No data, no problem, no action.

839. Mr Gardiner: Thank you very much for your presentation. Professor McCartan, you mentioned Craigavon, and I declare an interest as a member of Craigavon Borough Council. I was pleased that you did mention it, because the council has three leisure centres, and Banbridge — which is in my constituency — also has one. However, the real issue is not about the facilities themselves but in getting people to use them. For example, Craigavon has the only artificial ski slope in Northern Ireland, yet some people do not know that it exists. Craigavon also has some of the finest walks around the shores of Lough Neagh, and water skiing is available there and on the Craigavon lakes.

840. I want more of a concentration at school level. We must bring those children on and get them to use those facilities. What representation has Sport NI made to the schools to sell your wares or to tell them about some of the things that they can do to keep themselves active and fit?

841. Professor McCartan: Craigavon has a tremendous set of facilities: indoor, outdoor and natural. Furthermore, Craigavon was very fortunate to have an excellent sports development officer in the shape of John News, who developed a good sports development strategy before coming to Sport NI. I congratulate the work of Craigavon —

842. Mr Gardiner: He was properly trained then? [Laughter.]

843. Professor McCartan: He certainly received very good training.

844. Mr Gardiner: Lurgan Park, the largest park in Northern Ireland, also won a green flag award in 2008.

845. Professor McCartan: It did indeed.

846. The problem that you identified regarding the use of leisure centres is not one that is restricted to Craigavon but is experienced across Northern Ireland. For sports development to succeed, each district council must have a robust sports development strategy, and those strategies succeed best where they are people-focused rather than facility-focused. There is a need for facilities, but the “build and they will come" philosophy of sports development, which was prominent in the 1970s and 1980s, has now been replaced with a philosophy of “build and provide development officers, and they will come and multiply".

847. You also — quite rightly — touched on the issue of schools, with which there must be a crucial relationship. Indeed, we are trying to establish a strategy through Youth Sport where there is a relationship between schools, communities and sports clubs, and an iterative interaction with schools and clubs using community facilities. We encourage that, and, in our community planning under the RPA, we have asked the new authorities to take a slightly different approach. Our recommendation is that they continue to invest in facilities but that they also combine that with a strong and robust sports development plan, bringing the three key elements of school, community and club into an interface with them.

848. In that area, we have made representations to the Bain Review and the Department of Education with respect to facility provision. Our view is that there should be one public sporting estate as opposed to a local authority estate and an educational estate, because of the limited capital capacity. Sport NI contends that, if we can think smart, we can build a school facility that can be used by the school during the day and by the community in the evenings or at weekends.

849. I am originally from west Belfast, and one of the grammar schools there, in which I taught, has four grass pitches, a running track, a dust football pitch, a swimming pool and two handball courts, yet those facilities were closed during the summer, Christmas and Easter holidays. It would seem sensible that, if we are going to plan the development and use of our estate, we do so in the context of a holistic front and examine community and educational uses. In planning for the future, it is possible to plan facilities that can meet the needs of both, but that will require more investment in educational facilities, because the Department of Education currently builds facilities according to its green book. Although those facilities may be ideal for primary-school children or post-primary schoolchildren, they are not ideal for grown adults. Broadly speaking, an additional investment would be required to make them so, and we are trying to work with the Department of Education on that. Sport Northern Ireland has a significant level of capital funds available for over the next 10 years that, if combined with help from DE, could cater for the needs of schools and the community. That would stop the regrettable underuse of facilities that you correctly identified.

850. Mr Gardiner: You did not tell me how you will communicate with the schoolchildren to encourage them to become involved.

851. Mr News: Part of the Activ8 programme that was launched recently involved increasing the awareness, through publications, of primary schoolchildren and their parents of the Web-based resource, www.activeplacesni.net. Over the past few years, Sport NI has undertaken an extensive data-gathering exercise. To identify the exact location of all the recreation facilities, we contacted and worked with all district councils, private sports clubs, governing bodies of sport, private providers and the education sector. We have now mapped that information to a Web-based geographic information system (GIS). A child or parent can go to the website, type in their address or postcode, and the resource brings up a list of all the available facilities in their area. People being aware of where the facilities exist is at least a start. The next step is to assess the quality of the facilities.

852. We engage with schools by working closely with each of the education and library boards and the inter-board physical education panel to consider opportunities for engaging with children and young people. However, as we are aware that the PE curriculum must also be delivered, we are also assessing its quality. One of the actions identified in the draft strategy for sport relates to teacher education. I mentioned that some of the most resourceful people in this country are primary-school teachers. However, they leave their initial teacher training without the skills, competence and confidence needed to deliver PE training because they have not specialised in it. One of our fundamental tasks is to examine that initial teacher training. Teachers can take various bolt-on continuing professional development (CPD) courses to develop their skills, competence and confidence, thereby enabling them to build physical activity into the school day. While continuing to specialise in geography, mathematics, English or whatever their subject happens to be, we can provide ongoing remedial work. We must determine where the challenge lies and consider a review of initial teacher education.

853. That is how we engage with schools and support our colleagues. We invest in the five education and library boards to help them to support teachers, and we provide resources for teachers and schools.

854. Professor McCartan: On that point, we hope that, by 2012, 100,000 additional primary schoolchildren will be participating in sport through the Activ8 programme. If the Committee deems it worthwhile, we will leave the relevant information with you to consider.

855. The Deputy Chairperson: I am conscious that we are behind schedule, but two members still want to ask questions. Do you need to leave, or are you OK for time?

856. Professor McCartan: We are OK.

857. Mrs Hanna: I will be brief. Good afternoon, Eamonn and John. You are most welcome, and thank you for your presentation.

858. Much has been said about trying to prevent children from becoming overweight and good programmes. However, it seems to be a case of ensuring that the programmes are implemented. You talked about physical literacy and said that children are skipping, running and jumping. You also mentioned that it is important to make exercise fun, so that children want to continue with it when they get home from school.

859. You referred to the lack of leadership. We must figure out who should be tasked with delivering the programmes. The Committee will hear from educators next week, when we can put the same questions to them. You said that Scotland is slightly ahead of us. Has Scotland managed to task a specific person or group to take on that leadership role to ensure that physical activity takes place in all schools? It seems that much good work is being done and many good programmes exist but that they are not being rolled out in all schools. Who will intervene at the early stages to prevent obesity in young children? I know that we have to pick up the pieces in respect of some children, but we need to try to prevent it happening in young children.

860. Professor McCartan: When we were preparing for the evidence session, I reminded my colleagues about old-fashioned quality control. I used to teach business studies, and, in old-fashioned quality control, we went through the manufacturing process, looked at our product, and, if it was not up to standard, we threw it out. There was no prevention involved in the process, and there were no interventions along the way to put the problem right. Therefore, we advocate the early-years approach that you talk about, including skills for life, where we develop physical literacy — that is, running, throwing, jumping, landing, understanding the need to eat healthily, understanding the need to eat five pieces of fruit a day and to include fibre in their diet, as well as understanding the need to have sleep.

861. You said that it is crucial to have fun. People sometimes forget to have fun when they are participating in physical activity and leisure. People tend to repeat the things that they enjoy, which is why some of us eat too much or drink too much. Therefore, it is important to get the healthy lifestyle issue instilled into our young people, not just during their primary or post-primary years but for their whole lives. We need to develop a knowledge and understanding of the benefits of physical activity and not expose children at an early age to competitive team games. We are opposed to the exposure of very young children to competitive team games, because it quickly divides them into children who can play them and those who cannot, and the children who can play them will continue to play them for the rest of their playing lives, and those who cannot play them will be exiled to the side to stand in the cold and the wet. We are very much opposed to that.

862. Leadership is required, but, in Northern Ireland, we tend to work in partnership. As John said earlier: no data, no problem, no action. An issue that arises with partnership is the lack of action, because everyone is involved, yet no one is involved. Therefore, I like the idea of getting an organisation to be held responsible for taking the lead, albeit it will work with other partners in execution and implementation, but, ultimately, it will be held responsible. In Sport Northern Ireland, we are willing to take on that responsibility. If there is someone better to do that job, that is fine, but we are willing to take it on and to be held responsible in the same way as sportscotland is in Scotland.

863. Mrs Hanna: Is it working in Scotland?

864. Mr News: It has worked in Scotland as a catalyst for action. Sportscotland put the resources into schools, and the money came from the health budget. As a result of that action in schools, principals have seen a step change in the attitudes of parents and pupils. Some years ago, Tessa Jowell talked about tackling the “poverty of aspiration", and principals have reported that pupils and parents in the communities that they serve now want something better, and they are making more proactive choices.

865. There was an earlier question about planning and fast-food outlets. The Active Schools programme is about adopting a whole-school approach. It is not simply about saying that we have to ensure that every child must have two hours of physical activity or physical education. It looks at the diet and nutrition of school meals and the roads infrastructure around schools. There is an exclusion zone for cars around schools at drop-off times in the morning and at pick-up times in the afternoon. Bike sheds have been installed, and all the broken windows have been fixed. Representatives went to local councils and said that they did not want any fast-food outlets licensed within 200 yards of the school gates. They said that they wanted to make water available free of charge to all their pupils, and they distributed water bottles to them.

866. Therefore, it was a whole-school approach. It was about changing lifestyles, and it has delivered dividends. That happened because there was leadership, resources were invested, someone was made accountable, but the accountability was for others to act as well. Therefore, the school, the local council and health and social services board had to take action. It was about joining that up and saying that that organisation — in this case, sportscotland — was accountable for the success.

867. Mrs McGill: I have listened to everyone’s contributions and responses. Although schools and education play an exceptionally important role in tackling obesity, there is more to it than that. All the blame cannot be levelled at the door of schools.

868. I was looking at the priorities for action and the implementation plan in your submission. I repeat — and I have a reason for saying this — what happens in schools and the role played by the Department of Education is critical. Sport NI also has a vital role to play. You suggest that every child should get an additional two hours of, presumably after-school, extra-curricular sport and physical activity. How will that be achieved in rural areas such as mine? I would like you to be able tell us that Sport NI will step in to assist in some way. Perhaps it will, and, if so, I would welcome its contribution.

869. You also suggest that all newly qualified teachers should have the necessary training to deliver physical activity programmes in schools. How would that work? You have made that a priority for action and implementation. Have you spoken to the Department of Education? If you consider it to be a key priority, I would have thought that you would have dealt with it before the Committee began its inquiry into obesity.

870. I apologise for not being brief, but I ask that your answers be brief.

871. Professor McCartan: I shall try my best to answer the member’s questions as briefly as possible. We have spoken to the Department of Education with respect to teacher training, and it has accepted, and will implement, our proposal.

872. Mrs McGill: Will that apply to all primary and post-primary teachers? What did you recommend?

873. Mr News: In the draft Northern Ireland strategy for sport and physical recreation, there is a table entitled “Key Steps to Success". Those implementation suggestions are eight out of 100 key steps to success, so you are absolutely right to say that schools are not the only answer. However, those key steps to success have come about as a result of positive engagement with all Departments, particularly the Department of Education.

874. The Department of Education and the education sector recognise that reviewing initial teacher education is a key issue in delivering the high-level target of halting the rise in obesity in Northern Ireland by 2013. Therefore, they are signed up to implementing that proposal. The next challenge is to make it happen. For instance, when will the Department of Education undertake the review of initial teacher education? Several hours a year are already set aside in teachers’ initial teacher training to educate them about physical activity and physical education. We should step back and consider what teachers are actually trained to do in those hours. It may be that the content of that training must be changed, or we might have to increase — from six hours to eight hours per annum — the amount of training that teachers receive in physical education. It is about what we do and how we do it, and the Department of Education is signed up to that.

875. Professor McCartan: The policy and principle have been agreed, but the implementation has yet to be worked out. All new teachers will receive that initial training.

876. I will try to answer the second point about Active Schools. We all have to work smart to get the biggest bang for our buck. There are four sectors that we must address if we —

877. Mrs McGill: I am sorry, Chairperson. I was asking whether Sport NI would have a role in promoting the two hours of extra-curricular sport and physical activity that it mentions as one of its implementation priorities. I am not sure whether the following priority, which is to establish a network of Active Schools, is the same thing.

878. Mr News: The short answer is yes. Many of the investments that we have made over the past number of years in governing bodies of sports, community and voluntary organisations and district councils have been about trying to put a network of people in place to help to deliver that two hours of extra-curricular activity and make use of the £15 million that was earmarked for the Active Communities programme. That programme is not about delivering the PE curriculum; we are clearly focused on the opportunities for one million participants that can be delivered through that programme over the next five years. Approximately 100,000 people will be involved in that extra-curricular programme: some of that number will be children and young people; and some will come from the other under-represented groups that we mentioned earlier — older people, women, people with disabilities and people who live in rural areas.

879. The Deputy Chairperson: Thank you very much, gentlemen. The session has been very informative and will help our inquiry to move forward.

880. Professor McCartan: Thank you. I wish the inquiry well.

14 May 2009

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mrs Claire McGill
Ms Sue Ramsey

Witnesses:

Ms Gerry Bleakney
Dr Carolyn Harper
Dr Eddie Rooney

Public Health Agency

881. The Deputy Chairperson (Mrs O’Neill): We now move to the inquiry into obesity. Today’s witnesses are from the new Public Health Agency: Dr Eddie Rooney is the chief executive, Dr Carolyn Harper is the director of public health, and Ms Gerry Bleakney is a health promotion commissioner.

882. Dr Eddie Rooney (Public Health Agency): I will give some context of where we are as an agency, because it may have a bearing on how much we can tell the Committee. The Public Health Agency has been in existence for six weeks. The agency has inherited many strands, but it is still putting its own stamp on priorities and how those will sit in its business plan. That work has become a little more difficult over the past couple of weeks because we did not quite expect that element of health protection — swine flu — to take such a high profile so early. Nevertheless, we are trying to move on as quickly as we can to establish the agency’s priorities. We will hold our second board meeting next week to try to progress that as quickly as we can.

883. There is no doubt that tackling obesity will be one of those high priorities because it is a priority for the Department and the Executive, and we know that it is a vital health issue, particularly in our area of health, which assesses prevention and wider public health. It is not an easy issue to tackle because it is so embedded in our lifestyles. It has taken many years to reach our current position.

884. My colleagues Carolyn and Gerry will very briefly take us through the presentation. One issue that they will address is how far we have moved towards becoming a sedentary population over the past 50 years. We will not be able to turn the tide quickly. However, much has been learned. We know that we must plan, and we must demonstrate to the Committee that we are on top of the task and the level of attention that we are giving to it.

885. At the outset, it is clear to us is that the issue will not be solved by the Public Health Agency or the health sector. It is at the core of cross-departmental and inter-sectoral working. That will inform how we approach partnerships with other organisations and bodies. That will not happen through strategies. For too many years, we have been involved in different aspects of nutrition and physical activity. I chaired the Fit Futures steering group, and I emphasised its cross-sectoral nature.

886. We must link strategic words with community action. One advantage of having an agency such as the Public Health Agency is that we can straddle that link. The agency is an implementation body, and we realise that we must work at ground level to have an impact. That will guide our approach as we start to develop our own planning system and our actions in relation to obesity.

887. We will take members through some key parts of the strategy. We are very happy to take as many questions as members can come up with. Our responses will be on the basis of it being very early days for us. We do not have a blueprint that demonstrates our solution, but formulating that is a priority.

888. Dr Carolyn Harper (Public Health Agency): Members have received much information from other presentations, so I do not want to spend too long on that. I will then highlight some programmes and interventions in Northern Ireland and indicate the direction in which we think our own actions and those of others need to go.

889. It struck us that, when daily activity levels of the current population are compared with those of the population 50 years ago, it equates to running one marathon each week. That is a lot of activity and a lot of calories being burnt.

890. The key facts are: 60% of adults and one in five primary 1 children — four- and five-year olds — is overweight or obese. There is increasing evidence that the impact of obesity is similar to that of smoking more than 10 cigarettes a day. Therefore, it is not simply an aesthetic issue; it is a genuine health issue, and there are some health conditions for which the risk is increased among those who are overweight or obese.

891. There is also a significant impact on our health services. I need to draw your attention to a correction to one figure in paragraph 3 of our paper. The paper states that the current cost to the Health Service of anti-obesity drugs is £0·5 million a year; the cost is, in fact, £0·5 million a quarter, with a total figure of £2 million a year. Overall costs to the economy have been estimated at some £500 million a year, much of which relates to lost working days.

892. Action is focused on different settings and target groups. The Health Promoting Homes initiative is intended to get the entire family involved in changing behaviour and understanding the need to do that. The Healthy Steps for Life programme tries to embed some of those good habits in children at an early age. Eddie mentioned the need for community involvement, real engagement and ownership. There are schemes that are targeted at communities to own and take a lead on the issue. The workplace is another key setting.

893. FRESH is a weight-management programme for 11- and 12-year-olds. For children in their early years, there are programmes that are targeted at playschools, nursery groups, childminders and those who interact daily with young children. Nutritional standards have been introduced for school meals, and we are trying to address where children spend their days, both in school and at home.

894. Our approach is to prioritise obesity prevention and to own it at both central Government and local government level. It is a genuine issue that needs to be tackled with co-ordinated action across all Departments and with central Government action reflected at local government and within local communities and neighbourhoods. Obesity prevention needs to be brought down to neighbourhood level. A key task over the next few months will be to strengthen our existing relationships with local government, councils and other partners in education, transport, planning, and so on, and to translate that central direction into action on the ground.

895. On the matter of working with communities, I have highlighted the approach in France with the Ensemble, Prévenons l’Obésité des Enfants (EPODE) programme, of which you may have heard. It is concerned with planning the environment to promote walking and cycling. Parks, leisure facilities, and so on, have their part to play in tackling obesity. That emphasises the importance of cross-Government working.

896. 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.

897. Although some interventions are in place, it is essential that we are able to extend their scale and sustainability. Evidence has shown that 3,000 four- to five-year-olds and 4,500 11- to 12-year-olds already require interventions because their habits and behaviours are creating weight problems for them.

898. 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.

899. Another key issue concerns measuring the impact of programmes and knowing what does and does not work. That will require an additional focus and some specific attention. Without that, we will simply continue to hope for the best rather than tackle the issue in a cohesive way.

900. We need to learn from effective practice elsewhere. Evidence has begun to emerge from some areas about what does work. We need to think that evidence through, accept it at a Northern Ireland, cross-Government level and then make sure that it is implemented at a local level. Finally, it is important that we bring that evidence base to others so that we can inform policies.

901. Our paper lists some immediate priorities that I will not go through. However, I want to draw out some concluding points. As a society, we cannot treat ourselves out of this situation by prescribing drugs or performing operations; rather, we must focus on prioritising prevention.

902. A key lesson to be learned from other areas where there has been some success in tackling obesity is that it is about communities and neighbourhoods. People must recognise and accept that they own obesity and that is not done onto them by health and social care professionals. They need to accept that obesity is much more fundamental than an aesthetic issue; it is a health issue of which they have to take ownership for their sake and the sake of their families. Those are the key points.

903. The Deputy Chairperson: The Public Health Agency has a key role to play not only in tackling obesity but in addressing many others issues such as prevention and getting that message out early through education.

904. You referred to the good evaluation of the EPODE programme in France and said that the programme resulted in overweight boys experiencing a 50% decrease in obesity, which is a good statistic. How big is that programme? Was it very costly to implement? Could it be easily adapted for a pilot scheme here?

905. Ms Gerry Bleakney (Public Health Agency): That is one programme that is being trialled, and those are preliminary results. Some health professionals from England are in France to evaluate the programme fully. The preliminary results look very promising; however, we will have to wait for the full results.

906. As regards evaluation, many health improvement initiatives that have been used over the years have not been as good as they should have been. We need a gold-standard-type agreement on the sorts of issues that we should be building into evaluations, and then we can move towards achieving that across the UK. The Institute of Public Health in Ireland, the all-Ireland obesity observatory, the Public Health Agency and others will work together to achieve that for the country.

907. Mr Easton: During the inquiry, I have harped on about a particular point that I will also make to you. The work that the agency does is all well and good, but it is really designed only to try to keep a lid on matters.

908. No matter what we come up with in the inquiry, the situation can be resolved only by getting everyone to exercise and, more importantly, to force the food industry to limit the fats, sugars and salts in their produce. Until we do that, other measures will only keep a lid on the problem. I know that you cannot force the food industry to act, but what action are you advising the Department to take? Can we force the food industry to put the right ingredients in their foods, because that is the way to tackle obesity?

909. Dr Rooney: In many ways, you have hit the nub of the issue. If you think of all the issues that we tackle as mathematical equations, obesity should be one of the easier ones to solve: restrict what and how much people eat and get them to exercise. Those two measures will solve the problem.

910. However, it is difficult to tackle obesity, because there are so many players and interests, and because we are trying to turn the clock back on 50 years in which we have been going in a very different direction. It is also difficult to tackle the problem because we are dealing with fundamental aspects of our culture and what makes people tick. Even some of the basic aspects of tackling obesity that look simple turn out to be complex. For example, early investigations pointed out the importance of early years and early intervention. In the research that formed part of the Fit Futures initiative, which included kids as young as two and a half years of age, the basic messages were understood, such as the difference between good and bad. The role of enjoyable activity as part of a solution was also well understood, but it is not necessarily matched by the way in which society works. One cannot deal with children if one does not deal with parents and carers at the same time.

911. We are trying to turn the tide on many historical practices and behaviours at the same time as dealing with the issue at its source, which is not easy. The problem is multifactorial: for example, people’s rights are highly valued, but where they bring people into clear areas of risk, we have to turn the tide. That points to community-based approaches, which is why we are interested in examining some of the evaluation work and international research. There are lights in the tunnel; the holistic approach seems to be showing some benefits in countries such as New Zealand and Finland among others.

912. Research is a key element of the agency’s work, and we need to sharpen up our research on what measures work here and make sure that we do everything to publicise them. We are dealing with several interests and factors, many of which we do not have direct control over but still have to influence.

913. Mr Easton: We all know the health message, and I am fit at the moment, because I am knocking on doors and canvassing for the European election. However, I am in the habit of eating what is put in front of me; I do not look at food packaging and will probably die 10 years younger as a result. That is why legislation on food packaging is required; I need help to eat the right food, because it is too convenient for me to eat the wrong foods. That is why I encourage you to force the Minister to do something about that.

914. The Deputy Chairperson: We must all be very healthy, because we are all out knocking on doors.

915. Dr Deeny: As a GP, I want to be able to prescribe exercise regimes for patients where appropriate and play a role in preventative medicine as opposed to drug treatment. That is part of the future and does occur in some areas in the east of Northern Ireland.

916. The EPODE programme mentions boys, but are there any results for girls? As I have mentioned before, I am a little worried about obesity in girls: two young girls admitted to me in front of their parents that they smoke to suppress their appetites, which is a worrying development. I do not know whether girls get as much exercise or are as proactive as boys. Why does the EPODE programme make specific reference to boys?

917. An astounding number of people do not eat fruit or say that they do not like fruit. The same people will say that they feel guilty that they are not eating the recommended five portions every day. They are even unsure about what constitutes five portions, so will you quantify exactly what is meant by five portions? Some people think that it means eating five meals, but the five portions could be contained in two meals.

918. Ms Bleakney: Primary care and secondary care are able to make referrals. Referral schemes have been operational across Northern Ireland; there is a scheme in the eastern area and part-schemes in the southern and northern areas. As a new agency, we need to draw on what has been best practice and what has produced good results. We will try to share that information to ensure that there is an equitable provision of good practice across the region and that as many people as possible are granted access to good practice.

919. I have been heavily involved with the referral scheme in the east, but the evidence base to support it is questionable. We had already committed to the scheme when the National Institute for Health and Clinical Excellence (NICE) guidance came out, and it was then suggested that it should be run only as part of a well-researched approach. Clients from general practice, primary care and secondary care give good reports about the scheme in the east, and we think that it is working. We will continue to assess the scheme because it is an expensive intervention. It is also a potentially very cost-effective intervention given the health outcomes that it creates.

920. EPODE is a community intervention that includes boys and girls. Our paper reports the boys’ figure simply because it is the most striking; I could not give you the corresponding figure for girls off the top of my head. EPODE is a holistic project that is taken forward by the mayor of the local town or city. It develops community spirit and engagement around social action for change. EPODE is about physical activity and healthy eating rather than obesity, although its outcomes influence obesity.

921. The five-a-day message has been around for quite some time, but we need to do some more work on public awareness. There has been a difficulty in Ireland in that, although potatoes are still part of many people’s staple diet, they do not count as one of the five a day. The former Health Promotion Agency has used some very good material to raise awareness. How many grapes are in a portion of fruit? We can all visualise apples, oranges and bananas, but what constitutes a portion of kiwi or another more unusual fruit? We need to work on the public awareness of some aspects of the five-a-day message.

922. Mr Gardiner: Have you briefed families and agencies that take children into their care? What is your role in ensuring that those children, boys and girls, are properly cared for?

923. Dr Rooney: We are in the process of developing priorities and identifying target groups in the health and public health agenda. Families with children in care will be one of those groups. We will be able to provide you with more information over the next couple of months as we formulate our strategies. It will be a priority for the agency across the public health area.

924. Mr Gardiner: Do you think that that will be up and running in a couple of months? Will people be briefed, know what they are expected to do and what information to pass on?

925. Dr Rooney: We will certainly do our very best to ensure that that is the case. The agency is an action agency, and we will follow through on all development areas down to community group level. However, it is still early days.

926. Ms Bleakney: Much work has already been done for looked-after children in residential care or children who are placed with foster carers. Much has been done to make nutrition education and support available to those carers. We have identified the development of clear nutritional standards for residential care and children’s homes as a potential area of work. There are clear nutritional standards for education in schools, but there have been issues about children in residential homes. The main emphasis is on having as few children in residential homes as possible. However, we have a corporate parenting responsibility, and nutrition and physical activity are two key elements of that. Therefore, there is a plan to work on that within the next year.

927. Mr Gardiner: It is the family home that I am thinking about. When children are placed in care, what follow-up is there? Do you check whether that is being implemented to protect that child from going down the route to obesity?

928. Dr Rooney: We will certainly take that issue on board.

929. Mrs Hanna: I agree with Alex about food labelling. Often, the bargains are the rubbish food with the least food value and the most additives. There is an issue about our fondness for food and how it is used as comfort or reward. When my children were small, the thinking was that, if parents did not give their children anything sweet, they would never like sweet foods. Whether we like it or not, however, children seem to like sweet foods instinctively. It is about the culture. However, as the Public Health Agency, your message has to be about all of us taking ownership and responsibility for our own health, albeit with as much support as possible. You said that this issue covers many Departments and that much of what can be done for children is in the area of prevention, starting, for example, with antenatal classes, parents, preschool, and, if necessary, healthy breakfasts in schools. Much of that is happening. However, a lead person or agency is needed to ensure that it is happening and that its progress is monitored. Everybody is doing bits and pieces, but, unless someone is given absolute responsibility for progress, it will never come together.

930. Years ago, one of my children was involved in a piece of research. All I can remember is a man named Dr Sean Strain, and that it was carried out by the University of Ulster and Queen’s University. For a week, we had to keep a diary of everything that my daughter ate. We were not to be “good" for that week; we were to be honest. They did cardiovascular tests, and she loved being on the exercise machine. I did not hear about any outcomes, but it was a major piece of research at the time. I wonder if you know anything about it. You said that not enough research is being undertaken. It comes down to having one person in charge with the authority to involve all other areas and to monitor what is happening.

931. Dr Rooney: To have effective ownership, people need to know what to do, believe that it is right and know how to do it. We need to provide support on all three issues. We have gained a lot, and, although I would never try to turn the clock back on technology, we have also lost a lot. I have seen, particularly at community level, the loss of some basic skills. Programmes such as Cook It! try to reinstate those lost life skills. It is up to us to take that leadership role. However, it is a collective leadership; it is up to the agency to play its part, and it is up to many other people to play their parts. We have to break down the message and understand it from the perspective of people living in the community, as opposed to the message descending from on high. That will be a challenge for us. It is a thread running through the whole public health agenda. It cannot be done remotely. It must be done in communities and working with them. The agency must be able to demonstrate that it can work in that environment, and we are actively pursuing that.

932. When that barrier is broken, we have a real chance. There is a need for animation in communities and a real desire to do something. However, people struggle with how it can be achieved, and extra support is needed to make it happen. We must fill that challenging gap.

933. Mrs Hanna: I agree with you that it is about leadership. Everyone has to give leadership, but if there are no specifically dedicated people who have responsibility, it can be difficult to quantify the progress. That is what it is about. If we could see that we were improving, we could build on that.

934. The Deputy Chairperson: As there are no more questions, I thank you very much for your presentation.

21 May 2009

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister
Ms Claire McGill

Witnesses:

Mrs Maria Jennings
Mrs Andrea Marnoch

Food Standards Agency Northern Ireland

935. The Deputy Chairperson (Mrs O’Neill): I welcome Maria Jennings, deputy director of the Food Standards Agency (FSA), and Andrea Marnoch, head of the agency’s dietary health unit. You are both very welcome. I invite you to make a presentation, after which members may want to ask questions.

936. Mrs Maria Jennings (Food Standards Agency Northern Ireland): Good afternoon, Madam Chairperson and members of the Committee. Thank you very much for inviting us to give evidence. You have received the agency’s formal written submission. In the time that is available, Andrea and I will try to give you a flavour of some of the work that we are doing with the food industry and to raise consumer awareness of dietary health issues.

937. The Committee has met me previously. The Food Standards Agency is a UK-wide Government Department. It is our responsibility is to ensure that all food is safe to eat, and we also aim to protect consumers’ interests where food issues are concerned. Our local office in Belfast ensures that the agency’s principles and objectives are suitable for the needs of all consumers in Northern Ireland. We have a vision, which is that there must be safe food and healthy eating for all. For the purposes of the obesity inquiry, Andrea and I will concentrate on how the agency works to achieve the element of the vision that concerns healthy eating for all.

938. I am sure that you are all aware of the little chart that shows the eatwell plate. All our messaging is based on that plate, which is used widely by healthcare and education professionals. That chart illustrates that is a question of trying to get the balance right. We want people to get one third of their food intake from the fruit and vegetable part of the plate and about one third from the fibre part of the plate, which consists of bread, rice, pasta, and so forth. The final third should come from proteins such as meat, fish, eggs and beans, and milk and dairy products. Members will be glad to see that there is also a small segment for foods that are high in saturated fat and sugar. Our message is that healthy eating is all about balance; we are not in the game of demonising foods.

939. The agency set a number of high-level dietary health targets in its 2005-2010 strategic plan. Those include reducing the population’s intake of salt and saturated fat and encouraging improvements in nutrition labelling to help consumers make healthier choices.

940. Our work has three key strands. First, 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. I am sure that members will have heard about those barriers.

941. Andrea will give more detailed examples of how we influence food products and help people to make healthier choices.

942. Mrs Andrea Marnoch (Food Standards Agency Northern Ireland): As Maria said, the agency works with food businesses and their trade associations to support and encourage a reduction in the levels of saturated fats and added sugars in the foods that they prepare. For the past 18 months, the agency has been working on an energy intake reduction programme. I will discuss that programme and the effects of saturated fat on the diet. 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.

943. 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%. We focus on four areas of action: raising consumer awareness; promoting healthier choices; considering reformulating mainstream products to reduce their levels of saturated fat and sugar; and reducing portion sizes.

944. The agency launched a consumer campaign in February this year that targeted women between 25 and 60 years old and who are from social classes C1, C2 and D. That campaign was based on qualitative research that the agency carried out that suggested that the consumption of saturated fat was higher in that demographic.

945. The campaign was about raising awareness of the health effects of saturated fat and giving consumers simple tips on how to reduce such fat in their diets. Examples included cutting fat off meat and grilling rather than frying and grating instead of slicing cheese. I hoped that we would have feedback from that campaign for the Committee today; however, it is still early days, and the data are still being accumulated. Early indications suggest that consumer responses to the campaign have been positive and that they have understood the key messages.

946. The agency 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.

947. I will give examples of how that work is progressing. Premier Foods, whose brands include Mr Kipling, Ambrosia and Sharwood’s, has reduced the saturated fat in its Mr Kipling ‘Delightful’ range by 50%. McCain Foods has reduced the saturated fat in its potato products by more than 70%, and since 2006, Marks and Spencer has removed 70% of saturated fat from a range of crisps and 30% from a range of sandwiches. Therefore, that demonstrates that a lot of work is being done in that area.

948. The agency is working with the food industry to identify opportunities to reduce the size of single-serve portions of, for example, soft drinks and sweet and savoury snacks. How we address portion sizes with the population and the food industry will be a big part of our work over the next 12 to 18 months. A large part of that work will include examining with the retail sector how they could realign in-store promotions so that healthier options are promoted. At the minute, in-store promotions can encourage the increased consumption of energy-dense, salty foods.

949. Mrs Jennings: That leads me neatly to front-of-pack signpost labelling; it deserves a special mention. 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.

950. We started that work because consumers told us clearly that that was what they wanted. There was no front-of-pack labelling when the work commenced about four years ago. 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.

951. 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.

952. The agency, in partnership with the Department of Health, Social Services and Public Safety (DHSSPS), commissioned a comprehensive independent survey that looked at all the current schemes. It took almost 18 months to complete that work, and the findings have just been published. 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.

953. The full report on signpost labelling is available on our website. The agency and the Department of Health will consider the report’s findings and agree on the next steps. A public consultation will then take place, so the Committee might wish to hear from us again on this issue.

954. I will highlight briefly the work that we are doing on catering premises. People are eating outside the home more than ever before. What used to be a treat is now becoming the norm. Therefore, it has become more important for pubs, cafes and restaurants to provide nutritional information on their menus. Our work in catering premises is aimed at giving consumers the information that they need so that they can make healthier choices. Again, consumers told us that they want to see such information when they eat out. In Northern Ireland, we are working closely with environmental health officers to take work on that forward.

955. Several major national catering chains are taking part voluntarily in a pilot programme to provide calorie labelling for their customers. We have also secured healthy eating commitments from six of the UK’s largest high street restaurant chains. The work that is being done with Burger King provides a good example of how that company has started to reduce the salt, fat and sugar in its dishes. It has also started to provide a range of healthier options using healthier cooking methods, and it gives nutritional information on its menus.

956. We are planning to extend that work to workplace catering, and we are keen to discuss with the other Departments how we could improve catering in the public sector in Northern Ireland.

957. Mrs Marnoch: I will talk about how we influence the environment and some of the partnership activity in Northern Ireland that we are involved in that may be of interest to the Committee.

958. The agency has been involved in the school meals steering group, which led to the development of nutritional standards for school lunches. Those standards have been rolled out. We have also been involved with the new food policy that will be launched in schools as part of a whole food in schools policy. We have entered into a partnership agreement with the Council for the Curriculum, Examinations and Assessment (CCEA) in Northern Ireland in setting up a teachers’ panel to help support the dissemination in the primary and post-primary sector of a number of educational resources that focus on nutrition.

959. We have also started work with the Department of Culture, Arts and Leisure (DCAL) as part of work on the Olympics and the 2012 strategy in Northern Ireland. Over the course of the next 12 to 18 months, we hope to bring forward a joint package of measures on physical activity and eating well for young people in Northern Ireland. We have also worked with the Department for Social Development (DSD) on the development of the magazine ‘The Good Life’, which targets households in Northern Ireland with vulnerable people over the age of 65, and we support the Department’s promoting social inclusion (PSI) work on homelessness.

960. As Mrs Jennings said, we work closely with district councils on what we do with the food industry and local caterers. We launched a grant scheme early last year on the saturated fat campaign, and several initiatives are going on across the Province that will support the work in that area.

961. Finally, the Food Standards Agency is an evidence-based organisation, and all our policy work is based on sound evidence. I will touch briefly on the two main surveys that are relevant to the Committee’s work. In the UK, the diet and nutritional status of the general population is monitored through the national diet and nutrition survey, which until last year, had been rolled out across the rest of the UK but not in Northern Ireland. However, for the first time the survey is in Northern Ireland, and we have completed the first year of fieldwork. It is funded jointly by the Food Standards Agency, the Department of Health, Social Services and Public Safety and Safefood. It is an important survey, because it will tell us for the first time whether what we are doing is having an impact on the nutritional status of the population in Northern Ireland.

962. The national diet and nutrition survey collects detailed information on food consumption through four-day food diaries and through checking nutrient intakes and nutritional status, which is done through blood sampling. Information is also collected using physical measurements, which means that there is a physical activity questionnaire for all ages, and through actograph measurements, which are taken over the course of seven days for children aged four to 10. It also collects information on the socio-economic, demographic and lifestyle indicators of the households that are involved. We hope to report back in the next 12 to 18 months about what it will mean for Northern Ireland in comparison with the rest of the UK.

963. The low income diet and nutrition survey (LIDNS) was carried out between 2003 and 2005, and its results were published in 2007. Its aim was to study material deprivation in the diets of the bottom 15% of the population. The fieldwork included 400 households in Northern Ireland, and that enabled us to make inter-country comparisons with Scotland, Wales and England for the first time. In many respects, the areas of concern about the food that people eat that that survey pinpointed were similar to those identified already in the general population. However, 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.

964. In Northern Ireland, we work in partnership with Northern Ireland Statistics and Research Agency (NISRA) to support the fieldwork of these surveys.

965. Mrs Jennings: I reassure the Committee that we will continue our work in Northern Ireland. We have been delivering on the relevant objectives that were identified in ‘Fit Futures: Focus on Food, Activity and Young People’, and we have a seat on the obesity prevention steering group, about which you heard. I chair its food and nutrition subgroup, which is tasked with putting a framework in place for us to take forward work in Northern Ireland.

966. The agency is also consulting on its strategic plan for 2010-2015. We would like the Committee to visit our offices so that we can outline some of our priorities for the future.

967. The Deputy Chairperson: Thank you for the presentation and for the invitation, which we will take you up on.

968. The signposting, labelling and traffic-light system is very handy. People are always in a rush in supermarkets, and they do not have time to study labels. Therefore, something like the traffic-light system, which is a positive move, will help.

969. Andrea said that one of the agency’s strategic targets is to reduce the intake of salt and saturated fat. You gave good examples of companies such as McCain Foods and others that have worked with you. How do you engage locally with the food and drink industry across the North? Are supermarkets reluctant in any way to get involved and work from positive examples?

970. Mrs Jennings: I am sure that you know that the larger supermarkets control a lot of the movement of food around the UK. At a national level, we can influence the production of food and getting it on shelves. We are involved with some of the local supermarkets and independent retailers in Northern Ireland to try to influence them and what they provide for consumers.

971. The biggest impact will be felt with large manufacturers at a national level. Northern Ireland is a food producer, and it exports a lot of food, so we work closely with the red meat industry, for example. We work with the Meat Exporters’ Association and the Northern Ireland Food and Drink Association (NIFDA) to try to take forward a lot of the work in Northern Ireland.

972. We are building on the partnerships that we have in trying to encourage some of the manufacturers and retailers in Northern Ireland to start to mirror some of the work that has been going on in the rest of the UK.

973. Mrs Marnoch: It is worth adding that 11 companies in Northern Ireland have adopted the signposting scheme.

974. Mrs Jennings: We have been pleasantly surprised that a lot of the food companies in Northern Ireland have taken the high moral ground, are very interested in the health agenda and are moving towards taking up signposting labelling.

975. Dr Deeny: The traffic-light signposting seems to make a lot more sense for the public. However, who in God’s name would have time to read the GDA? For example, an item may contain 12% of the daily recommended intake of sugar, but one would need to be a mathematical genius to work out that, having eaten the item, one could eat a further 88% of sugar and a further 81% of fat that day. Other elements will only confuse people, and no one will pay any attention to them.

976. The traffic-light system seems to be ideal. It mentions low saturates, and there used to be much talk of polyunsaturates. Is that still a big thing? Do the public need to know about saturated fat and polyunsaturated fat?

977. My second question is of interest to me as a GP. Does your organisation have an input into making advice on healthy eating available in health centres? As I said last week, there is still a lot of confusion out there. For example, in my surgery, we have a lot of worthwhile leaflets that we give to patients about how to lower cholesterol. We also give out diabetic sheets, which provide information on how to lower sugar levels. Those leaflets are very helpful, and if patients have those problems, they will often try to tackle them. However, I would like to see a leaflet that tells people who do not have those problems what they should eat.

978. Last week, I mentioned that we need to eat five portions of fruit and vegetables a day, but people do not know whether that means that they should have meals and have fruit with every meal or whether it means something else. If leaflets were produced and placed in health centres and leisure centres, for example, people could pick them up, and they would find out exactly how to get their five portions of fruit and vegetables every day. It is just confusing. I was wondering about your input into that. It would be very worthwhile to have such information. Many people, myself included, do not eat enough fruit, and some people do not eat any fruit at all. How can we encourage our young people to get to like fruit in schools, for example?

979. Mrs Jennings: The overall amount of fat that people eat, particularly saturated fat, is the issue. There was a whole discussion about trans fats and the amount of trans fats that people eat, but 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.

980. Mrs Marnoch: The magazine ‘The Good Life’, to which I referred earlier, targets people in Northern Ireland who are aged over 65. It has been distributed to all health centres in Northern Ireland, and whenever we produce publications, we send them to health centres. However, I know what you are saying about people having a role in providing information and advice. Historically, it has tended to be dieticians and possibly trusts who have supported giving advice and information at a local level.

981. Mrs Jennings: It is right for dieticians to give one-to-one consultations and specific advice on people’s diets. We are in the game of providing those overarching messages that you are saying are quite confusing. In England, lot of money is going into a big marketing campaign called Change for Life, and in Northern Ireland, we need to push for an integrated, single form of messaging that is simple enough for the public to understand. We will be pushing for that in the obesity prevention steering group.

982. Mrs Marnoch: There have been a lot of positive developments in schools in the past few years, particularly through new nutritional standards in school lunches. That has changed fundamentally the food choices that are available in schools. The curriculum has a lot of positive messages that are joined up with the healthy eating messages to reinforce that. However, schoolchildren are a very difficult group to reach, and their intake of fruit and vegetables is very low. A study carried out by Queen’s University shows that that has a particularly negative impact on the bone density of pubescent girls. Therefore, we carried out research a few years ago with Queen’s University and the University of Ulster, and we launched a survival guide for first-year students, because they were the most vulnerable group. A lot of emphasis was put on their fruit and vegetable intake, and we worked with the caterers on site and with students in halls of residence to try to reinforce some of those messages through that resource and through catering. It is always going to be a challenge with that age group, but the environment has changed significantly, so the message can be supported.

983. Mrs Jennings: With the whole school approach — and I am sure that you will be hearing from the Department of Education about that — there are a number of schemes in schools, such as the better break schemes. Schools are doing brilliant work with trying to encourage children to eat healthier food.

984. Mrs Marnoch: The Big Banana project is being launched. Actually we have five of them, so I suppose we could say that a bunch of bananas is being launched. We are going to roll that project out across primary schools from September.

985. The Big Banana has games about nutrition and food hygiene, and it has food-safety messages for children in primary schools. It has a mixture of board games and card games, and we are looking forward to getting it out to people and then seeing what the response will be.

986. Dr Deeny: What about putting leaflets in health centres to explain to people who do not have conditions such as diabetes how they should get their five portions of fruit and vegetables a day? Many adults do not know how to go about that; they need practical advice.

987. Mrs Marnoch: We would be keen to discuss that with the Public Health Agency. The Department of Health, Social Services and Public Safety would have tended to have led on the five-a-day campaign. However, we will reinforce that point in all our messages.

988. Mrs Hanna: I assumed that five-a-day meant an apple, an orange, a banana and a few carrots and peas. I take a simple approach, but perhaps it is not as simple as that. Some of the questions have been half answered already, but it is good to hear that we are going to have one signposting scheme. We need to know what average amounts are; it is a bit like buying tomatoes, because they are sold singly, in trays or in 1 kg packs, and it is impossible to figure out which are the cheapest.

989. You talked about food processors that are working with you, such as the makers of the Mr Kipling brand. However, those companies seem to reduce salt and fat only in their light and diet ranges. I know that they will say that the public want the products that contain salt and fat, but it would be better if you could persuade the food processing companies to make gradual reductions in all their product ranges.

990. How much influence do you have? You told us what was happening across the water, but are you part of an organisation that has more power? The answer lies somewhere between forcing people to change what they are doing by way of legislation and influencing change. It is a question of how far you can go. It is a carrot-and-stick situation; with a bit of encouragement, some will go further, but others will not move at all. We need everyone to make changes, and not just in the light or diet ranges; those are for the people who are looking already at the traffic lights and thinking about their diet. However, most people are not doing that, and the light food ranges are often dearer, even though they supposedly contain less salt and fat. We must make things simpler for everyone so that all processed food is a bit healthier.

991. Mrs Jennings: There is no doubt that you are right. Through our own surveys, we know that products that are marked “light" or “healthy eating" do not attract the general population, and people steer away from them. We are trying to get the food processing companies to make improvements to the standard, routine products by reformulating them and taking salt and saturated fat out of them.

992. We are working with a full range of manufacturers in a sector. For example, if we are working with all the major manufacturers of potato crisps, we establish a norm for that industry and set a target below that norm. That target has to be met over time, because it takes their customers time to change their tastes. If you took half of the salt out of a packet of crisps, no one would buy them, which defeats the purpose of the exercise. Those targets, and the commitments that have been made by all those industry groups, have been published on our website. The industry groups are now publicly accountable for the achievement of those targets over the specified period.

993. Mrs Hanna: Are you saying that they have to achieve those targets?

994. Mrs Jennings: Yes. It is about getting the industry to take collective responsibility so that individual companies are not left behind.

995. Mrs Hanna: I can understand that they want to sell their products. I like salt in my crisps, and I need to be weaned off it gradually. That is what a lot of people do at home when they are using salt with their dinner, but eventually, they will not have it on the table anymore.

996. I want to ask you about what is happening in school and hospital canteens. I know that a lot of work is going on in those places. How much influence can you have in that area?

997. Mrs Marnoch: A school meal nutritional group was set up a few years ago. It was established to develop food-based nutritional standards for school lunches. That started in 2003, and it was piloted in approximately 100 primary and post-primary schools in Northern Ireland. The standards have been reviewed and, subsequently, developed, and new nutritional standards are being rolled out in schools now.

998. In the past six or seven years, there have been developments around school lunches. Added to that are healthy breaks and out-of-school-hours clubs that provide food according to agreed standards that have been developed against a whole-school food policy.

999. Mrs Hanna: I have watched television programmes featuring the likes of Jamie Oliver and have read articles on the subject, but in spite of what has been achieved by those, problems arise because chips are available with everything. A gradual move to low-fat chips will help to change diets. It is obvious that people will choose chips instead of an apple or baked potato, for instance.

1000. Mrs Jennings: Schools are a real success story; the improvement in the food provided in schools is one of the biggest successes of the Fit Futures strategy. Daily menus are devised in blocks of three or four weeks. That planning is aimed at giving children a balance in their diet, as it ensures that children receive one third of their recommended daily nutrition from their school meals in that period. School caterers have set up standardised recipes. They have been trained in nutrition and have been working extremely hard; it is a success story.

1001. Mrs Hanna: We need to get children to take school meals instead of eating a Mars bar and crisps.

1002. Mrs Jennings: That is correct. Mrs Hanna also mentioned legislation. It is important to note that we are constrained because, as members will know, all the legislation that is relevant to our work comes from Europe. We have to be careful that we do not do anything to prejudice the way in which UK food products are sold. We import a lot of products from the rest of Europe, so we cannot introduce legislation that gold-plates what Europe is doing.

1003. Mr Easton: It is recommended that we eat five portions of fruit or vegetables a day. Is it sufficient to eat five apples a day, for instance? I eat only one portion each day, so I am bad.

1004. Mrs Marnoch: It is recommended that you eat a variety. 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.

1005. Mr Easton: Since we started this inquiry, I have harped on about the importance of getting the food industry to control the fats, sugar and salt that are put in our food. That is the only way to control obesity. Although everything else that is done is good, it is merely a sticking plaster. The Food Standards Agency can only force food producers a wee bit. Are you saying that the matter is controlled by Europe rather than by Westminster or here?

1006. Mrs Jennings: We cannot legislate on the matter here, so we cannot propose legislation stating, for instance, that a particular food sector has to reduce its salt input by 50%. However, we can work in partnership with the food industry. That partnership has been successful in driving down the amount of fat and salt that is in our diet.

1007. Mr Easton: Can Westminster do that?

1008. Mrs Jennings: The UK Government cannot introduce national legislation on this matter, because it would disadvantage UK food companies in relation to the rest of Europe. We would be setting a standard that would be much higher than that for food produced in the rest of Europe or the rest of the world.

1009. Mr Easton: This is an example of the European Parliament needing to get its act together, because we are all suffering.

1010. Mrs Jennings: A lot of European countries are in different places on this issue. We are pioneering some of the work, particularly around signpost labelling and front-of-pack nutritional labelling. We do a lot of work in Europe, and we lobby on behalf of UK consumers.

1011. Mrs Marnoch: To be fair to the food industry, there have been significant developments in the area. We have received commitments from six of the UK’s largest high street chains, including Burger King, KFC, Subway and McDonalds. They account for a huge percentage of the market share. Those companies are working towards reducing the levels of saturated fat and salt in foods. It is a voluntary arrangement at the moment, but they have publicly made those commitments; they are stated on the FSA website.

1012. Carmel, you asked earlier why those companies only introduce such changes in certain ranges. I do not come from a technical background, and when all of the reformulation work started it was fascinating to find out how those products are produced. In relation to saturated fat, what is really interesting is that once the huge processing plants and factories change the oil used for one product, that impacts on all of the others. Those companies use the same oil and fat for most of their product range, meaning that a change for one product impacts across the entire range.

1013. Mrs Hanna: Therefore, we need those companies to change to using a better oil.

1014. Mrs Jennings: I agree, although sometimes that is a very expensive process. The FSA has reduced the overall salt intake by the UK population from 9·6 grams in 2007 to 8·6 grams in 2008; that is a reduction of one gram. Our estimates indicate that that reduction prevents around 6,000 premature deaths in the UK and is worth £2·7 billion to our economy each year. The FSA knows that the food industry is moving to implement some of those changes.

1015. Mr Easton: If the FSA gets rid of all the salts could it get us out of a recession as a result of all the money that that would save the economy?

1016. Mrs Jennings: We all need to eat some salt.

1017. Dr Deeny: Are low salts beneficial?

1018. Mrs Jennings: Low salt is the potassium equivalent of sodium chloride, and there are other issues surrounding potassium, as the Committee will know. It is also a much more expensive option, and the FSA would certainly not advocate swapping sodium chloride with potassium chloride.

1019. Mrs McGill: Thank you for the briefing. On the issue of schools, the west is definitely leading the way, particularly those schools in the Strabane District Council area. The council recently received a report on the work that has been done to promote healthy eating in schools in the area, and it seems to be a very good and effective project. Therefore, be assured that that message is getting through to the schools in the Strabane District Council area. I am familiar with a number of schools and sit on the board of governors for a couple of them, and I know that they are very energised by the project, which they have been involved with for a couple of years. I congratulate those schools and the FSA on that success.

1020. In your submission, you refer to the ‘Low Income Diet and Nutrition Survey’. That survey involved 400 households in Northern Ireland, was carried out between 2003 and 2005 and was published in 2007. Do you consider that research to be up to date?

1021. Mrs Jennings: All such research is extremely expensive to conduct. Following that survey, FSA put its allocated funding into the ‘National Diet and Nutrition Survey’, which takes the general population into account. However, there is no doubt that the low-income groupings will need to be looked at again. It is important to keep all surveys as up to date as possible.

1022. Mrs Marnoch: As Maria has said, the FSA is involved in a rolling programme and is committed to year-on-year monitoring. That involves 200 households in Northern Ireland being surveyed each year, meaning that we are getting data that is as up to date as possible.

1023. The national survey allows us to focus on particular subgroups. Next year, we hope to look at infants and young children, including those aged between 4 months and 18 months, as that age group is not currently included in the ‘National Diet and Nutrition Survey’. It also allows us to look at older people or other subsets of the population, depending on what the policy priorities are.

1024. Mrs McGill: It is important that the survey is based on up-to-date research and results. Is the Food Advisory Committee part of the Food Standards Agency? How many people sit on that committee? Am I correct in thinking that you have 43 staff?

1025. Mrs Jennings: We have 43 staff in our Belfast office. The Northern Ireland Food Advisory Committee comprises members of the general public. The chairperson is a member of the national board of the Food Standards Agency and, depending on the time of year, the Northern Ireland Food Advisory Committee has eight or nine other members. The committee members sit for a term of three years, which can be renewed for another three years. It is sometimes difficult to find members for that committee, and we will recruit for another couple of members in the summer. Therefore, you should encourage people to submit an application.

1026. I must jump to the defence of the other district councils in Northern Ireland, as it is not only Strabane District Council that works well. They work extremely well collectively, and there is a system for grouping them, which works according to whether they are based in the north, south, east, west or Belfast. The Northern Ireland food liaison group, which is the group of principal food officers in Northern Ireland, will take examples of good practice from all the district councils and apply those across the North. I hope that the work in Strabane will be captured and rolled out at a Northern Ireland level.

1027. The Deputy Chairperson: Thank you for your presentation and for answering members’ questions.

21 May 2009

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister
Ms Claire McGill

Witnesses:

Mr Andrew Dougal

Northern Ireland Chest Heart and Stroke Association

Mr Iain Foster

Diabetes UK Northern Ireland

Ms Victoria Taylor

British Heart Foundation

1028. The Deputy Chairperson (Mrs O’Neill): We will now move on to the next set of witnesses. I welcome Andrew Dougal from the Northern Ireland Chest Heart and Stroke Association (NICHSA), Iain Foster from Diabetes UK Northern Ireland and Victoria Taylor from the British Heart Foundation (BHF). I invite each of you to make a presentation, after which members will ask questions.

1029. Mr Andrew Dougal (Northern Ireland Chest Heart and Stroke Association): The obesity epidemic threatens to reduce the advances in health that have been made since the Second World War. For the first time in our history, young people may not live for as long as their parents. More than 60% of Northern Ireland’s population is overweight or obese, which greatly increases their risk of heart disease and stroke.

1030. For more than 60 years, the Northern Ireland Chest Heart and Stroke Association has campaigned for healthy lifestyles to prevent people suffering from those illnesses. We urge the Assembly to ensure that there is more effective cross-departmental efforts and resources to tackle that disaster. In particular, we make a plea for the Department of Education to work in conjunction with the Department of Health, Social Services and Public Safety. In the past, that did not always happen.

1031. The private sector must play its part and work with the voluntary sector and the statutory sector. Statutory regulatory bodies must remember that their role is to protect the consumer rather than the industry. Although the Food Standards Agency concentrated on food safety in its early days, it is now responding to the need for information on nutrition. For many years, the Chest Heart and Stroke Association and other organisations campaigned for the establishment of that agency, and the legislation to do that was enacted eight years ago. The FSA must protect the consumer in the same way that Ofcom protects the consumer rather than the TV industry or the advertising industry.

1032. Over one third of all deaths in Northern Ireland are caused by heart disease and stroke. Stroke is the third biggest killer and the leading cause of disability in Northern Ireland. Of those who have a stroke, one third make a full recovery, one third die, and one third have a substantial disability that results in some level of dependence on others for the rest of their life.

1033. To give the Committee some idea of the costs involved; £102 million is spent on direct health and personal social services; £87 million is spent on informal care in Northern Ireland, particularly by the families of those who are in care institutions; and £65 million is lost in income because of mortality, morbidity and benefit payments. That means that, in total, the cost to Northern Ireland is over £250 million.

1034. The Northern Ireland Chest Heart and Stroke Association believes that 40% of strokes could be avoided through proper preventative measures. That is why we are asking for a primary prevention programme on stroke. We asked for a similar programme on heart disease in the Assembly in 1984, and we finally got one in 1986. In the last 20 years, the number of premature deaths from coronary heart disease in people under the age of 75 has declined by 71%, so it is worthwhile to have a prevention programme. It is time that we had one on stroke.

1035. Thankfully, we have the Northern Ireland stroke strategy, and the Assembly has voted to spend £14 million each year on combating stroke. We want to see that money well spent. We want to see it used in reducing stroke and in treating people much more effectively, particularly with clot-busting drugs that have been available in the United States for 10 or 11 years but are only now becoming available in Northern Ireland.

1036. Figures from January 2008 show that over 150,000 people in Northern Ireland are obese. According to the Foresight report of 2007 — which is a seminal report — it is estimated that if current trends continue, by 2050, nine out of ten adults and two out of three children across the United Kingdom will be overweight or obese.

1037. It is the view of NICHSA that over the last quarter of a century, public representatives have had a binding duty to do all that they can to protect the health of our young people. As far back as 8 June 1984 — 25 years ago — NICHSA held a one-day conference entitled ‘the healthier Ulster diet’, which was chaired by Professor Philip James, who now chairs the World Health Organization’s task force on obesity.

1038. Sound nutrition must not be solely for the middle classes. Health authorities, food producers and retailers must see it as their duty to ensure that everyone is empowered to have a healthier diet. In essence, it is important that we have leadership on this issue. There may be a need for a tsar who could take the issue on.

1039. The importance of school-based activities must be emphasised. It is essential that we ensure that healthy eating is part of a whole-school policy. We have been asking for that for 25 years, and we are pleased that the Food Standards Agency, the education and library boards and the Health Promotion Agency are now getting there. There have been major changes. That should be a requirement in every school, not only middle-class schools. Coronary heart disease and stroke is most rampant in the lower socio-economic groups, and that is where we have not been successful. We must focus more and more of our efforts on dealing with that.

1040. The point that Dr Deeny made about guideline daily amounts in the previous evidence session is very valid. 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.

1041. 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. Those companies, which I am not going to name today, have done no good for the health of their customers. They have failed to empower their customers. We would like to see all companies sticking to one simple system that people understand.

1042. Stroke is the largest single cause of disability in our community. Preventing stroke can be of huge benefit to the people of Northern Ireland, the Health Service and our economy.

1043. Ms Victoria Taylor (British Heart Foundation): Good afternoon. Thank you for inviting us to speak to the Committee. As a dietician, obesity is an issue that is close to my heart and one that I spend a lot of time working on. The British Heart Foundation is keen to see improvements in obesity levels, as 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.

1044. The INTERHEART study estimates that 63% of heart attacks in western Europe were due to central obesity. Another factor that we need to consider is whether people are apple shaped or pear shaped; the apple shape being more inclined to central obesity, which has a greater link to heart disease. People who are apple shaped, or have more central obesity, are twice as likely to have a heart attack as those who are not.

1045. The reasons for action have been set out in the Foresight report, which contains stark and sobering predictions of what will happen by 2050. Based on changes to BMI alone, the report predicts that heart disease will increase by 20% by 2050. That will have not only human costs, but economic costs, through the treatment of those who have heart conditions. We are pleased that death rates from heart disease have fallen since the 1970s. Although the fall is partly due to reductions in risk factors, such as smoking, the decrease is also due to better treatments; people with chronic diseases are living longer with long-term medication.

1046. The question of how to solve the problem is very difficult to answer. We are aware that there is no single solution; a joined-up approach is needed not only between Departments, but between the different sectors. The food industry was mentioned but, as a non-Government organisation, we are keen to work with the Government also. We are also aware of the need to raise problems that we see in food advertising.

1047. The focus of the British Heart Foundation is more on prevention than management. We want individuals to receive good advice, but we recognise the need for a supportive environment. The approach to obesity should be a combination of diet and physical activity, which are the two sides of the energy-balance equation, as well as behaviours.

1048. As a whole, the population is getting bigger, but there are groups of the population who find it more difficult to select and prepare a healthy diet, which is partly based on income. Therefore, as we have already heard, it is vital to make healthy choices the easier choices.

1049. Before I talk about our recommendations to the Assembly, I will point out what the BHF is doing. We are keen to support work that is ongoing, and hopefully our educational resources will help individuals and front line staff to do that work. We are also very proud of our social marketing campaigns. The Food 4 Thought campaign, which looks at what children should do to combat obesity and targets 11- to 14-year olds through schools, has been taken up by schools in Northern Ireland — 128 signed up the most recent campaign. This year, the campaign also takes an innovative look at the consequences of the choices that children make.

1050. The two most pressing policy calls concern advertising to children before the 9.00 pm watershed, rather than just during children’s programmes, and front-of-pack food labelling. We are strongly in favour of the traffic-light system, so we welcome the support expressed for it this afternoon.

1051. A joined-up approach is vital; we need to see all Departments working together. The approach to physical activity and planning policies may involve Departments that would not obviously lend themselves to the obesity problem; however, the problem is not the responsibility of only the Department of Health. We are looking forward to the publication of the service framework for cardiovascular health and well-being. It is also important that we have good monitoring and evaluation of the Fit Futures strategy so that its goals are achieved and we can know whether it has been successful.

1052. Although those goals cannot necessarily be achieved directly by the Northern Ireland Assembly, we would welcome its support for halting the advertising of junk food to children before the 9.00 pm watershed and also for ensuring that there is a single system of front-of-pack food labelling that is clear and that people will understand.

1053. Mr Iain Foster (Diabetes UK Northern Ireland): I am Iain Foster from Diabetes UK. Six years ago, I was diagnosed with type 2 diabetes. Therefore, I have a personal and a professional interest in the issue.

1054. I understand that the Committee’s inquiry has been ongoing for some time. You have heard a range of evidence. I do not need to rehearse the statistics; the evidence is very clear. Dr Michael Ryan from the Northern Health and Social Care Trust gave fairly comprehensive evidence on the medical side of diabetes. I would challenge one or two of his statistics, although only on minor details; I will not quibble over them.

1055. Essentially, I want the Committee to bear in mind, particularly with regard to obesity and diabetes, the importance of getting beyond the misconception that diabetes is a mild condition. 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. You can imagine the impact that that has on a person and his or her family, as well as the impact on the Health Service.

1056. At current levels, over £1 million is spent each day in Northern Ireland to treat 65,000 people who have been diagnosed with the condition. Current prevalence models predict that that will rise to over 80,000 people during the next five to 10 years. The Health Service cannot sustain that level of care. Diabetes is a complex condition; patients must see a range of health professionals and take a range of medication. It is intensive and cost heavy. Therefore, it is in the interests of individuals, communities and the Health Service to stop the increase in the number of people who develop diabetes.

1057. With regard to obesity, it is important to remember that there two types of diabetes; type 1 and type 2. Type 1 is genetic and tends to develop in younger people. It has no connection whatsoever to weight issues. At times, even as a diabetes charity, we can be slightly guilty of raising the profile of diabetes in a simple way to get the message across. Yet it is important that we do not have the simplistic model that all diabetes is weight-related, particularly because people who are diagnosed with type 1 diabetes are mainly children. We have a lot of anecdotal evidence of children being bullied and stigmatised because of their diabetes. Type 1 diabetes is not weight-related, and it is important to make the distinction between the two types.

1058. Even type 2 diabetes is not exclusively caused by excess weight or obesity. The causes of type 2 diabetes are still not fully known. Much research is still being done. Weight contributes to around 80% of cases of type 2 diabetes. The other 20% of people who have type 2 diabetes have no weight issues whatsoever. We are aware of people who are heavily obese but have never developed type 2 diabetes. Therefore, it is a complex picture and it is important not to become too simplistic about it.

1059. As regards current treatments of diabetes and obesity, it is clear that society and the Health Service have failed. There is no issue about that. That is not an attack on the Department of Health. The amount of money that it invests in diabetes care is quite clear; however, statistics show that there has been a steady increase in the incidence of diabetes. Logically, therefore, it would seem that the cause of that increase is beyond the remit of the Health Service. There are wider factors that are very much to do with lifestyle that the Health Service currently cannot control. Obesity and the health complications that it causes are a lifestyle issue.

1060. Until now, the Health Service has treated the complications and consequences of obesity using a medical model; it has not viewed obesity as a lifestyle disease. Skills, investment and knowledge relating to people’s lifestyle choices are at a basic level throughout the Health Service. Lifestyle is not a technical, medical issue. Many healthcare professionals feel uncomfortable tackling other people about their lifestyle choices. Many of those issues are outside the Health Service’s control and, to be honest, are probably beyond politicians’ control.

1061. Therefore, I understand that it is a difficult challenge for you as politicians to try to affect that situation. It is a complex situation and no single piece of legislation will achieve the desired result. As it is beyond your control, you will, obviously, not have experience of it and you may feel uncomfortable addressing it.

1062. Unless we start to regard obesity as a lifestyle disease, we will not stop its increase. Levels of obesity will continue to rise, and its consequences will be phenomenal and much worse than other issues that receive far more resources and applied intelligence. Obesity as a lifestyle disease has received little investment or attention. It is important to consider someone’s wider lifestyle and all the factors that feed into it.

1063. We do that by changing people’s attitudes, and that is a challenge in a similar way that dealing with drink-driving, wearing seat belts and smoking in public places were big challenges. However, changing people’s attitudes to lifestyle choices presents an even bigger challenge. Strong legislation played a role in shifting people’s attitudes to smoking and drink-driving, and politicians must face that fact when thinking about obesity.

1064. Until now, all efforts to tackle obesity have concentrated on information, advice, and awareness. By and large, that message has been received. People might not know about daily allowances and other technical details, but most have a reasonable idea of what is or is not healthy. Even having a good knowledge, however, does not affect some people’s behaviour positively. Therefore, there must be an additional trigger or lever to change people’s behaviour. I am quite sure that legislation is required. In the past, people have taken a hands-off approach and have been scared of having nanny-state accusations made against them. To shift the wider cultural sense of what is acceptable and signal what direction should be taken requires stronger political leadership from the Health Service and other areas of Government on legislation, the food industry, education and leisure activities. Without that, the trend in obesity will continue, and the Health Service will face the consequences and possibly start to crack under the strain.

1065. I stress that leadership, the recognition of obesity as a lifestyle disease, and legislation are required. Obesity is a complicated issue, because it does not require a single piece of legislation or affect only one section of society; it covers a many elements of modern life. I advise you not to underestimate the challenge. One thing is certain: if we do not attempt to tackle obesity, the future will be very bleak for us all. I could go on, but I am conscious of time.

1066. The Deputy Chairperson: There is little that you said with which the Committee does not agree. We all recognise that obesity must be tackled across all Departments. To pick up on a couple of key points, Victoria, you said that healthier choices must be the easier choices. That is a simple point, and we can work on it.

1067. Iain made a point about having to regard obesity as a lifestyle disease, and I agree that it must be examined in that context. You also discussed the need to challenge attitudes, and smoking has long been described as the single greatest cause of preventable premature death. Much effort went into bringing about a cultural shift, and smoking is now socially unacceptable.

1068. You told us today, and we heard in previous evidence sessions, that the obesity epidemic is a massive threat to public health. One submission stated that for the first time in our history, parents will outlive their children. You also said that 145,000 people are obese and that the prediction is that nine out of 10 adults and two out of three children will be obese or overweight by 2050. Are you saying that it is time for obesity to be recognised as the number one public-health issue facing society and that it should be tackled accordingly, in much the same way that smoking was dealt with in the past?

1069. Mr I Foster: Absolutely. Unless obesity is tackled, we will not make progress. Obesity requires the level of leadership and investment that would be given to the number one public-health issue. There are always competing demands for resources, time, energy and so forth, but obesity must be put at the top of the agenda. A significant amount of complications, even beyond the diabetes epidemic, result from obesity, and it places restrictions on people’s quality of life and their life expectancy. People may live longer, but only if they are supported by extremely expensive Health Service resources that would, as a consequence, be denied to other areas of need.

1070. We do not often talk about it, but, in a sense, public spending is a competition. Health is important, but should we spend less on education, on the environment or on other issues? Ultimately, we have to, because society makes choices about where the budget goes. Obesity will increasingly demand more public resources. 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. It has to be top of the agenda, and we have to have very strong political leadership.

1071. Mr Dougal: Let us hope that the politicians will have the moral courage to act swiftly on this issue. It took almost 40 years for resolute action to be taken on smoking. As far back as 1965, the Health Minister, Sir Kenneth Robinson, and Tony Benn banned the advertising of cigarettes on television, but almost 40 years passed before there was a total ban on the advertising and promotion of tobacco products. That indicates weak and irresolute government.

1072. Some 25 years ago, when we in the Northern Ireland Chest Heart and Stroke advocated that nutrition was linked to heart disease, people thought we were not quite sane. Now that link is proven, and people know that there is a connection between nutrition and cardiovascular disease. 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.

1073. It is important that people understand that they should get that opportunity. I know that the single European market has created difficulties. This is an issue at European level; I know that 800 amendments have been tabled to a Bill that is proceeding through the European Parliament. However, that is not to say that moral pressure should not be put on food manufacturers and retailers here to have an effective voluntary system through which they can indicate that they care for their customers’ health and wish to give them choice. If that were to happen, we would like to see Government put their shoulders to the wheel and make sure that something is done. If we cannot do that by statutory means, we should do it through moral obligation.

1074. Mr I Foster: The evidence is very strong. We need to restate and clarify it, and we need consensus, but the evidence exists. However, we must ask what we are going to do about it.

1075. It is almost like a battle. We have a child in one hand, with its life before it, full of avenues that it may go down, and we are up against a lifetime of habit and the example that parents and society give. We are also facing the food industry, the advertising industry, transport, technological advances and sport, which is now mostly a spectator event. People do not participate in sport; they watch it on television. These days, the most popular leisure activity is probably shopping. Consumerism is one of the huge forces that focus on the individual. To combat all that, we must encourage people to make healthy lifestyle choices. It is an unfair struggle, and it is almost impossible.

1076. If we were to sit back, take a hands-off approach and talk around the edges, we would lose the battle. There must be more focus and more dedicated action to counterbalance all those other forces. Therefore, legislation is necessary.

1077. Ms Taylor: Given that the Foresight figures are predictions, it is not too late to change things. It should also be remembered that in 2050, nine out of 10 adults will be obese. Those adults are today’s children, so we need to work with them now.

1078. Dr Deeny: We held a very interesting conference here on obesity on Tuesday. Many top people — professors, researchers and clinicians — from different countries attended. You mentioned one of them, Dr Michael Ryan, who is a paediatrician. There is no doubt that the message is coming through, and we need to get awareness of the issue in the media. The public are not aware that this is an epidemic. The epidemic is not coming; it has started already. The clinicians’ frustration is palpable, and they want something done about it as soon as possible.

1079. You talked about the knock-on effects of obesity, including diabetes, ischaemic heart disease, renovascular disease, stroke, and hypertension. Often, the precursor to those conditions is obesity. The cost of the situation to public health, productivity and the economy will be enormous.

1080. You mentioned a stroke strategy. You are right; it is not before time that that strategy has been introduced. Moreover, heart disease and other illnesses are dealt with much better now. It is great to see that in my professional career. Do we need an obesity strategy? As we all know, it is a societal problem, but the health sector will have to take the lead again.

1081. Some people at Tuesday’s conference believed — and you are right about this, Victoria — that all Departments must be involved in a joined-up way. However, the Department of Health, Social Services and Public Safety will have to drive any strategy and will have to ensure that other Departments participate. DHSSPS will have to pick up the consequences of the illnesses that arise from the obesity epidemic. Do we need a tsar to lead our strategy? Should we give one individual the responsibility to pull together all Departments and the authority to ensure that the issue is placed at the top of the agenda? As we can now see in primary care, the problem is worsening.

1082. The medical journals and at least one newspaper covered a story this week in which some eminent medical researchers said that everybody over the age of 60, regardless of whether they have high blood pressure, should take a pill to reduce their blood pressure. That is not the right way to tackle that issue. Indeed, it is similar to the concept of a polypill. Giving people a polypill is like closing the stable door after the horse has bolted; it does not deal with the situation, but treats the outcomes of obesity, for example, rather than preventing the problem. However, some people are pushing that idea.

1083. I am sure that the multinational drug companies are keen to introduce a polypill. All those companies are trying to create the first pill that controls blood pressure, blood sugar levels and cholesterol. It could earn a company billions of pounds. What is your view on that matter?

1084. Do we need someone to take the lead on the obesity strategy in Northern Ireland? We need to take the issue seriously and, through the media, get the message across to the public, who probably do not realise how serious the obesity problem has become.

1085. Mr Dougal: The first research from the States into obesity in children was published here in 2001 or 2002. Seven years have elapsed, and we have not advanced that much. A tsar is essential. Professor Roger Boyle, who is the heart tsar in England and who subsequently took the lead on stroke services, has been highly effective. Northern Ireland led the field in the development of stroke services and stroke units. However, after Roger was appointed to lead the stroke strategy, England overtook us. We need a personality and a focus to provide the leadership that has not existed in Northern Ireland. Roger Boyle and others in England have done a great deal to advance the battle against heart disease and stroke.

1086. My chairman, Professor Varma, and I are not keen on the idea of everybody over the age of 55 taking a tablet for blood pressure. Only people with elevated blood pressure should take such medication. I have heard Sir Richard Doll from Oxford talk about the polypill. I think that the idea of having such a pill has many flaws. Last week, an epidemiologist from Liverpool said that reducing the population’s cholesterol measurement by 1 mmol/l will save many lives. However, we still take the view that a population approach could benefit people hugely. People who are diagnosed with diseases need tablets, but the whole population should not be on tablets.

1087. Mr McCallister: You are all very welcome. The discussion has been interesting so far. The difference between the discussion on obesity and that on smoking is that there is no debate about the science or the lobby behind this argument. We need to prevent obesity rather than tackle it once it has happened. I listened to the discussion, and I agree that we need to consider how to plan communities and develop new towns and villages and the schools therein. For example, we must encourage more families to walk to school and to build that into their routine, and we should support the ongoing work in that field.

1088. Education through schools has been mentioned, and a joined-up approach should be taken to training our teachers. Supermarkets and others in the industry will respond more quickly to a market-led exercise when their customers start telling them what they want. We must get back to what we described previously as honest food; the issue is to know where the food is from and what is in it. There is a huge job of work to be done in promoting that agenda, because it is critical to address the inequalities that have been discussed.

1089. I have a background in the food industry, and I have visited some of the businesses concerned and have seen what goes into cheaper products. That is one of the key reasons for our having such health inequalities and a reason that people in certain communities will have their life expectancy reduced by 10 years or more. I agree with what you say, and your input into the inquiry will be invaluable in helping us to take the matter forward. I hope that the Public Health Agency will set about becoming a tsar-type figure and start to address the issues. How do you see that moving forward? Have you had any interaction with the new agency, or are you hoping to do so?

1090. Mr I Foster: It is early days for the Public Health Agency. We have taken a step forward from where we were previously, but the Health Promotion Agency should be able to learn lessons and learn from mistakes that have been made in the past and take the matter forward. The matter must be given more of a priority, and the agency should have a greater budget. We must also ensure that it has a closer connection with other parts of the Health Service, that is, the other bodies, commissioning groups and regional bodies. If that were to happen, there would be more communication and interplay. Hopefully, that will improve things. However, it is not the final answer, and it will not solve the problem. Additional things need to be done.

1091. The Public Health Agency was conceived and developed in the context of the wider review of public administration (RPA) for the Health Service. It was not constructed to solve the obesity crisis. It may be one useful mechanism to take us forward in that direction, but far more remains to be done across Government. Essentially, the issue is about budget; it is about other Departments signing up to a strategy and perhaps allocating some of their resources to see the benefits that becoming involved in such a strategy would bring and how their self-interest as an Education Department, a transport section or an Environment Department could be served. If they were to become involved, they may be able to tick some of the boxes of their target cultures and decide whether they could allocate money to the Department of Health, Social Services and Public Safety or to a new organisation that could take on some of the issues.

1092. It is a challenge, and a range of practical day-to-day things could be done. Education was mentioned, and I remember doing home economics when I was at school. However, my son has just left the education system, and he has no idea how to cook. His education did not include any of that. His concept of cooking is using a microwave. Perhaps I have failed as a parent in that regard, but, on a practical level, he does not know what honest food is.

1093. There are pros and cons with having a tsar to deal with the matter. Nevertheless, it should be explored.

1094. Ms Taylor: I am not able to say to what extent we are working with the Public Health Agency at the moment, but as I said, we would welcome working with any of the Government agencies. That is an effective way of working.

1095. To go back to the comment about honest food, it would be great if consumers were demanding that supermarkets supplied them with more healthy options. We want to know how informed the consumers’ choices are, what informs them, and how the marketing of junk food with its high fat, salt and sugar compares with the healthier options. We need to address the extent of the advertising of such food and level the playing field. At the moment, we cannot compete in the same way, and our messages are sometimes drowned out by those about the less-healthy options.

1096. Sport has been discussed, and I was glad that how we plan communities and make families active was mentioned. It is important to remember that overweight or obese children are much less likely to participate in sport and that we must encourage physical activity in our daily lives.

1097. Mr Dougal: We will be working with the Public Health Agency, and that work must be led by epidemiologists who are heavily involved in research on the matter. Our campaign to prevent heart disease began in 1984, which was a time when many thought that heart disease could not be prevented. That campaign was led by world-renowned epidemiologist Professor Alan Evans. Given that, the work of the new agency on obesity must be informed by epidemiologists’ research.

1098. Mrs Hanna: The seminar on Tuesday was excellent, and the point was made strongly that a lot of good research exists that must be used — in fact, a lot of time and money is spent on research. I made the point that a person or an organisation must take ownership of the situation or take a lead in dealing with it. I am not dying about the terms “tsar" or “commissioner". A lot is happening, but that work is not being brought together, and unless somebody is tasked with taking control, nothing will happen.

1099. The Committee has just taken evidence from the Food Standards Agency. I asked its representatives about the legislation, because it certainly modifies behaviour. Iain Foster mentioned — and I was aware of this — that even when we know what we should be eating, we do not eat it. That is true, and we must all put our hands up and admit to eating a chocolate bar when we know that we should not. However, there remains a deprivation gap for people who do not have enough money to make choices. Some of us can buy nice fruit or other food in Marks and Spencer, but others do not have those choices. There is also the fact that schools no longer teach home economics, and it is quicker and cheaper to buy carry-out burgers.

1100. Given that not enough is happening, we must adopt a carrot-and-stick approach that is more about the stick. Legislation must be used. Do all the witnesses agree that obesity is the number one priority and that it is almost like a time bomb? People often do not change their behaviour until they get a frightener — as people here say — and fall ill or are forced to change. The many statistics that are available indicate that obesity contributes to other illnesses, including heart disease, stroke and diabetes.

1101. People are dying younger. Unless we address obesity, we will be reminded of the awful idea that some parents will outlive their children. We do not want to overly frighten people, but warnings must be balanced.

1102. A great deal of support is necessary. We must lead, and the Committee and the Public Health Agency must take that lead. The agency was represented at the seminar on Tuesday, where it was accepted that dealing with obesity involved more than just the Department of Health, Social Services and Public Safety. It was acknowledged that the pieces must be picked up by the DHSSPS and that it is probable that someone from that Department will take the lead. However, I believe that the responsibility should rest with the Public Health Agency.

1103. A lot is happening, and some of that work was brought together at the seminar on Tuesday. The Committee has taken a lot of evidence, but it is now time for what may be called a brainstorm to move the process on. Some of what is done about tackling obesity must be based on what the Committee heard from the Food Standards Agency. Pressure must be put on food producers and manufacturers to do the right thing. That may not be possible immediately, but there should be a timescale for weaning us off fat and salt. Moral pressure must also be exerted, but it takes more than that to change people. At the same time, complications in European legislation must be teased out. I am merely thinking aloud about what must be done and what support and advice is needed to make progress on the situation.

1104. To return to my question, I would like to know whether we all agree that obesity, which feeds into all our other priorities such as diabetes, stroke, heart disease and cancer, is the number one priority. There can be no better time than now to take action, given that the Committee is in the middle of its inquiry. However, support and input from other people will also be required.

1105. Mr I Foster: In itself, the inquiry will create a lot of societal challenges. For example, what will happen to the inquiry’s findings? How will they be pursued? Will the ensuing report just be added to all the other documents that have been produced on the subject? I know that you are concerned about the number of commissions in Northern Ireland; we have had enough commissions and quangos, and we do not want any more. We need to see action, and that will depend on how the Government use the limited finance and influence that they have to the maximum benefit. They must be a bit more creative and not approach the matter in the same bureaucratic and inward-looking way that they have approached other matters in the past.

1106. Andrew Dougal 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. The challenge, therefore, is to determine how aspirations can be translated into actions by investing in programmes that might produce societal changes. However, we must be realistic and not set one- or two-year targets; we are talking about a 10- or 20-year process. As we have seen in the past, when the Government talk about a 10- or 20-year process, it can be code for saying that they do not need to worry about the matter at hand. The real test will be the shift in how the Government respond.

1107. Mr Dougal: We must act speedily. Research has been available for seven or eight years, we have the obesity prevention steering group, and the World Health Organisation has produced a report on the matter, as has the Department of Health in England. Let us get on and do things.

1108. We must also remember that although we have had success in preventing heart disease and stroke, that was achieved in the higher socio-economic groups. Therefore, although I agree with the total-population approach, 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. Many of those people feel that their lives are so awful that there is no point in changing their lifestyles. Therefore, we must get the message across that if those people quit smoking and change their diets, there can be benefits for them, such as avoiding coronary heart disease, strokes, cancers and diabetes. Those are the important points to make, and we must home in on those people and empower general practitioners and those who work in primary care to provide the support in the community that is necessary to allow those people to believe that the health that they enjoy and their lives can be improved greatly.

1109. The Deputy Chairperson: Thank you for coming along. Your evidence has been informative, and you made a number of points that we hope to look at more closely and incorporate into our response.

28 May 2009

Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Mrs Claire McGill
Ms Sue Ramsey

Witness:

Dr Una Lynch

Queen’s University Belfast

1110. The Deputy Chairperson (Mrs O’Neill): The witness for this evidence session is Dr Una Lynch from Queen’s University Belfast. By way of introduction, Dr Lynch is a qualified nurse, midwife and health visitor. Dr Lynch has an MSc in community health from Trinity College Dublin, and, in 2007, she graduated with a doctorate in governance from the School of Law at Queen’s University Belfast.

1111. Dr Lynch has worked in public health practice, and education policy and research, across the island of Ireland. In 2000, she was seconded to the World Health Organization (WHO) in Copenhagen to work on a ministerial conference on public health nursing. In 2005-06, a leading lights lecturers into industry award from Queen’s University enabled her to travel to Cuba to study the country’s health system.

1112. Dr Lynch, we are privileged to have you here today to talk to us as part of our inquiry into obesity. I invite you to make your presentation, after which members may have questions.

1113. Dr Una Lynch (Queen’s University Belfast): Good afternoon, and thank you very much for inviting me to address the Committee. The evidence that I will present this afternoon is based on my research of the Cuban health system. I spent four and a half months in Cuba researching the country’s health system.

1114. I welcome the leadership that has been shown by the Committee in holding an inquiry into the obesity epidemic, which is symptomatic of the deficits in the existing model of healthcare provision in Northern Ireland. The inquiry, therefore, provides an excellent opportunity to act as a vehicle to address those deficits and to create a health service that is truly fit for purpose. We have much to learn from the Cubans on that subject. Obesity is rapidly emerging as the main public health issue in Northern Ireland and throughout the developed world. However, the burden of obesity and its associated problems, such as diabetes and heart disease, are disproportionately borne by the poorer sectors of society.

1115. My paper and presentation stress the importance of primary healthcare, active citizenship and community participation in delivering effective public policy generally and in addressing the issue of obesity in particular. I am conscious that some — perhaps all — members of the Committee have not yet had the opportunity to visit Cuba. Therefore, I spoke to the Committee Clerk, and he kindly agreed that I could table a second paper, which is a pictorial guide to my presentation, and I will refer to that too.

1116. The first photograph is a typical image of Cuba: the seafront in Havana. The quotation that is superimposed on the photograph is from an extremely interesting character, Professor Francisco Ochoa. He was one of the first doctors to qualify after the triumph of the revolution in 1959. He qualified in the same year and has subsequently become one of the leaders in public health throughout Latin America. He is featured in ‘The Lancet’ and has won awards from the Pan American Health Organization. I felt that it was fitting to start with his reflection:

1117. I will leap now from the seafront in Havana to the House of Commons. A report of the House of Commons Health Committee on health inequalities was published in March 2009. It states:

“In 2006 a girl born in Kensington and Chelsea has a life expectancy of 87·8 years, more than ten years higher than Glasgow City, the area in the UK with the lowest figure (77·1 years)."

1118. The reality is more shocking, because Belfast Healthy Cities published a report in 2008, ‘Divided by Health: A City Profile’, which revealed that the life expectancy for boys born in west Belfast is 71 years, which is 17 years less than girls born in Kensington and Chelsea. That is a startling fact and reflects the inequalities among citizens in different parts of the UK. It is an indictment of our capacity to realise William Beveridge’s vision of the National Health Service.

1119. Cuba, I believe, provides us with inspiration and hope, and makes us realise that, with all the resources that we have at our disposal in Northern Ireland, we can do so much better. Cuba has a very poor economy. Despite its economic situation, however, Cuba has managed to achieve quantitative health indicators such as infant mortality and life expectancy that are comparable with all the high-income countries.

1120. The infant mortality rate in Cuba and in Northern Ireland is five: five babies in every 1,000 born live will die in their first year. We do not want any babies to die in the first year of life, but that is a reality. In the developing world — in Zambia, for example — for every 1,000 live births, 102 children will not see the end of their first year.

1121. Cuba has achieved those results despite a pitiful economy. It is spending 7% to 8% of its gross domestic product on healthcare, which is a similar proportion to the UK and Ireland. However, because of differences in economy, the UK is actually spending seven times as much, the Republic of Ireland eight times as much and the United States of America 18 times as much as Cuba on healthcare. Something interesting is going on in Cuba, and we can learn from that.

1122. Modern health systems are dominated by diagnosis and treatment of disease, with prevention and public health relegated to a back seat. That was highlighted in the 2008 World Health Report. Cuba, by placing primary care as a driver for its health system, has managed to turn that traditional paradigm on its head. Even Cuba’s most strident critics will admit that it does health very well. For Cubans, it is fair to say that health has become emblematic of the success of the revolution. Cuba makes that happen through a powerful Ministry of Public Health, which governs the entire health system.

1123. I will now return to the photographs in the ‘Hello!’ magazine-style guide presentation, as it were. I will focus on the second photograph, which is captioned “family doctor/family nurse". In 1984, the Cubans, having visited initiatives throughout the world and considered different health systems, were hugely impressed by the British model of general practice. That year, they decided that general practice was where it was at, and they were going to build a system around general practice and primary care.

1124. Twenty-five years later, they have established a system that supports primary care. They do not have the notion of primary and secondary care. They have a health system that is built around primary care, to which the family doctor and family nurse are crucial. They work and live in the communities and, depending on population density, work with between 1,000 and 3,000 people.

1125. The third photograph was taken in a family doctor’s practice, but it could have been taken at any practice in Cuba. If one walks off the street into any family doctor’s practice, one sees, in the waiting room, the needs analysis of the area, which shows the population profile, the age/sex distribution, the breakdown of conditions affecting that population and the uptake of vaccination and screening. Sometimes, the charts do not look pretty, because the resources at the practices’ disposal are not equivalent to ours; sometimes, they will be hand drawn, but they are all displayed in waiting areas.

1126. However, even more excitingly than that, the family doctor/family nurse practice is governed by a local health committee, which brings together representatives from all the key stakeholders, including the local women’s groups, and so forth. Every six months, they sit down and draw up an action plan — not a strategy or a glossy document. They examine the needs of the population, the environmental factors and the social issues to see how they can plan together. The beauty of that system is that it feeds up from that small level to municipal level and, finally, to national level, which has enabled the Cubans to develop a system that is constantly evolving.

1127. The next page contains three photographs of primary-school children in Cuba. In 1959, education and health were the two priorities for the new Government after the revolution. If one wants the public to participate, the public must be educated and have confidence. Confidence comes from education, and education is prioritised all through a Cuban’s lifespan. Primary-school, secondary-school and university education is free.

1128. I have included a photograph that has a relevance to obesity. The Cubans are interested in education not only from an academic point of view but in preparing children for life. At the beginning of each academic year, Cuban schoolchildren are measured, weighed and undergo a fitness assessment, which examines how far they can run and how high they can jump. That is then reassessed at the end of the year. The school is being measured not only on its academic performance but on how its children’s physical and fitness levels are progressing.

1129. The next selection of photographs show círculos de abuelos — grandparents’ circles. Health promotion, prevention and public health covers the lifespan of a Cuban, and it is not focused on children only. Anyone who visits Cuba and goes out early in the morning — from 8.00 am to 8.30 am — will see groups of older people doing gentle exercises in the parks and plazas. The lady in the photograph with her back to the camera has come from the equivalent of the Cuban sports council. Someone from that institution will visit those groups about two days a week to keep the group motivated and ensure that exercises are done properly and safely. Another photograph shows a lady standing side on: she is the peer leader. These are peer-led initiatives that are run by the community and taken by the community. Another lovely thing is the fact that, because the family doctors and nurses work locally in the community, they can drop into those sessions and chat with people. They may check blood pressure and blood sugar levels, and generally keep an eye on the population with whom they work so that health issues and contact with patients is not always carried out in a medicalised environment.

1130. I am stressing a focus on primary care, on needs analysis that enables people to target resources on those areas that are most needed, which realises the vision of equity, and on education, which enables the community to participate and be active players.

1131. I started with a quotation from an interview that I conducted with a Cuban, Professor Francisco Ochoa. I will end with another quotation, which is a challenge to all of us. My research question was about public health and why the Cubans are so successful. The quotation is from Professor Silvia Martínez, another highly esteemed medical doctor in Latin America. She challenged my question and said that a low infant mortality rate is not a success. The fiercest critics of Cuba are the Cubans themselves, because they are continually striving to do better. Bearing in mind the difference between girls born in Kensington and Chelsea and boys born in west Belfast, Professor Martínez said:

“To maintain the infant mortality rate is a social responsibility. Responsibility like Beveridge says: responsibility. A child of one year has a right to this. I imagine that there should not be anything lacking that will guarantee its protection: if you work for this you are fulfilling your duties, nothing more."

1132. The Deputy Chairperson: I enjoyed reading your paper and am interested to learn more. The paper clearly outlines the successes of the Cuban Government. We need to examine more closely the fact that, given the current economic climate in Cuba, it achieves better health outcomes than some developed countries. I particularly like the design of your submission and the concept of the umbrella, which shows how public health is the backbone of, and the dominant ministry in, Cuba and how it plays a key role in determining the work of all other Departments.

1133. Time and time again, the Committee has discussed the need for cross-sectoral working and how one Department should take the lead on the issue, provide information and filter it to other Departments. The new Public Health Agency was established last month. The Committee argued strongly for the establishment of that body, because we thought that it should play a key role in tackling public health, which might have been lost on a board that deals with general daily health needs.

1134. One of your recommendations mentions that the systematic needs assessment successfully underpins policies and strategies in Cuba and that its Government often consider that matter. The concept of placing information on the wall of doctors’ surgeries will probably alert people to the fact that they are more prone to, for example, heart disease because of the area in which they live. All those ideas are welcome. The challenge is how to gather information here and what to do with it. Do we do well here? Do we have effective needs analysis here? Have we gathered information, and do we use it properly?

1135. Dr Lynch: Thank you for your comments. I am glad that you have taken the paper’s contents on board; you have reflected the information accurately. I also hope that the Public Health Agency puts public health at the forefront.

1136. We collect information very well here, and we collect any amount of it: we have information overload. However, we share that information poorly, and we are incredibly bad at using information that we have collected from the population to consult with the community in order to decide priorities and responses. The Cuban system is sophisticated but, at the same time, simple. The Government make issues simple and accessible to the population in order to make them workable. They recognise that the local community understands best.

1137. Infrastructures are in place here, and the existing system does not need to be tweaked much. As a health visitor, I noticed a headline in the ‘The Guardian’ in 2004 — it may have passed members by — that described 1994 as the “year the tots grew out". A researcher from the University of Manchester, who was not from a health background, considered the health visitors’ percentile charts. Every health visitor who visits a family checks babies’ weight, height and head circumference. The researcher examined the composite information and concluded that three-year-olds started to show a trend towards obesity in 1994.

1138. I am unsure why we cannot share that information. Rather than collect information on individuals, we need to collect that information and, thereafter, consider real public health practice. Our system tends to focus on the individual, which is why debates tend to be around hospital beds; one person fits in one hospital bed. We must consider the issues in a community context. We need to create more life pictures.

1139. We have excellent resources. The Northern Ireland Statistics and Research Agency (NISRA) website proves that we have good access to resources. However, those resources are not filtered down. Every citizen has a right to know the risks of living in a particular area. For example, a person has a right to know that his or her life expectancy is 17 years less in a particular area. How can we change that situation and provide people with that information? People have a right to information. We tend to use language such as “service user engagement". We should change that type of phrase, because it suggests that a person uses a service rather than being part of that service.

1140. Cuba uses that information to ensure that the public feel part of the system. The public are creating the system; they are real stakeholders. In Cuba, they do not use the language of “stakeholders" or “user". They focus on citizens.

1141. We have the information, but it will take a change in mindset, which it is possible to achieve. It will take no additional money; it will be cost-effective if we just ensure that people living in areas are familiar with the situation.

1142. Mr Gardiner: Thank you very much, Dr Lynch, for the presentation and for the photographs that you provided. It immediately struck me that there are more females trying to keep fit than males. The men in the photographs are like beanpoles. Is there a reason for that?

1143. In Northern Ireland, we pride ourselves on the Health Service that we offer to our community and citizens. However, Cuba seems to be more active on obesity than we are. Can we pinpoint our problems? What should we put into action?

1144. Dr Lynch: The dominance of the women was not noticeable to me, but perhaps that is my bias. There is a very slim older man in the photograph. When that photograph was taken, there was an exercise wherein older people stand balanced on one foot in order to improve balance and co-ordination. The gentleman in question sat that one out. I thought that he was not putting in as much effort as the women, as it transpired that he was 95 years of age. It is very powerful to see this system in action, in which someone in his 90s is actively involved. It is still not too late to focus on prevention.

1145. Mr Gardiner: It speaks well.

1146. Dr Lynch: It does, but get down there to see it in action.

1147. In preparing for this session, I revisited some of the literature, and I commend to you an article by Sharon Friel, Mickey Chopra and David Satcher, “Unequal Weight: Equity Oriented Policy Responses to the Global Obesity Epidemic", in the ‘British Medical Journal’ in 2007. The authors highlight the fact that obesity is a multifactorial problem:

“Missing in most obesity prevention strategies is the recognition that obesity — and its unequal distribution — is the consequence of a complex system that is shaped by how society organises its affairs."

1148. That recognition is also missing in Northern Ireland. For example, I met some young parents in Sandy Row as I was on my way to Queen’s University from the Europa bus station. I asked them about parks and facilities. Down there, one often sees cars parked on both sides of the street and children out on little bicycles. The place is not really conducive to children’s play. The parents told me that the nearest park, which is not Botanic Gardens, is not a place in which parents want their children to play.

1149. If we are serious about a policy that is conducive to health in every sense, including to the prevention of obesity, we need to look at safe areas that enable children to be active and to play safely. It is not just about health; it is about linking up education so that people can make informed decisions. It is all very well having information printed, but people do not understand what is meant. Education, play facilities and transport are all interlinked. Every Department can assist with this.

1150. Mr Gardiner: In many schools, and particularly in primary schools, exercise is being introduced more and more, at least compared with the situation over the past 10 years.

1151. Dr Lynch: You are right. There was a policy that was working against that. Schools are playing their role, but children also spend a lot of time outside school. There is a move in many schools to open up their facilities, and that is very welcome. However, there is much to be said for creating safe spaces for children to ride their bicycles and to use roller skates and skateboards so that they can exercise more.

1152. Mr Gardiner: I agree that there is room for improvement, but you definitely practise what you preach.

1153. Dr Deeny: You are more than welcome, Una. I would love to go to Cuba to see how primary care works there. At long last, we are starting to see that health promotion and disease prevention are the way forward for a much healthier population. There is far too much short-sightedness in the Health Service here. We wait until someone gets a disease and then we treat it, but, if health promotion and disease prevention were taken on, we would save loads of money. As a GP, I am very interested in that. For well over 20 years, I have seen protocols and strategies, and I am fed up to the teeth with them. It is, as you said, information overload. It is good to hear about Cuba’s action plans.

1154. You mentioned that community involvement, through a local health committee or something similar, runs primary care in Cuba. How exactly does that happen?

1155. More and more healthcare provision is moving into the community. As healthcare professionals, our concern is whether we will have the financial and personnel resources to meet that challenge in the future. I hope that we will. Is primary care in Cuba provided with the finances and the personnel? It seems to be, so perhaps that is an easy question.

1156. My final question is the big one. How can the Department of Health, Social Services and Public Safety, and the Minister, be convinced that the future lies in focusing on primary care rather than in having a divide between primary and secondary care, which I have seen for years?

1157. Dr Lynch: I thought that those were all big questions. I am very happy for you to head to Cuba. I can set that up to be done cost-effectively. I could set up accommodation for you in the school of public health, and it would not cost much. The system in Cuba is an inspiration to anyone who works, or is interested, in public health, and it shows us that we can make a difference.

1158. I shall start by explaining the governance structures. The community health committee comprises the family doctor, the family nurse, representatives from the local schools, grocers, bakers, people who are responsible for transport, and so on, and local elected representatives. Every six months, the committee plots out its action. That health committee also has a governance role relating to what happens in the practice, and we also have lessons to learn from that.

1159. To give an example: I worked with a GP in Havana, and, towards the end of the placement, I took her out to lunch. She had been on holiday, so she should have been relaxed, but she seemed anxious. She told me that she was anxious because she had to appear before the health committee. A child from her patch with whom she had been working had been born at 36 weeks. By any stretch of the imagination, a birth at 36 weeks is not a big problem, but it is officially classified as being an early birth, and the baby is classified as having a low birth weight. The baby was absolutely fine, but it is standard practice that a health committee gets together to revisit the pregnancy to see whether anything could have been done during the pregnancy that had not been done and whether something could be learned from it. That was not done in a defensive way or as part of a blame culture but to ensure that it did not happen again.

1160. That is only one example of how the committee works. Everyone works together; it is not only the doctor’s responsibility but that of other people in the local community. People are employed at municipal level to oversee the functioning of those health committees and the taking forward of action plans.

1161. I shall give another example of how that needs analysis works and how it is responsive. The demographic challenge that Cuba faces is similar to ours in that we have exactly the same life expectancy, although Cuba has a slightly larger percentage of older people. The challenges are the same; as the population gets older, more people will have diabetes and heart disease. For that to be managed effectively, people need to be seen early and in primary care.

1162. The next stage up from the family doctor/family nurse is the polyclinic. Unlike our polyclinics, those in Cuba function 24 hours a day, seven days a week. They are serviced by GPs, who feed into it. I was in Cuba for three months, and, eight weeks after leaving, I came back for a further six weeks. In that space of time, the Cubans had been feeding their profiling data up to a national level.

1163. In Cuba, rates of car ownership are low, and older people face challenges using public transport. Consequently, they are unlikely to use public transport. Similarly, older people are more likely to need specialist medical services. Therefore, cardiologists are sent to the polyclinics. Depending on needs profiles in the area, cardiologists might be there for one to five days a week. The same arrangement applies to endocrinologists, and so on.

1164. Interestingly, in 1984, Cuban doctors did not want to work in primary care; it was not considered an exciting part of medicine. Today, primary care is where it is at, and all doctors want to get into it. It is not about money; in Cuba, people are not generally motivated by money, and doctors there are not offered financial incentives. Initially, the Cuban Government used access to housing to encourage doctors and nurses to work in primary care. Nowadays, family doctoring and nursing are recognised as the exciting areas of healthcare.

1165. Healthcare professionals in Cuba do not use the words “primary" or “secondary" care, and, if we wish to get rid of that split in the Health Service, we need to devise a system that concentrates exclusively on serving the public. It is irrelevant where care is delivered. It should be focused on the needs of the population. Therefore, your point is well made; we need to get rid of the division between primary and secondary care. It should not be about a competition for budgets and who gets what. Rather, it should be about how to best serve the needs of the population.

1166. With respect to resources —

1167. Dr Deeny: The Department and the Minister seem to be focusing on primary care.

1168. Dr Lynch: Everyone here on the hill depends on public support, but members of the public do not talk about primary or secondary care; they just know that the system is not working. If people were better informed about the burden of risk on certain communities, there might be greater accountability. As Fidel Castro said: “el maldito dinero" — that awful thing, money. Do not let money get in the way. We must decide where we want to go and what we want to achieve, and then work towards those goals. The difference between Cuba and here is that, having decided where we want to go, we tend not to get there for this, that or the other reason, whereas the Cubans decide where they need to go based on their citizens’ needs, and do what is necessary to get there. If we set clear goals, things will fall into place. It is not always about money.

1169. Mr McCallister: That was an excellent and interesting presentation, and I would be happy to join Kieran in Cuba.

1170. One of the striking, and alarming, facts to come out of your presentation is the 17-year difference in life expectancy between two parts of the country. I wish to tease out some of the points that you raised. The new Public Health Agency, which the Deputy Chairperson mentioned, provides an opportunity to focus on some of the points that you raised. Moreover, during the inquiry, we have come to realise that many of the things that need to be done do not involve rocket science; it is just a matter of doing much better in some of the areas that you highlighted, such as community planning.

1171. Kieran referred to local health committees, and it seems to me that we are getting stuck in our attempts to deliver services on the ground. Regardless of whether councils or the Assembly are responsible, we must remain focused on the agenda of decentralising care and delivering services locally. On average, how many people do local health committees serve? How local is local?

1172. Dr Lynch: I am delighted by the growing list of people who are going to visit Cuba, because they will be made very welcome. Cubans are the last people to blow about what they do; however, once people come to visit, they are open and generous in sharing information with them.

1173. The family doctors and family nurses work with populations of between 1,000 and 3,000, and there are local health committees at that level. The family doctor/family nurse practices feed into basic work groups, which bring together between 10 and 15 practices, and those feed into another group. It is a matter of acquiring information about the local population at a low enough level. We get caught up in whose responsibility it is rather than getting down to the grass roots and creating family practices and other facilities in housing estates.

1174. A great relationship and trust is established between patients and general practitioners and nurses. We have a very sophisticated system that involves district nurses, health visitors, midwives and social workers. Northern Ireland’s capacity for an integrated system is a strength that other parts of the UK have not had, and we can create something that feeds in at policy level. It is important that we start with the really vulnerable populations. There are already good models and initiatives such as the health action zones and Sure Start.

1175. I did a wonderful interview with Francisco Ochoa, and he said that the Cuban system has evolved, which is why, in my submission, I used the metaphor of a repaired umbrella that is continually evolving. There is a notion that it is difficult to make changes within socialism, but healthcare in Cuba has evolved. Francisco laughed and said that he had travelled the world and seen pilots, particularly in Europe, that have gone on for 20 years. We are good at initiating small-scale measures such as health action zones and Sure Start, but we need to take measures on a larger scale. If the political will is there, anything can happen.

1176. Mr Gallagher: Your very good presentation makes it clear that we can learn important lessons from the Cuban system. I am sure that you will agree that there are different circumstances in the two countries. Indeed, you talked about the disposition of the Cuban people and how they have a different lifestyle to people here. They are more relaxed and comfortable with themselves, which is probably a relevant factor. The climates are also very different; people in Cuba can spend many more hours outdoors in most seasons, and that helps them to have more active lifestyles.

1177. Given that Cuba is an island and the political circumstances in that part of the world, I assume that Cuba is fairly self-sufficient in food production. I am sure that the Cuban climate helps the growing of a great variety of fruit and vegetables. Can you comment on Cuban people’s diet and how it contributes to how long they live?

1178. Dr Lynch: One does not go down to Cuba for the food, because the food is terrible. Cubans eat lots of fried food. They have lived through difficult times, particularly with the collapse of eastern Europe in the 1990s. Cuba was isolated not only geographically but politically. It went through the same situation then as we are going through now.

1179. You made a point about fruit and vegetables. Cuba has a warm climate, but its location in the hurricane belt means that its production is challenged. The hurricane season is between May and November, and Cuba has developed great practices to manage that. It has been able to keep mortality rates low. In fact, its production of fruit and vegetable is not great.

1180. In his interview, Francesco Ochoa said that Cubans’ diet is appalling. There is a notion that they are never satisfied and that they continually want to do better. Cubans love pork — a bit like we love our bacon. Therefore, they consume a lot of pork and fried food. It is certainly true that they do not consume much processed food. However, their diet per se is not particularly good.

1181. Cubans take plenty of exercise, partly because of transport problems. However, the Government create interest in, and an appetite for, sport among children. Baseball is Cuba’s national passion, and anyone who is interested in sport likes baseball. Participation in sport is considered to be a citizen’s right, so entrance to baseball games is free. Compare that with rugby or GAA. In Cuba, entrance to games is a right, which encourages interest in sport.

1182. Participation in dance is also encouraged. It is not considered to be a pastime for elite children, and all children can take part in dance. For example, Cubans are encouraged to go along to the national theatre and attend the ballet. I paid around $40 to watch a performance. One US dollar is worth around 21 Cuban pesos. Cubans pay five pesos to watch the national ballet or to visit the theatre. Therefore, the culture promotes exercise from childhood onwards. It promotes dance as a form of exercise, and sport.

1183. The Cuban diet is not great, and the Government are working to improve it. Television programmes educate people about food and teach them how to cook. If you visit Cuba, it is not for the food.

1184. Mr Gallagher: Do Cubans eat largely home-produced food?

1185. Dr Lynch: They do, largely. However, much of their food, particularly chicken, is imported from the United States.

1186. Ms S Ramsey: I welcome Dr Lynch to the Committee. Her presentation was great. I have been to Cuba, and I agree that dance is one of the country’s major pastimes for people of all ages. No matter where you are in Cuba, you can turn around and see people dancing in the streets.

1187. Mr McCallister: Did you participate, Sue?

1188. Ms S Ramsey: I did indeed.

1189. A key lesson is that we should not be afraid to look at other countries and to learn from best practice elsewhere. The inquiry has meant that, although we are the Committee for Health, Social Services and Public Safety, we have been in touch with various Departments because we know that obesity is not only a health issue. That will be reflected in our recommendations. The health budget is a sizeable portion of the overall Budget. A key aim of the inquiry is to show that obesity is not always a health issue: it is also about prevention and exercise.

1190. I want to take a holistic approach to the issue and not simply focus on health. We operate in the context of the outworkings of the review of public administration, devolution and local Ministers, the majority of whom live, work and socialise in the constituencies that they represent; that is good. You mentioned the health action zones, and I have seen the positive work that they have done on specific issues. However, in certain constituencies, it is piecemeal. We must consider that issue.

1191. The Deputy Chairperson made a point about a specific needs analysis for the North and its health boards, which can be extended to the border counties and throughout the island. We must also consider that issue. I have used this example before: in some constituencies, there has been an increase in asthma. It is accepted that the planting of more trees can have a positive impact on reducing the instances of asthma. The Department for Social Development has planted trees in various constituencies to address that. Although asthma is a health issue, the Department for Social Development had the authority and the money to deal with it. It just takes small tweaks here and there.

1192. I agree with you about the Investing for Health strategy. Kieran Deeny made a valid point. I was a member of the Committee for Health, Social Services and Public Safety when the ‘Investing for Health’ report was brought forward by Bairbre de Brún. I agree with you that it was visionary. It was probably the first time that all the Departments got together with the Executive and considered investment in health. It was not just a health issue. Do you believe that other Departments still play their part in the Investing for Health strategy? Do you believe that, with the establishment of the Public Health Agency, public health and prevention will take centre stage or will it remain a poor cousin?

1193. Money has been mentioned a few times. Do you think that we need to overhaul the boards’ funding formula? We must get away from the piecemeal approach. Do you think that there is a need for the Department of Health, Social Services and Public Safety to overhaul it?

1194. Department of Education officials gave evidence some weeks ago, and we had two Departments fighting over which would fund after-school projects and breakfast clubs. It is all very well for the Executive, Ministers and Committees to be visionary, that mindset still prevails among civil servants. Their approach is one of “we can only go so far" and “it is not my responsibility" instead of a collective approach.

1195. Your presentation was top class, and I recommend going to Cuba to witness its healthcare system at first hand.

1196. Dr Lynch: It will be only when the Departments work together and have some joined-up thinking that a difference will be made.

1197. The Assembly is a fledging Administration, and we are only getting on our feet. I do not for a moment advocate that the current membership should still be here in 50 years, but the Cubans have had 50 years of continuous Government, and that shows that much can be achieved through joined-up thinking and working together.

1198. From 2002, devolution has been synonymous with public health. The new Public Health Agency is most welcome because it puts public health on the agenda. It is early days: some things could be tweaked and worked out, but I am optimistic about how it will work. Your example of tree planting is exactly the sort of thing that does not cost much in resources but is sustainable for the future. It is a simple act that, done today, prevents expenditure in the long term. It is not always about money. Unfortunately, in Northern Ireland, money is always at the front of health issues. Some healthy discussion would help. There is a debate about the number of MLAs, but the number of MLAs could be a real strength if we take on board the notion of MLAs sitting on local health committees. Those committees would be spread out across Northern Ireland, and MLAs would bring their voices right into Stormont.

1199. That would make a genuine connection from the grass roots to Stormont, and that is the link that is missing. We tend to talk in grandiose language and produce beautiful documents. Last night, I spoke to Dot Kirby, who is a former BBC Northern Ireland health correspondent. She said that one could always judge the importance of a report by the weight of the paper and the colour quality of the photographs. Perhaps there should be an embargo on coloured documents and strategies, and we could focus on actions and on what people see on the ground. We could save much money on that and spend it in small ways to make a difference.

1200. As for funding, healthcare is not necessarily about money. We all need to take a long hard look at ourselves and think about how we can do better with our resources. More money would be welcome and would mean that we could do an awful lot more, but we are already much wealthier in every sense: we have a highly educated country; we are a small country; we have a great environment. We have scope to do so much.

1201. There is a short-sighted notion that it takes the market to sort out the health system. I went to Cuba with that notion. We have an ageing population, and the risk of older people developing cataracts will increase. Cuba has the capacity to meet the needs of more than its own population. When I was in Cuba, an apartment block was being used to treat people who were flying in from Venezuela every day to the misíon milagro — the miracle mission — where cataracts are treated and people are given back their sight.

1202. People arrived from Venezuela, were taken by bus to the apartment block, went by escalator to the top floor and gave a blood sample. They then went back down and settled into their rooms. Later that day, they went back up and were seen by a general physician, an ophthalmologist and an anaesthetist. If they were deemed fit for surgery, off they went and had their cataract treated and returned to Venezuela a few days later.

1203. That is happening in a developing world country that is able to plan strategically by using information. We are closing hospitals here. Northern Ireland could be a centre for health tourism. We could sustain hospitals in rural areas and build up an infrastructure if there were a wee bit of imagination. We are bringing in teams from elsewhere to treat cataracts in Northern Ireland. Therefore, it is not always about money; it is about using what we have.

1204. Mrs Hanna: Good afternoon, Una. You are very welcome. We have a great opportunity through this obesity inquiry and the establishment of the new Public Health Agency. The timing is right to try to make a difference.

1205. I was fascinated to hear about a different culture, and we are all fascinated by Cuba. I have not been there, but I have read about it. It is interesting that, despite the fact that Cubans have far less money, they have equal or better health outcomes. You said that health workers are charged with looking after the health of others. You spoke about 24-hour clinics and specialists going to the people. We have had debates about that here, but we have not done anything about it. Equipment is often unused from 5.00 pm and over the weekends, yet we have long waiting lists.

1206. You talked about the Cuban diet and the fact that they do not use processed food. However, we are told that exercise really makes a difference. It is not that people are eating so much more but that we have sedentary lifestyles, and people are not burning calories.

1207. We do some positive things in the community. We plant trees, and we are considering more playgrounds and parks. Does Cuba experience antisocial behaviour as we do? If a tree is planted here, it almost needs a 6 ft wire fence with lights on the top to stop people from pulling it down. As for attitudes to health, we are inclined to depend more on the Health Service. We have all seen the “I need a prescription" and the “doctor, doctor" advertisements.

1208. How do we encourage or empower people to take more responsibility for their own health? Is the situation any different in Cuba? There is also the issue of tackling and challenging lifestyles — for example, smoking and drinking. I appreciate that there is a better chance of scoring hits with prevention and early intervention. However, it is harder to pick up the pieces, and, in the Health Service, we are inclined to pick up the pieces all the time. So much money goes on picking up the pieces that it is a vicious circle.

1209. We do not seem to be able to prevent or to intervene early because we spend so much time picking up the pieces. However, a start has been made with children, and Sure Start is an example of good practice. However, pilots can go on for ever. We do not evaluate pilots, and good pilots are not mainstreamed. It does not matter whether they are good, bad or indifferent. They are not judged on their merits, but some of them last and some of them are dropped, even if they are good. That is where we fall down. The culture should be about getting down to the grass roots to try to make a difference. There is a huge difference between the haves and the have-nots. That is an issue for the Committee. How do we encourage people and communities to take more responsibility and work with health professionals to consider their own health?

1210. Dr Lynch: That means that you are on the list to go to Cuba. If you go, you will see it in action. It is about rights and responsibilities. No matter where one goes in Cuba, one will see notices giving information about rights and responsibilities; it is double-edged. People can realise those responsibilities only if they are given education.

1211. You mentioned vandalism; I will quote another Latin American, Paolo Freire, whose work advocates practices similar to those in Cuba. His view is that people talk by their actions; actions are often more expressive than words. When people are destructive, it usually means that they do not feel included. People feel excluded and alienated from society. In Cuba, work is done to create that engagement and bring people in. In socialism, there is a strong notion about the pursuit of the perfect human being; socialism recognises that everyone is intrinsically good. In Cuba, all citizens are valued, whoever they are, and engagement is promoted. The work that is done with people with disabilities is amazing, and carers of people with a disability are prioritised.

1212. I will provide Committee members with a copy of a ‘British Medical Journal’ article that highlights the challenge of trying to address the obesity agenda when faced with market forces that promote processed foods that are empty of nutritional value but very high in calorific value. If one goes to Cuba, one can see the exchange. It is about citizens engaging with the health professionals. The health professionals do not have all the knowledge; we all have different pieces of knowledge, and we are in it together.

1213. Mrs Hanna: Are the differences between Northern Ireland and Cuba down to the ethos of socialism and the different culture?

1214. Dr Lynch: In Cuba, medicine and nursing are considered as vocations, and humility is valued; perhaps the greatest insult that one can give to Cubans is to call them ostentatious or arrogant. They pride themselves on humility.

1215. Mrs McGill: Thank you for your briefing, Dr Lynch. In your paper, you mention equity; it is written on the umbrella diagram. Is there equal access to all services throughout Cuba? I am from the west, and we have had several debates about the provision there. Tommy and Kieran will be aware of that. You also mentioned hospitals in rural communities. I will not go over all the argument again, but I am interested in whether there is equal access to services in Cuba. Although Cuba focuses on primary care, that clearly is not the case here, and we rely not so much on prevention as on dealing with problems when they arise.

1216. In the area that I represent, for example, the out-of-hours provision is changing, and we are concerned about that. That service will move from Strabane — a small rural town — to Derry. People feel that the services there have been reduced. I am not clear, Dr Lynch, about how that can be addressed.

1217. It was interesting to hear that the Cuban diet relies so heavily on fried foods and contains little fresh fruit and vegetables. As for exercise, if we had Cuban weather, people might be more encouraged to go out and exercise in the morning, and so on.

1218. At the start of your presentation, you used the word “epidemic" when referring to obesity. If the health system in Cuba were transposed here, would it end the obesity epidemic?

1219. Dr Lynch: The Cubans would be the first to say that their health system is particular to Cuba. The health system that evolves in each country is reflective of its context, and Cuba has a particular political context and structures. One could not simply take the Cuban model exactly as it is and bring it into Northern Ireland. However, key elements of that model, such as the focus on primary care, equity, needs assessment and community participation, could be central to our system. The health system in Cuba has evolved over 50 years. It would, therefore, be difficult simply to introduce it here.

1220. Mrs McGill: As far as the Committee’s inquiry into obesity is concerned, is Cuba, therefore, not a particularly good example of what can be done to address the problem?

1221. Dr Lynch: It is in a sense, and that brings me on to the second part of my answer. Cuba has managed to create its current health system because it has a strong political will to ensure and safeguard the health of the population. It has a Ministry of Public Health that is not one of the lowly Ministries. It is a powerful Ministry that influences the action of the Ministries of employment, economy, foreign affairs, and so forth. Everything is influenced by the Ministry of Public Health. It does not merely receive the crumbs from the table but influences the actions of every other Ministry. That is crucial. If we are serious about public health, it is not simply a matter of improving the health system; it involves all the wider social determinants of health.

1222. In answer to your question about the situation in the west, I may come across as a real fan of Cuba. However, before travelling there, I was suspicious of the socialist ethos and wondered whether I would be shown only the best aspects of the health system. I spent some time in Havana before travelling around the country. We know about Guantanamo because of the military base there, but it is a huge province in Cuba. It is the country’s most rural and isolated province, and I was curious about how well the health system worked there. It all worked well in Havana, but how would it work out in the sticks?

1223. It was simply amazing to see a family doctor/family nurse practice that was exactly the same as one in Havana, even down to the paint. The shortages in Cuba mean that the same green/blue paint is used on walls everywhere. The practices with GPs and nurses are exactly the same; all have health profiles on the wall.

1224. I interviewed the director of public health in Guantanamo, because it blew my mind how a country with the resources of Cuba was able to achieve that parity. I asked him about clinical governance, because we argue about doctors having to see a certain number of cases to remain clinically competent, and so forth. I asked him how he ensured the clinical competence of practitioners. I wish that I had brought a video camera at that point, because he looked at me as though I had two heads. That is when I realised that our system is focused on profit and the market.

1225. He told me that the citizens in Guantanamo have the same rights as the citizens in Havana and other parts of Cuba. Therefore, the surgeon or doctor must, of course, be competent, so their duties were rotated to ensure that they retained their level of competency. Geographically, Cuba is a much bigger country than ours, but there are ways in which systems can be put in place to ensure that the citizens, irrespective of where they live, are not subject to bias.

1226. The Cuban example is a challenge. They do not look two or three years ahead; they have a vision for five, 10, 15 or 20 years into the future. The Cubans argue that to close down a service in a certain area and to remove its capacity and infrastructure will result in an urban migratory shift, which itself creates problems and depletes capacity. Consequently, there is a bias towards an ageing population and other related factors. The Cubans take a holistic view; it is difficult to do it justice in an hour’s discussion. I recommend that the Committee go to Cuba and see the system upfront, because it challenges the notion that there is only one way to do something.

1227. The Deputy Chairperson: I take your point about rotating doctors in order to maintain their competences. Trusts have had to close hospitals in rural areas because the doctors say that they cannot maintain and update their skills. The simple answer to that would be to rotate them among the other hospitals in the trust area. That seems like the logical thing to do, even at GP level.

1228. Dr Lynch: It goes back to the mindset of what the system is there for. Is its purpose to protect public health, or is it to make life comfortable for the people who work in it? If we mean to put citizens’ public health first, we must create systems that support that. The solutions can be found if there is a political will to make something happen.

1229. The Cuban people make incredible demands on their health service and have huge expectations. The Cuban Government are very pragmatic; when we asked them why they set certain priorities, they told us that, if they did not do things in a certain way, they would lose the support of the people, and the revolution would not continue. It is all about political will.

1230. Mrs Hanna: Are you saying that we need a Castro? [Laughter.]

1231. The Deputy Chairperson: That concludes our questions. Thank you for coming along; it has been a very interesting presentation, and it will help our inquiry.

11 June 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
Mrs Carmel Hanna
Mr John McCallister

Witness:

Mr Michael Bell

Northern Ireland Food and Drink Association

1232. The Deputy Chairperson (Mrs O’Neill): Our first evidence session is with the Northern Ireland Food and Drink Association. Members have copies of the submissions from the Food Standards Agency, Safefood, the Food and Drink Association, as well as a briefing paper from the Assembly Research Services. I welcome Michael Bell, the executive director of the Northern Ireland Food and Drink Association. He will give a brief presentation, after which members can put questions to him.

1233. Mr Michael Bell (Northern Ireland Food and Drink Association): I will start by telling the Committee who I am and why I am here. I have been involved in the local food and drink industry for 25 years. I was involved in manufacturing for 12 years and have been representing the industry for some 14 years. I am also a chartered food scientist. After putting Northern Ireland food and drink into context, I will address the questions posed by the Committee.

1234. How important is Northern Ireland food and drink to Northern Ireland? It is the biggest industry, bar none. In 2007, our turnover was £2,724 million — that is, £2·7 billion. We employ 18,400 people directly, a further 25,000 farmers depend on manufacturing, and 10,000 people work in haulage, hygiene, cold storage and other services. Some 20,000 people work in food retailing in the Province. In total, approximately 80,000 jobs are dependent on the agrifood sector in Northern Ireland, making it far and away the biggest part of the economy. Of the £2·7 billion turnover, 65% is exported, of which 41% goes to GB and the rest to the Republic of Ireland or the EU.

1235. That is the good news. The not-so-good news is that the industry’s profit margin is, at 2·8%, very low. I am happy to give the Committee copies of the statistics. All the statistics that I quote come from the Department of Agriculture and Rural Development, and they can be accessed from its website.

1236. To underline the importance of the industry, 19% of total manufacturing sales in Northern Ireland come from food and drink. It accounts for 15·8% of external sales and approximately 24% of all manufacturing employment. One of my member companies employs more people than Shorts. It tends to be overlooked because it has always been there as a background industry. However, I want to stress that it is extremely significant. The industry is a big supplier to GB.

1237. What is the role of the Northern Ireland Food and Drink Association in the industry? Our vision is of a sustainable, strong, growing cluster of local quality food and drink enterprises. The association will build an internationally competitive industry that will create wealth for our society stakeholders.

1238. If I have read the Committee material correctly, the obesity agenda is the focus for today, and the association engages with that agenda in several ways. 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. However, the association is active at the local food service channel through its subsidiary company, Taste of Ulster; I brought some materials for the Committee on that.

1239. Members of the FSA and I sit on a food subgroup of the Department of Health, Social Services and Public Safety. The subgroup is preparing a paper on obesity for the Minister, and that is due in early 2010. Our members are also engaged in the reformulation of products in an attempt to reduce sugar, fat and salt as per FSA and Westminster guidelines.

1240. However, having said that the association is engaged in those activities, I must make one or two things clear. No one has more of a vested interest in healthy, happy consumers who live for a long time and eat many of our members’ products than the Northern Ireland Food and Drink Association. The Government appear to have missed that point, so we have been consistently making it to them. There are no bigger stakeholders in this matter than our members and our industry. Without healthy consumers, we would have no industry.

1241. The complexity of the issue is worth mentioning. There is a shared responsibility for the obesity agenda, which is complex and multifaceted, and a co-ordinated approach is required to prevent and address the problem effectively. Responsibility for addressing the problem must be shared by Government, sectors, professions, communities and individuals, and, in order to get anywhere, we need integration and harmonisation among those stakeholders. Furthermore, a commitment to taking action based on evidence rather than opinion is vital in making progress.

1242. My final two points are important. First, in light of the economic position in which we find ourselves, work on the obesity agenda must achieve the maximum impact and outcomes for the minimum cost; we must achieve value for money. Secondly, local needs must be addressed.

1243. I was struck by a statement from our colleagues in the Scottish Parliament, in which a Minister said that, although Scotland produces some of the best food and drink in the world, it has the worst diet and health. I do not agree with the first part of that comment, but I am struck by the fact that the Government there are trying to address both matters simultaneously.

1244. I have more material that should be useful to the Committee, so, if you are happy, I will download some of it for you. I am happy to answer questions.

1245. Sir Liam Donaldson, the Department of Health’s Chief Medical Officer, stated that the core issue is that only 6% of people understand the risks of being overweight. Obesity is seen as a vanity rather than a health issue, and we must change that mindset.

1246. In late 2008, the Cabinet Office, to which the association gave evidence, published a paper on the food industry, ‘Food Matters: Towards a Strategy for the 21st Century’, which states:

“The Government’s vision for the food system is one that is more sustainable — economically, socially and environmentally. The future strategic policy objectives for food should be to secure: fair prices, choice, access to food and food security through open and competitive markets; continuous improvement in the safety of food; a further transition to healthier diets; and a more environmentally sustainable food chain."

1247. Our industry believes that Northern Ireland is uniquely situated to make great strides on the environmental agenda and, indeed, on the health agenda. However, we need commitment from the Assembly.

1248. There is a presumption that much of the obesity agenda can be addressed by the food and drink industry in isolation from other stakeholders. That ignores the energy output agenda. To illustrate the energy output agenda, I will quote some statistics from ‘The Times’:

“On average British children spend five hours and 18 minutes watching television, playing computer games or online each day. The total of 2,000 hours a year compares with 900 hours in class and 1,270 hours with their parents."

1249. The elephant in the room is that children are becoming incredibly sedentary. I am happy to pause there. As I said, I have a significant amount of material on which to draw.

1250. The Deputy Chairperson: Thank you, Michael. I neglected to apologise at the start of the meeting for having to rearrange your visit to the Committee; you were due to come along three weeks ago.

1251. I will pick up on a few points. You said that the association’s members are actively engaged in the labelling system, whether traffic light or GDA levels. Are all your members involved in that?

1252. Mr Bell: To answer that question, it must be understood how food is distributed from our members to the public. Approximately 60% of the food goes through food retail — that is, the shops that we all use. An estimated 40% is distributed through food service — restaurants — which do not have a point-of-sale, nutritional-labelling system. Therefore, 40% of the food distributed by our members through that channel is not labelled, because the portion size is beyond the manufacturers’ control. It is supplied to a restaurant as an intermediate and is portioned as that establishment sees fit.

1253. In respect of food retail, the answer varies. Manufacturers may sell goods bearing their own label, in which case they have complete control of labelling, and, as required by law, that virtually always carries nutritional information. Beyond that, those manufacturers are moving towards GDA or FSA-style labelling. However, a significant proportion is sold as retailer-own product by major supermarkets under their own label. In that case, the supermarkets, not the manufacturers, control how the labelling is presented. I hope that that is clear.

1254. The Deputy Chairperson: Yes, that is fair enough.

1255. Mr Bell: There are different channels. My members can control some matters, but there are quite a few that they cannot.

1256. The Deputy Chairperson: You stated that the public presumed that obesity can be tackled by the food and drink industry alone. The Committee recognised early in the inquiry that that is not the case and that tackling obesity is also about people becoming active. The relationship between consuming too many calories and weight gain is accepted, but there is less recognition of the link between alcohol intake and calories. Is the drinks industry doing anything to raise awareness of that issue?

1257. Mr Bell: I cannot represent the drinks industry per se. My association does not have alcoholic drinks firms as members; they are represented by a separate organisation. However, I can comment that alcohol is a significant calorific contributor in, and rising component of, the diet. In response to the FSA draft plan that is out to consultation, my association has stated that it is illogical for the FSA to discuss sugar, fat, salt and calories but make no mention whatsoever of alcohol or of fibre, which remains critical to the debate because fibre has a dramatic affect on how much sugar, fat and salt is absorbed and retained.

1258. Mr McCallister: I register an interest. I am a shareholder in a milk-processing company, which may be a member of the Northern Ireland Food and Drink Association.

1259. Some of the evidence that the Committee has received suggests that calorie intake has not increased dramatically over the past 20 years in comparison with weight gain in the population. Therefore, the Committee accepts that a sedentary lifestyle plays a key role in obesity, which leaves just about everybody with a part to play. Evidence suggests that the FSA tends to target sugars, fats and salt for food labelling. Although it is fine to reduce those ingredients in some products, how can people be encouraged to eat a balanced diet, bearing in mind that we need a certain amount of everything for a balanced diet? Does the food industry have a problem with the FSA’s approach to food, especially to salt?

1260. Mr Bell: The science of nutrition is young and evolving. In my working life, nutritional messages have been stated, withdrawn a few years later and a different position adopted. That has turned the public off new nutritional messages.

1261. The FSA and the Government are committed to their 6 g a day of salt. As a scientist, however, it is wrong to say that 6 g of salt a day is the right amount for everyone. Body mass, diet and metabolism rate all have an effect, as does whether one burns 2,000 calories or 4,000 calories a day. However, the message that society in general needs to reduce its salt intake is correct, and the Government chose to use that mechanic to address the issue.

1262. The problem that association members and I have is best illustrated by a specific incident. In 1987, when I was technical director of a large and well-known Belfast bakery that has since ceased trading — the brand name lives on, so I will not name it — we were asked by the Government, in the original Committee on the Medical Aspects of Food and Nutrition Policy (COMA) report, to reduce salt in the product. The industry dropped salt from 2·2% to approximately 1·8% in finished products, and sales immediately nosedived.

1263. At the same time, the Government were telling people to eat more bread, particularly wholemeal bread to increase fibre intake. Salt plays a major part in making wholemeal bread palatable, because it is quite insipid without salt. As a result of sales nosediving, the industry returned to the previous salt levels.

1264. Furthermore, trying to adjust the formulation of individual products, apart from the accusation of nannyism from the state, flies in the face of what our European colleagues are doing. Every chef in the land will talk about Parma ham or prosciutto, and hold them up as super-products and include them in their dishes. They contain more than 4% salt, which is twice as salty as any product in our market. Therefore, we are not standing back and considering balanced diet and exercise. Instead, we are focusing on reformulating all the food in the supermarkets and thinking that that will address the issue. It might, but probably not in my lifetime.

1265. Evidence for that comes from what has been learned about smoking. I do not know whether there are any smokers in the room who read what is printed on cigarette packets — before they are taken out of public view in shops, which is the next Government proposal. To print on a product, in huge black letters, that it will kill you had minimal effect on particular social groups. In fact, consumption is still increasing. That tells me that the public are beginning to become immune to messages, and the principle that the public’s behaviour will be changed by putting ever more information on the product is flawed.

1266. Mr McCallister: We want to give people the message that their diet should be balanced and contain a little bit of everything. Someone who eats a lot of Parma ham would have an enormous salt intake, but no one would suggest that a diet should consist entirely of Parma ham. I sometimes worry that, if the FSA targets one aspect of the diet, it might get a result for the overall population but not the desired balance.

1267. Mr Bell: The association expressed its concerns about that to the FSA. I encourage the Committee to read the London Department of Health’s short paper, ‘Economic Costs of Obesity and the Case for Government Intervention’. In that article, Barry McCormick logically argues that emphasis needs to be put on children. Once poor eating patterns have been learned, they are extremely difficult to correct. It is difficult to correct the poor life skills education that some youngsters have received. My 25-year-old niece now has perfect teeth because she was encouraged to eat more fruit and vegetables and screened from having too much sugar.

1268. Mr Easton: I agree with your suggestion that an overall approach should be taken. My stepdaughter spends all her time on a computer, which does my head in. She goes out with her friends but does not do any exercise, and that is probably not good for her longer-term health. You mentioned the effect that alcohol can have on weight, which I had not thought about. Indeed, it might be helpful if we got more information about how alcohol affects weight.

1269. Many people are so set in their ways that they may be incapable of changing their diets. I have been honest enough to say that, although I know about the traffic-light system, I go into the supermarket and buy anything that looks good. I am lucky that I am skinny, but one does not know what is going on inside the body; a heart attack, for example, may be just down the road.

1270. We talk about a multi-agency and multifaceted approach, but I get the impression that people will not listen unless they are forced to cut down on the fat, sugar and salt in their diets. Regardless of the traffic-light system, the majority of people will buy a product unless there has been a major health scare about it. We have an awful lot of work to do to change attitudes. I do not know how we will to do that, because we have given so many different messages.

1271. You mentioned that there was a reduction in the sale of bread that had been made healthier. Would serious cuts in the amounts of fat, sugar and salt in foods have drastic effects on food companies, leading to job losses, and so on?

1272. Mr Bell: I am afraid that the answer to that question is very complex. I represent about 140 companies that produce a combined total of some 2,000 products. Every one of those products is different and has a different level of sugar, fat, salt, some that is added and some that is not added. For example, butter is 80% fat, and spring water is 0% fat. However, water is toxic in overdose. Last year, a radio station in California ran a competition entitled “hold your wee for a Wii". A lady died after drinking five gallons of water in an attempt to win a Nintendo Wii.

1273. Everything is toxic if taken to an extreme. The central theme is balance. 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.

1274. A behavioural pattern in Northern Ireland that amazes me is that people season food with salt and pepper before they taste it. I have observed that everywhere. Many carry-out and restaurant meals have a sugar, fat and salt loading that is worse than anything from a supermarket.

1275. I am sorry that that has not answered your question directly, but it would take a long time to unpack the issue because it would involve examining the issue sector by sector. The recession has had a significant effect on food-purchasing patterns and consumer behaviour. Although the overall turnover in the industry is significantly recession-proof, I will give one statistic to illustrate the point. Butter sales, year on year, have risen by 15%; for a while, the industry scratched its head and wondered why butter sales would increase during a recession. The answer is that people are making their own sandwiches at home. People who make their own sandwiches invariably use more butter than is used in commercially made sandwiches, which have a nutritional declaration that manufacturers are committed to meet and not exceed.

1276. Dr Deeny: You mentioned schools earlier; does your association have any input in schools? It is important not only to have input and output exercises but to have an input into what schoolchildren eat and drink — soft drinks, for example. A few years ago, I had an issue with my kids because they were drinking Coke until it was coming out their ears.

1277. Does your association have a responsibility to draw the dangers of some of those foods to people’s attention, or do you represent only the businesses that produce them? I hope that I have picked you up incorrectly, but it concerns me that you mentioned the advertising of cigarettes and said that, although there are warnings on the packets, they are more or less dismissed. That is not grounds for saying that warnings should not be given. Advertising has a powerful influence on what people eat. Does your association not have a responsibility to ensure that advertising is responsible and informative?

1278. Mr Bell: The answer to your last question is yes. Advertising by local food and drink manufacturers is relatively low-key and small-scale. That goes with the size of the industry. You are probably referring to major multinational companies with significant advertising capacity. Those multinationals can speak for themselves, and there are such companies based in the Province. It is laudable that soft drinks companies associate their products with calorie burn, as are the resources that they have put into promoting calorie burn and balanced diets.

1279. 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.

1280. The obesity epidemic affecting the next generation will be won and lost in schools. It is an epidemic, and some of the worst statistics in the world come from these islands. I am struck by an experiment on snacking that a Welsh set of schools has been conducting for over 20 years. Fruit, vegetables and water were provided to a set of schools, and the subjects were tracked into their early adult life. The results showed a significant difference between them and a controlled population. That provides strong evidence that more intervention must be made at school level.

1281. Dr Deeny: Where does your organisation stand on the point that someone must keep a hold on businesses that are in the food industry only to make money? John referred to foods that have very high levels of saturated fats, salt and sugar. Someone must hold the industry to account so that the place is not coming down with foods that kids and adults see advertised on television and which will, in the long term, affect their health.

1282. Mr Bell: The paper to which I referred earlier mentions products that have a downside. That applies to almost everything that contains alcohol. If any product that is sold in an off-licence is taken to excess, it will take a male past the recommended maximum of 21 units of alcohol in a week. Alcohol has a significant downside, and it could have a further downside because it could lead to health problems, antisocial behaviour, and so on. The same argument can be made on tobacco. The sale of tobacco brings an economic advantage to the Government, and there is a list of downsides to it. The view has been taken that the downsides outweigh the upsides.

1283. The consumer’s right to choose food must be preserved, because very few products can definitively be said to be damaging. I have been challenged previously by people who have said that our members produce food that is unhealthy or bad. Not one of our members produces a bad food product. There are bad diets and bad consumption patterns, where people eat a particular product to excess, and it is not part of a balanced diet, but our members can provide only the information and the best-quality product possible. The dairy sector, for example, is a significant and high-quality industry, but to eat nothing but butter as a significant part of one’s diet for a significant amount of time would be damaging.

1284. The Deputy Chairperson: That brings the session to a close. Michael, I thank you for attending; it has been very helpful to the Committee.

1285. Mr Bell: Thank you. I shall leave some books for members, and I hope that you will visit some of the local Taste of Ulster establishments and sample the local food.

11 June 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
Mrs Carmel Hanna
Mr John McCallister

Witnesses:

Ms Jill Fitzgerald
Ms Louise Warde Hunter
Mr Alan McMullan

Department of Education

1286. The Deputy Chairperson (Mrs O’Neill): I welcome Louise Warde Hunter, Alan McMullan and Jill Fitzgerald, of the Department of Education, to the Health Committee. I invite you to make a presentation; the members may have some questions afterwards.

1287. Ms Louise Warde Hunter (Department of Education): There is much that I would like to say, but I appreciate that the Committee is short of time. Would a 15-minute presentation be reasonable?

1288. The Deputy Chairperson: We allow up to an hour for each evidence session; that includes your presentation and members’ questions.

1289. Ms Warde Hunter: Let me know if I am too long-winded on any area, so that I can move on to another. I want to do it in whatever way suits you best.

1290. Thank you for asking us to give evidence as part of your inquiry into obesity. We share the Committee’s concern at the rise of obesity and especially childhood obesity, which is the main locus of the Department of Education. The Department welcomes the inquiry and we hope that we can play our part in the shared drive to stop and ultimately reverse the trend. Alan McMullan is a former policy leader on school meals and the school food policy, which will be launched in September. Jill Fitzgerald is health and physical well-being co-ordinator for the Department. My background is early years, and I am new to this area. Forgive me if I read from my script.

1291. We understand that health-related policies span the whole of the Department, from what is taught in school to the design of schools, from school-based weighting and the measuring of programmes to the medical needs of individual children. We have a good broad knowledge of policies that contribute to obesity prevention. We will do our best to answer your questions. If there are questions that, between the three of us, we cannot tackle, we will take that away and give you formal written replies.

1292. You have seen the supplementary paper that was issued lately and which summarised the Department of Education’s vision and priorities. I want to make the connections between what we are trying to do and obesity.

1293. The Department of Education’s vision is to ensure that every learner fulfils his or her potential at each stage of development. In order to help us achieve that, our emphasis must be on learning and providing the highest quality of education for every child in a way that helps them transcend the barriers that they might experience in life. We are trying to raise standards for all and close the gap between the highest and the lowest attainments. However, there are also other important areas: how we develop the education workforce, improve the learning environment and transform education administration. Over the next 10 minutes, I will try to demonstrate to the Committee how all those points are linked to health and well-being and, in particular, to the issue of young people and obesity.

1294. Basic skills such as literacy and numeracy are essential to good physical and mental health. Last year, 47% of young people did not achieve a grade C or above in English and maths, and therefore our focus on raising standards is clearly important. In the revised curriculum, young people are not considered solely with reference to the qualifications that they acquire at age 16 or 18; we think of their holistic needs. They must be equipped to play their part in society, to be economically active and to participate as citizens. We must also equip them with an understanding of how to make healthy choices and adopt healthy lifestyles. We do that in the curriculum primarily, though not exclusively, through personal development. That includes making physical education compulsory until age 16 and home economics compulsory until age 14 for all students — that includes boys and boys’ schools.

1295. We recognise that the gap between the highest and lowest attainment of qualifications is even greater among socially disadvantaged pupils. I am sure that the Committee is familiar with that; I will not rehearse that. We know that low attainment can have an effect not only on young people’s employment or further education prospects, but on their future health and that of any family that they might have. We want to demonstrate that we are not just in the business of equipping young people to get qualifications, but equipping them in a much broader educational sense for all the issues that they will face in life.

1296. I want to highlight the extended-schools programme. It has a number of key aims around reducing underachievement and improving the life chances of children and young people from disadvantaged communities in tandem with the concept of fostering health, well-being and social inclusion. The extended-schools programme plays a significant role in promoting healthy lifestyles. Last year, approximately 700 extended-schools programmes were run in 450 schools in Northern Ireland, linked to the healthy lifestyles concept through breakfast clubs, after-school schemes and youth sport and leisure activities.

1297. We also work on pupils’ emotional health and well-being. Nowadays we talk more and more about resilience. Young people who experience poor emotional well-being, for whatever reason, and who have not developed the ability to deal with life’s challenges, cannot possibly fulfil their learning potential. To support that, we have introduced counselling in post-primary schools as a priority. We know that in times of stress, some people react by overeating. For many young people, that can spiral into eating disorders. Emotional well-being is fundamentally connected to physical well-being, and overeating is one issue that we can begin to address through school counselling.

1298. The education workforce is vital to securing and improving the education outcomes that young people need. It is about having the right people on the ground to address the issues that are pertinent to the Committee’s inquiry. The Department’s curriculum advice and support service provides physical literacy co-ordinators to the education and library boards as well as running programmes such as curriculum support in primary schools. All those programmes require professionals to understand and be equipped for delivery in schools. That is connected to what we need our teachers to do and how we need to relate to other school staff.

1299. We recognise that the review of public administration has identified the need for radical reform of education. Rather like the health sector, we have tried to reshape the Department of Education to place greater emphasis on policy formulation, the strategy for the management of education, monitoring of workforces and systems, and performance. We must look at how we are using public money in a way that supports our key stakeholders — children and young people, and their parents.

1300. In our written submission we have given details of a full programme of work by the Department that is specifically about obesity prevention. I would not dream of teaching my granny how to suck eggs but, as we know, it is about the imbalance between energy in and energy out, which results in undesirable weight gain among young people. There are two areas that I want to concentrate on. The first is about “energy in", which is to do with food in schools, and the second is about “energy out", which deals with physical activity.

1301. The Department’s most recent work on food in schools began in 2000. Rather than give members chapter and verse in a laborious way, I will say that the process has evolved through testing the development of a policy and consulting on it, working with nutritionists on healthier menus for school canteens, and working with dietitians. We started off in 2000 and had a public consultation throughout 2001-02. At that point we recognised that we were not turning a small skiff around — it was more like turning a tanker around — and that a more evolutionary and gradual approach to the issue would work best. That has been borne out by the experience across the water, where, post-Jamie Oliver, the snap decision on school menus meant that there was a huge fall-off in the numbers of pupils taking school meals. The revolution meant that young people were not taking as many school meals, and we had the spectacle of the tabloids reporting on mothers feeding their kids burgers through the school gates. That is not what we want to see happening in Northern Ireland. In a way, that is a justification of the more evolutionary approach that we have taken.

1302. Following that consultation, the Department of Education decided to publish nutritional standards in a booklet entitled ‘Catering for Healthier Lifestyles’. The Department also engaged with its partner bodies — the education and library boards and the Health Promotion Agency and Food Standards Agency — on a pilot project that aimed to implement the sorts of standards that had been developed.

1303. In 2004, around 100 schools were identified to pilot the new nutritional standards. That pilot lasted for a year. It was designed to establish pupils’ attitudes to change and how to manage the change across the remaining 1,150 schools. The idea was to test out the new standards. The pilot was fairly successful. The majority of schools and pupils responded very positively, and a number of key conclusions were drawn. The drop-off in the uptake of meals at a time of change was a feature that was noted even then. It was also noted that pupils began to return to the meals service in schools as time passed. The numbers began to rise, though not to the original level. If it was not “chips with everything", then young people were clearly voting with their feet and perhaps identifying other ways. Other features were that pupils did not like oily fish and certain types of vegetable were not popular. However, from the pilot, the Department and its partner bodies were able to develop a strategy that gave pupils time to become accustomed to new menus in an incremental approach.

1304. Interim standards were introduced to remove less healthy food from menus in a series of stages; to adopt preparation and cooking methods, such as puréeing, that disguised certain vegetables — as a parent at one time of three small children, I recognise such ruses; and to roll it out to manageable tranches of schools to try to get buy-in. It was a more gradual and gentle way of enabling young people to develop their tastes and to access the healthier option.

1305. The Department’s preparations for the first tranche of schools coincided with the Jamie Oliver work, at which point the Treasury came in. As a result of the Treasury’s initiative, Northern Ireland got an additional £3 million to support the increase in the quality of school meals. That funding was aimed at getting high-quality ingredients, investing in equipment, training catering staff, and supporting the communication and marketing plan targeted at our young people. Some national minimum targets were also set for the food element. I am happy to come back to that and to take any questions on it.

1306. We ended up with a rolling programme for the implementation of the new nutritional standards. It began in 2005 and ran to 2007, when all schools under the control of boards had implemented the new nutritional standards. Figures show that, in 2005, before the programme was introduced, the uptake of meals was 52%. That fell slightly and, by the end of 2007, it was about 51%. In October 2008, the meals census suggested that it had dropped by a further 0·5%. Therefore, there was an impact, but it was not the massive drop-off that perhaps other jurisdictions experienced.

1307. Since then, the Department has asked the Educational and Training Inspectorate to look at how schools are performing in this area. The Inspectorate has employed two nutritional associate inspectors to carry out that function. The results have largely been very positive in the first tranche of schools to have been inspected.

1308. As the development and roll-out have progressed, it has become clear that competing sources of food in schools were reducing the impact of the new nutritional standards. Therefore, in order to embed the gains made from the implementation of the standards, the Department has developed what it calls a “whole school" approach to nutrition. That involves addressing a number of issues that impact on childhood nutrition and the food choices that children make in schools. Those include the type of foods that are provided in school meals and the 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. I can bear that one out — I know from personal experience that we are not allowed nuts, due to the risk of anaphylactic shock, but we are also not allowed sweet biscuits or drinks. Other issues addressed included access to food en route to school and at lunchtime, and the quality of the dining environment. There are a range of other issues that span around that, but I just wanted to highlight the ones that children and parents experience most.

1309. The vehicle for achieving the objective of a whole school approach is, as I signalled earlier, the proposed policy that the Department now has on food in schools. The public consultation on that policy is planned to start in September. A final postscript to the bid on food in schools is that, in conjunction with developments relating to the food in schools policy, the Department, along with the Public Health Agency, the Health Department and the University of Ulster, is conducting research into a marketing and promotion campaign designed to support the drive against obesity. The aim of that strategy is to raise awareness of nutrition-based health-related issues and help children and parents make the connection between their present diet and the future consequences for their health.

1310. At yesterday’s meeting of the Education Committee, I mentioned that the Department in re-brigading itself — that is, changing how it is internally structured — is, with the advent of the families and communities directorate that I am responsible for, trying to place a much greater emphasis on its relationship with parents. Therefore, the Department recognises the importance of communication and of gaining the hearts and minds not just of children and young people, but also, critically, those who are looking after them at home, and those who are supporting and influencing them in the community background.

1311. At the other end of the spectrum — the “energy out" end of the equation — there are lots of opportunities for young people to be physically active before, during and after school. For example, there is getting to and from school, which provides an opportunity for children to walk or cycle when it is safe to do so. Indeed, the rural safe routes to schools initiative is a very good example of how a number of different Departments and agencies worked with 18 rural primary schools to put in place school travel plans that allow more children to cycle or walk to school.

1312. During the school day there are also opportunities at lunch and break times for children to run about and be active. Lots of primary schools have playground markings that encourage traditional playground games such as hopscotch, and there is an encouragement for children to get active. However, I think that the big, key role for schools is in teaching children the necessary skills to allow them to be physically active, both during the school day and in their chosen after-school or outside activities. Fundamentally, that is done through the delivery of physical education (PE) in the curriculum.

1313. 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. However, two hours of quality provision is what the Department, advised by experts, has assessed is required. It allows for the developmental brigading of skills and the gaining of knowledge and understanding in the range of activity areas that make up the PE curriculum.

1314. To meet the recommended two hours, there are developing opportunities through the connected learning associated with the revised curriculum. For example, the Council for Curriculum Examination and Assessment has produced ‘Ideas for Connected Learning’ to assist teachers across the different areas of learning. Examples of how activities in PE can actually be used to connect with the rest of the curriculum have been quite important, and those sorts of resources have also been provided to teachers.

1315. The Department has also addressed what we call physical literacy through the fundamental movement skills programme, which provides teachers with continuing professional development on the planning, teaching, learning and assessment of basic physical skills that form the building blocks for children’s active and enjoyable engagement in the activities in the PE curriculum. The PE curriculum also includes opportunities for pupils to develop knowledge, understanding and skills in athletics, dance, games, gymnastics, swimming and outdoors education.

1316. As the Committee knows, the Minister of Education was an active sportswoman earlier in her career, and she has been passionate about sport in schools and about young people being active. Having recognised the importance of developing children’s physical literacy, in the 2007-08 school year she introduced a physical literacy sport programme for the youngest primary-school students. It focused on Foundation Stage and Key Stage 1 — P1, P2 and P3. GAA and Irish Football Association coaches are working alongside teachers in some 550 primary schools to help develop the physical literacy of the young people who are taking part. Approximately 13,000 primary-school students take part in the programme each week. The programme is targeted at areas of greatest disadvantage.

1317. Teachers have also been receiving more support from the boards to help them deliver the physical literacy programme on skills for young people, and extra-curricular physical activities are provided to offer children and young people the opportunity to develop their skills in new contexts. That is sometimes about competing with other schools. However, it is important that the majority of children and young people are given the chance to demonstrate positive attitudes to increased opportunities to take part in sport and physical activities. Some of the latest research is saying that girls, in particular, fade out from taking part in PE and physical activity, and there are issues around that and what it can lead to. It is connected to issues relating to weight gain and self-esteem. That brings us back to the connection between physical well-being and emotional and mental well-being.

1318. I apologise if I have been long-winded, but I hope that I have given you some insight into how seriously the Department of Education is taking its role in obesity prevention. We are striving to do a number of things. The focus on healthy lifestyle choices, including the importance of healthy eating and physical activities, is about equipping young people with the capacity to go forward.

1319. Earlier, I mentioned the relationship between the Department and parents. I do not doubt that the development and management of the food in schools policy in the autumn will be an important learning point for us. Schools are taking a lot of positive steps to ensure that children are presented with healthy eating choices when they are at school, and with increased opportunities for quality physical activity.

1320. As head of youth policy, I am not sure how strongly the food in schools policy is being carried into youth settings. If we are doing so well on the notion of healthy choices in school tuck shops, we will need to think about joining up the dots for young people. It should not just be happening between 9.00 am and 3.00 pm; it should also be happening in any youth settings that they have. I will take that up with colleagues in the Department.

1321. The Deputy Chairperson: Thank you for your interesting and comprehensive presentation. I know that you are in charge of the early-years strategy, which we hope to see coming forward soon. Are there obesity targets in that? Education is key in giving young people the information to help them make informed choices when they get older. Early intervention will set their habits. Is there anything in particular in that?

1322. Ms Warde Hunter: I will have to double-check. I have seen so many iterations of my own strategy that I cannot remember what is in it. Early years and the play-based curricula that operate in preschool and P1 and P2 through the foundation curriculum are strongly based on play, including active outdoor play. If we are to have these healthy eating options through the food in schools policy, that will clearly apply in nursery settings as well. As you will know, voluntary playgroups do not have a long enough day in which to afford children a meal. Perhaps it is less of an issue there, but it will not be a diminution of their commitment to provide the healthy options — fruit and toast — as a mid-morning snack. Thank you for your comment; I will take that back and revisit the strategy from that angle to ensure that, if we do not have a clear expression on that, that we will try to express the physical well-being aspect more clearly.

1323. The Deputy Chairperson: The Department recommends that each child should have two hours of PE each week. That has been raised with the Committee on a few occasions, and Sport NI was also very vocal on the issue. Does physical education form part of the teacher-training programme?

1324. Ms Warde Hunter: I do not know if that is part of the initial teacher training. I imagine that there might be an element of it.

1325. Ms Jill Fitzgerald (Department of Education): I cannot give you the exact detail, but there is coverage for primary-school, non-specialist teachers. Specialist PE teachers will receive PE training, and non-specialists who go into the primary-school arena will have an element of PE training.

1326. The Deputy Chairperson: How is that monitored? Some schools may offer two hours or sometimes more, and other schools may not be meeting that two-hour target. Is that target monitored by the Education and Training Inspectorate?

1327. Ms Warde Hunter: The inspectorate certainly takes account of that target when it is carrying out inspections. That is the point that I was making about the target being set out in the guidelines that the Department has adopted in relation to the curriculum; it gives schools the autonomy as to how to conduct the curriculum. We are not being prescriptive; we are not saying, for example, that all post-primary schools have to teach French on a Tuesday. That is not the philosophy that we have had about the curriculum, and it is not what schools or teachers want. You are quite right. 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.

1328. Dr Deeny: I have raised this a few times: is it not the case that schools should have to do this? Sport NI told the Committee about the two-plus-two strategy in England: that is two hours of PE within the curriculum, and two hours outside it. I see it happening in general practice. You mentioned girls who fade out of doing sports. That starts a vicious cycle, because they start to put on weight, and then they do not want to take part in sport. I think that, rather than recommendations and simple guidance, it should be part of a school’s week. I am aware of schools that allow those pupils who are not very good at sport to fall by the wayside. That is what I have been told. Schools do not insist on every child having two hours of physical activity each week. I think that two hours is not enough. Can you not enforce this for the sake of our kids’ health?

1329. Two girls at my practice have told me that they are smoking because it keeps their weight down. I thought, mother of God, is that what they are doing? They have fallen out of the system. One person has told me that there is no interest in sport, so they go for a walk down the town. What is going on here? All schools like to do well in sports, whether it is between schools or on a larger scale, but a large section of our young population are falling by the wayside and not getting the physical activity that they should do.

1330. There is a duty not only on the Health Department and Health Committee, but on the Department of Education, to ensure that schools see physical education as important for development, and that it should be prioritised. I see that in primary care, with girls in particular. Boys seem to keep exercising, but you are correct that girls, as they get older, seem to drift away from exercise. That is a worrying development.

1331. Ms Warde Hunter: I reiterate that the Department takes an overarching approach to the delivery of the curriculum; as PE is part of the curriculum, the Department has not done anything more than issue guidelines. It is about consistency with the overall approach.

1332. Ms Fitzgerald: 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.

1333. Dr Deeny: There is a difference: unlike other subjects, PE has a very positive effect on people’s health. You could make a difference.

1334. Ms Fitzgerald: Personal development is also a subject that makes a difference to lifestyles, in terms of drugs and alcohol and self-esteem. PE is very important, which is why it is included in the inspections.

1335. Ms Warde Hunter: There are clearly strong feelings on the issue. I would be happy to take the concerns of Dr Deeny and the wider Committee, if it endorses them, back to the Minister so that she can consider them. It is important for us to conduct that message back.

1336. Mr Buchanan: Thank you for the presentation. I apologise for missing part of it, but what I did hear was very good.

1337. A change of mindset in children, going on into their parents and families, is required. There is a mindset where people are not geared up to do physical exercise, which must be completely changed. The provision of sport in schools also has to be looked at. There are folk who excel at sport; it is something that is built into them and they are energised about it. However, there is another section of the school who have no interest in sport. Maybe the provision of sport in schools should be divided into two sections; one for those who are energetic and want to get at it and one for those who slide back a bit. Perhaps there could be a more creative sports programme which would encourage the other section to get involved a bit more in sport and healthy programmes. I am sure that it is not beyond the wisdom of someone to sit down and look at how to get a more creative sports programme to encourage those other folk who do not like sport to take part.

1338. I agree that education has a big part to play in that. In your submission, there are some references to healthy eating programmes in schools. How are the various aspects of the Healthy Schools scheme being co-ordinated? How are the effects of that programme being measured and evaluated in individual schools and in board areas? Is there any evidence that the scheme is benefiting children?

1339. Mr Alan McMullan (Department of Education): I am primarily looking at the measures to change the type of food that is served in schools. Our principal measure of that is the uptake of school meals. We looked closely at the uptake of school meals when the nutritional standards, which aim to get a more healthy background, were introduced. We took a gradual approach to introducing those measures, and uptake decreased only slightly overall. The decrease has been bigger in secondary schools, where we feel that individual eating habits are already well formed and are, therefore, extremely difficult to change at that stage. In primary schools, the figures show a very slight increase.

1340. Through our food in schools policy, we aim to ensure that primary-school children get the healthy food that they need, so that when they go to secondary school they carry on the good eating habits that they have learned. We expect to see uptake increase even further in a few years’ time.

1341. Mr McCallister: My questions will probably overlap some of the other questions that have been asked already. Initially, are you aiming to introduce pupils to, and teach them about, good food, rather than going to the other extremes of banning tuck shops and removing vending machines?

1342. Mr McMullan: We needed to make a fairly big step change, so we went after the main meal of the day, which, in some cases, is the only proper meal that pupils get. Having introduced nutritional standards for all school meals in 2007, we are now extending the food in schools policy to all other food. We have the legislative base to impose nutritional standards on the main meal of the day, but we do not have any legislative power over other food in schools. Therefore, we are trying to improve what is in vending machines and packed lunches by educating pupils and parents.1343. 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. That said, 70% of the schools that were visited already had a food in schools policy in place; clearly, schools are taking the message on board.

1344. Our nutritional associates are out there inspecting schools; if they see any breaches, they try to cajole the school into changing the food that is sold in vending machines. Instead of taking the big bang approach, we encourage replacing one row of food in vending machines with other healthier alternatives every couple of weeks, so that there is a gradual process and pupils are brought along with that.

1345. Mr McCallister: I accept Kieran’s and Tom’s points about pupils who mitch PE and pupils who do not. It is almost like preaching to the converted with that more elite group. Are there any figures to show whether the percentage of kids participating in PE has improved over the past number of years? Is there any evidence that we have at least begun to turn the corner and increase or stabilise the numbers participating? Are any records kept on that?

1346. Ms Warde Hunter: I do not know the answer to that, but I will go away and find out.

1347. Ms Fitzgerald: I can hazard a guess. All children should be participating in PE, and it is the teacher’s duty to deliver PE to all the children in his or her care. All children have different abilities, and it is the teacher’s duty to assess those in order to help pupils progress. Teachers must bear in mind that girls will disengage from PE earlier and that some children might have disabilities. It is for the teacher to assess that and ensure that a pupil’s participation matches his or her ability, which will encourage interest.

1348. Mr McCallister: Your answer is no different to an answer that would have been given 10 years ago. Would the standard response 10 or 20 years ago have been that all children should have engaged in some form of exercise?

1349. Ms Warde Hunter: Through the curriculum? What you are asking is whether, given the guidelines for two hours’ exercise, there is a baseline through which we can identify that 50% of schools provide one hour a day, 25% offer an hour and a half and 25% offer another amount. I put my hands up; we are not gathering the data in that way — not recently anyway. If the Committee supports such an approach, it may be possible to gather statistical information on the implementation of guidelines and the uptake of such activity. That could supplement the work of the inspectors, who visit individual schools or area bases. It is a guideline approach, notwithstanding what Kieran said earlier.

1350. Mr McCallister: We have nothing against which to measure results. Your answer sounds similar to one that would have been given when I was at school: that children should do a certain amount of PE a week. However, that has obviously not happened, and, 20-odd years later, kids are becoming obese and, hence, the Committee has undertaken this inquiry.

1351. Are the 18 schools that are involved in the safer routes to school programme making any headway? I am aware of the success of that pilot project. Will the Department roll that scheme out to more schools?

1352. Ms Warde Hunter: Sorry; I do not know the answer to that question. As I said to the Chairperson at the beginning of the meeting, I have recently adopted this role. Therefore, sadly, I am not the fount of all knowledge yet. I will take that question back to the Department and provide a written answer.

1353. Ms Fitzgerald: The Department was a partner in that scheme, which was driven by Sustrans and the Department for Regional Development.

1354. The Deputy Chairperson: I met a couple of members of the Scottish Health and Sport Committee when they came here. They undertook an inquiry into the uptake of PE in schools and found that about one third of schools actually provided the required two hours of PE. Do you have any indication of whether we perform better or worse than that?

1355. Ms Warde Hunter: I do not know.

1356. The Deputy Chairperson: That is OK.

1357. Ms Warde Hunter: I am sorry; I am not good with statistics today.

1358. Mr Gallagher: We could not be better than Scotland, because today it is all about extending and expanding the curriculum and ticking boxes. It is not the fault of the witnesses, who provided a good presentation. However, in many cases, we do not know what physical education children do in school. Some kids, because of their health or their genes or whatever, might not be up to two hours’ PE a week. Therefore, I understand why the Department does not have a regulation that requires everybody to do a minimum of two hours’ PE a week. At the same time, part of the path that we have to take to address the obesity problem is to find out exactly how much PE children are doing in school. There seems to be a gap in that area, and the Department seems unable to keep accurate records on how schools teach PE.

1359. The other problem is that schools, because of all the curriculum pressures, are juggling responsibilities. They find it difficult to accommodate PE because it is getting pushed aside. We must bring some sense to how the curriculum is delivered nowadays, rather than telling schools that they must deliver all of it.

1360. In the present circumstances, it is simply not possible for schools to deliver the entire curriculum in a way that benefits children. Therefore, instead of making teachers, kids and everyone dizzy trying to jump through hoops, we need to take a more balanced approach. Certainly, it is important that the curriculum offers choice; however, it must fit into the school’s timetable alongside PE. I am sure that a way can be devised for schools to record the time that is spent on PE or for someone else to record it for the Department.

1361. Entitlement to free milk is a pertinent issue in schools because of milk’s importance in the diet, especially for growing children. Do all schools that have pupils who are entitled to free milk provide that entitlement? Does the Department do any checks on how free milk is administered?

1362. Mr McMullan: Certainly, there is an EU milk scheme. As far as I am aware, it is a voluntary scheme in schools. It is for schools to decide whether to take it up. I am not sure how many schools are involved in the scheme. I am sorry that I cannot answer your question.

1363. Ms Warde Hunter: We can certainly take it back to the Department to try to get a response.

1364. Mr Gallagher: It would be helpful to the inquiry if we had that data.

1365. Ms Warde Hunter: I appreciate members’ concern about balance and the Department’s apparent lack of clarity about the audit trail on the two hours of PE. If I can get a better answer on that issue, I will certainly bring it to you. I do not want to leave the member with the impression that we do not know what is going on in schools, so I want to read you the following paragraph about the minimum content for PE in schools.

1366. Schools are required to deliver athletics, dance, games and gymnastics at Foundation Stage and Key Stage 1. At Key Stages 2 and 3, those areas — apart from dance at Key Stage 3, for whatever reason — and swimming must be delivered. Therefore, teaching children to swim is statutory. At Key Stage 4, pupils may study PE at GCSE level or equivalent. They must have the opportunity to plan and participate in a regular, frequent and balanced programme of PE that, among other things, helps to develop and sustain a healthy and active lifestyle.

1367. The point is that we definitely know the progression of the curriculum, the importance of physical literacy and so forth. We know what activity children and young people should do at different stages. Kieran asked how we know whether that activity is being done for a minimum of two hours. I will try to get clarity on that point and bring it back to members.

1368. The Deputy Chairperson: Thank you very much for coming along and making your presentation.

1369. Ms Warde Hunter: Thank you very much indeed.

18 June 2009

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Mr Alex Easton
Mr Sam Gardiner
Mrs Claire McGill

Witnesses:

Ms Clara Swinson

Department of Health

1370. The Chairperson (Mrs I Robinson): We now come to the penultimate oral evidence session of the Committee’s inquiry into obesity. Members will recall that the Committee had planned to travel to London to meet the Department of Health and to examine how the obesity strategy is implemented at a local level by visiting a primary care trust, but, unfortunately, that was not possible. We are particularly grateful to Clara Swinson, deputy director of the cross-Government obesity unit in England, for accepting the invitation to come to the Assembly today to brief us on developments in England, and I welcome her to the Committee.

1371. Members have a briefing paper from the Department of Health, a copy of the executive summary of the ‘Healthy Weight, Healthy Lives’ strategy and a briefing paper from Research Services. Ms Swinson will make a brief presentation, and that will be followed by members’ questions. Before you begin, Ms Swinson, I apologise for the length of time that you had to wait, but the matter that we were discussing has to be dealt with before summer recess.

1372. Ms Clara Swinson (Department of Health): Thank you; it is good to be here. I am the deputy director at the Department of Health with responsibility for the cross-Government obesity unit, which is responsible for obesity policy for central Government in England. I will set out the approach to obesity in England, and then I will, of course, be happy to take your questions.

1373. Just like other nations, we have a growing obesity and overweight challenge. 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.

1374. Obesity has a significant impact on individual health, the Health Service and the cost to society and the economy. The Government are, therefore, committed to tackling obesity in line with the best available evidence, which comes from the Foresight review. In 2007, we set ourselves a public service agreement, which are the central Government targets in England, with an overall ambition to ensure that everyone is able to reach a healthy weight. Starting with children, the target by 2020 is to have flattened and then reduced levels of childhood obesity to their 2000 levels.

1375. With that ambitious ambition, 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. It also looks at the role of Government, but certainly does not believe that Government can solve the problem alone, and at the role of society. The strategy also recognises that we need to try some things out, see how effective they are and learn as we go on, not to wait until we have a perfect evidence base.

1376. The strategy, a summary of which has been provided for the Committee, first of all sets out for the individual what we are doing to help people to make healthier choices. A large part of that is the Change4Life movement and social marketing campaign, which was launched earlier this year. That will be extended to younger people with the launch of Start4Life in the autumn for children from 0 to 12 months old. That will be extended to adults next year.

1377. 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. We also have a national child-measurement programme which weighs and measures all children in reception year and at age 11. That information can now be routinely fed back to parents.

1378. That is what we are doing to help the individual to make a healthier choice. The second strand is very much about ensuring that the environment supports those choices and makes the healthier choice the easier choice. A lot of work has been done on children in early years and in the school environment; there are strict standards on food that is available in schools, increased focus on physical education (PE) and sport, and, from the early years, encouragement for breastfeeding and healthy habits.

1379. On the “energy in" side of the equation, our healthy food code puts in one place the various things that we want industry to do, and consumers, too. Those range from labelling to portion size and product reformulation. I will not go through them all, but there are a whole set of issues around “energy in". On the “energy out" side — we give each side equal weight — our aim is to help people to build physical activity back into their daily lives, focusing on programmes for individual walking and cycling. The programme also involves working with town planners on future development, and we have a Healthy Towns programme which is in its second year.

1380. For adults, we are thinking about the role of the employer in encouraging healthy choices and about what employers in both the private and public sectors can do in respect of that. That is a brief overview of what we are doing about the environment.

1381. Obviously, we need to provide services to those who are at risk and to those who are overweight and obese already. In England, we have the National Institute for Health and Clinical Excellence guidelines and primary care trusts (PCTs). We allocate money — £69 million this year — to PCTs for them to translate as they see fit into the weight-management services that they need to provide for their local communities. We do some work centrally to help them to make the case and to commission high-quality services.

1382. Finally, we look at the whole delivery system. There is a role for central Government. I spend a lot of time cross-Government working with my colleagues in other Government Departments. We report to a ministerial committee that has 10 or 12 Departments represented on it. There is a lot of work for local government in schools and the wider public sector. There is a large task of building a coalition of the willing with commercial and voluntary sectors so that everyone plays their part in creating a society where we can all reach a healthy weight.

1383. We are doing a lot to increase our knowledge. As I said at the start, we do not have a perfect evidence base, and, therefore, we still work with the advisers who were involved with the Foresight report. We have a national obesity observatory. We evaluate what we do. We are committed to producing an annual report that sets out what we have done each year and that also looks at what we have learnt in that year so that we can amend policy as required.

1384. I hope that that gives a helpful overview. We are by no means there yet. It has been years in the making and it will take years to tackle the problem fully. However, I believe that we have a comprehensive strategy, with some exciting bits of work under way. The Government are certainly taking a leading role, but we know that Government alone cannot change the situation.

1385. The Chairperson: Thank you very much, Clara, for that very interesting presentation. Given their usage of computers and so on today, children become couch potatoes and do not get a lot of exercise. Do you work closely with local authorities to deliver free entry to their recreational facilities for children to use the football pitches and other equipment in those areas?

1386. Ms Swinson: Yes; you are quite right that changes over time have made us more sedentary. We have two messages for children: 60 active minutes and activity in school. For local authorities it is very much about making sure that their open spaces and what can be done for free are attractive and that people know about them. As regards other recreational spaces, one particular initiative is the free swimming that is available in many areas of England now for the under-16 and over-60 age groups. As you said, we need to build regular activities into children’s lives from an early age.

1387. Mrs O’Neill: We also recognise that the problem is not going to be fixed overnight and that it is a societal thing. Any changes will be seen over the longer term.

1388. We had the Department of Education along last week and we were talking about PE in schools and about how some schools deliver two hours of physical education each week but others do not. The direction from the Department is that schools should provide two hours. We discussed whether that should be made a mandatory minimum requirement for schools. Are there any targets or mandatory obligations on schools to provide more PE? Obviously, if children and young people are provided with encouragement to take part in physical activity at an early age, they are more likely to carry that on into adult life.

1389. I would also like more information on the healthy community challenge fund referred to in the paper to the Committee.

1390. Ms Swinson: Yes, schools should provide two hours a week of PE, and about 90% of children now receive that. Many schools offer an additional three hours of activity that need not be standard PE or sport but that could be offered to children through after-school clubs, at lunchtime, or throughout the day rather than just in PE lessons. That is what is happening in schools.

1391. 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.

1392. Therefore, we set out what we wanted to achieve but did not specify to areas what they had to do. Instead, we asked for proposals. Some of the proposals focused on food and others on activity. They all had to involve both local authorities and primary care trusts, but the proposals varied depending on whether they focused on infrastructure or prevention.

1393. We were seeking seven or eight applications but received more than 160. We went through a process that led to the selection of nine towns — one in each region of England. The programme was also match-funded; the aim was not to tell people what to do, but to let them know that money put forward for their proposal would be matched by central Government. We have now signed off on all the Healthy Towns project plans and they have been granted their second year of funding.

1394. At a national level, we are also conducting an evaluation of the nine Healthy Towns. By the very nature of what we asked for, their projects were very varied. Therefore, in another year or two we will have the results of their first year or 18 months in operation.

1395. Mr Gardiner: I am chairman of the boards of governors of two primary schools that have breakfast clubs to encourage healthy eating. Rather than bring in sweet stuff to eat, the children are dropped off at 8.00 am and they have breakfast at school. We are not doing away with flowers or things like that, but our children plant apple trees, carrots, parsnips, beetroot and the like, and the children are taking an amazing interest in a healthier lifestyle. The schools also provide water coolers and containers with which the children can get water at any time during school hours. Therefore, we are on that track and trying to overcome this problem that we are facing by cutting down on sweet stuff.

1396. Ms Swinson: Many groups in our society need to reconnect with basic knowledge about food such as vegetables and basic cooking skills that have been lost over the past few decades. That should be encouraged when people are young.

1397. Mr Gardiner: Are we on the right track, then?

1398. Ms Swinson: Yes.

1399. The Chairperson: In the absence of any other questions, I thank Ms Swinson for coming all the way from London and wish her a safe journey back to the mainland.

18 June 2009

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Sam Gardiner
Mrs Claire McGill
Ms Sue Ramsey

Witnesses:

Dr Naresh Chada
Ms Christine Jendoubi
Mr Rob Phipps

Department of Health, Social Services and Public Safety

1400. The Chairperson (Mrs I Robinson): This final evidence session of the inquiry is with officials from the Department of Health, Social Services and Public Safety. Members have been supplied with the Department’s submission to the inquiry and a briefing paper from the Assembly Research Services.

1401. I welcome Mr Rob Phipps, Ms Christine Jendoubi and Dr Naresh Chada. I invite you to make a brief presentation, after which members may ask questions. We will allow up to one hour for the evidence session.

1402. Mr Rob Phipps (Department of Health, Social Services and Public Safety): We are pleased to be back at the inquiry’s conclusion. We have been following its progress with interest, and, through reading the Hansard reports, we have noted some of the comments and points raised.

1403. When we first gave evidence to the Committee on 5 March 2009, Andrew Elliott outlined the Department’s position on the issue and stressed its commitment to addressing obesity across the life course. I wish to update the Committee on the work that has been, and is being, carried out on the issue of prevention. I will hand out copies of a newsletter to members; in fact, you are the first people to see it. It will be distributed to everyone who deals with the issue of obesity at local and regional levels and elsewhere.

1404. At the last evidence session, we spoke about our intention to develop a 10-year strategic framework to address obesity across the life course. In our original submission, we annexed a logic model. The 10-year framework will be outcome-focused and outcome-based. It will take a thematic approach to the life course. For example, not only will it target young people, children, adults and older people but it will subdivide maternal matters into antenatal and post-natal issues. We can then consider other outcomes such as obesity in the workplace. The framework lends itself to a matrix-type approach, because it not only considers obesity in younger people or older people but it is also settings-based.

1405. The short-term outcomes, which will probably take two to three years to achieve, have the potential to address many of the issues that have already been brought to the Committee’s attention, such as nutritional standards, levels of participation in physical activity by young people and older people, and the role and support of the food industry. All those issues can be covered within that outcome-focused approach.

1406. Our steering group is cross-departmental, and the final framework must be cross-sectoral and cross-departmental. At present, four advisory groups are working on that to develop the outcomes, which they will complete by the end of September 2009. An email address has been provided in the newsletter for people to send in their thoughts and to make comments. Between October 2009 and January 2010, we will develop the framework. That will involve discussion and negotiation with other sectors and, in particular, the Departments. It is important that there is buy-in across the entire sector.

1407. The big question is: how do we measure the success of those outcomes? How do we measure the difference that they are making and the impact that they are having? A data research group is currently working on that. It is examining the evaluation of good practice, as well as the types of surveillance systems that are in place.

1408. Assessing progress and impact, and measuring the difference that is being made, is a big challenge. That will be built into the process, and we will have indicators that will demonstrate the difference that is being made. That is absolutely essential. A group is working on that, and we hope to finish that process by January 2010. People will feed their ideas and thoughts into the initial consultation, and it will then go out for full public consultation in February, March or April 2010. We will take on board the comments that we know we will receive, and we will then redraft the strategic framework. It sounds rather frightening, but we hope to launch the strategy by June 2010. That may seem a long way off, but there is much work involved to get it right.

1409. That is where we are. I hope that the newsletter gives you more background to the process.

1410. The Chairperson: It is very helpful. Thank you very much.

1411. Mrs O’Neill: Early intervention is crucial, and the new Public Health Agency has a key role to play in tackling the epidemic. Do you see the agency having a role?

1412. Mr Phipps: The Public Health Agency is part of the process. The agency is represented on all the groups that I mentioned, including the steering group. It is already inputting to the development process, but it has an essential role in delivery and implementation. I am sure that members will appreciate that the agency is in the process of getting its structures in place, but we are keen to work closely with it, because it will be a key partner in the delivery of the framework.

1413. Mrs O’Neill: In relation to primary care, an incentive was introduced for GPs to identify patients over 16 years of age old who have a body mass index over a certain level. Does that not place more focus on treating obesity as opposed to adopting a more preventative approach? Is there an incentive to work with GPs so that they can help their patients to be more active or to refer them to use council leisure facilities, for example?

1414. Ms Christine Jendoubi (Department of Health, Social Services and Public Safety): It is opportunistic. We do not have anything in place for GPs to go out and hunt down fat patients. However, when such patients present, GPs are paid to offer them a resource pack that provides them with dietary advice as well as advice on smoking. However, one must remember that patients are free to turn down offers of treatment. GPs will refer patients to smoking cessation clinics, give them advice, carry out routine blood pressure monitoring and thyroid function tests. They will keep a register of obese patients and follow them up annually to measure their weight, test blood lipids and glucose. GPs will refer them to physical activity resources or programmes, but they are not universal.

1415. I have read about practices in England that will prescribe patients a physical activity course in their local leisure centre. A GP can prescribe anything that a pharmacist can dispense, but, obviously, a pharmacist cannot dispense swimming lessons. However, it is entirely possible that arrangements can be made with leisure centres so that the cost of physical activity courses can be redeemed from the former Central Services Agency, or the Business Services Organisation, as it is now known. I do not know it for a fact, but I imagine that that is the general idea behind the Grove Wellbeing Centre, where the swimming pool is on site. That type of cross-governmental approach should be encouraged. That is the purpose of those types of dual amenities.

1416. Mrs O’Neill: Community planning will be vital, and that will provide the opportunity for the different agencies to get together to look after the population that they serve.

1417. Mr Phipps: In the early 1990s, the former Northern Board had a voucher scheme; GPs gave out vouchers to people whom they felt would benefit from them. Community planning will kick in in a couple of years’ time, and 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.

1418. The Scottish weight-management programme Counterweight involves a patient’s GP and family. We are aware of those schemes; a representative from Counterweight made a presentation to the obesity prevention steering group. That programme is popular in Scotland. Further discussion is required for many of those issues, and there is potential to make suggestions.

1419. The Chairperson: Some councils do that already. Castlereagh Borough Council has a set-up in which people can use the leisure facilities to improve the quality of their health. As you say, local authorities will play an important role in the future with the redrawing of local government boundaries.

1420. Mr Easton: You are doing good work. I am not knocking you, but much of what you are doing, or what we are considering, is directed at people who already have a problem. Apart from the work that is being done in schools and exercise being recommended, what are you doing to try to ensure a healthier population? That is vital.

1421. I keep harping on about the muck that food companies put into food. If that does not change, there will always be a problem, regardless of what we do; it will be akin to treating the problem with a sticking plaster. Are all our food laws governed by Europe? Is that our major problem? Are you examining legislation that we could use to try to force food companies to moderate the doses of various ingredients that they use?

1422. There are four advisory groups examining four issues. Why do you need four groups? Is it merely to speed up the process?

1423. Dr Naresh Chada (Department of Health, Social Services and Public Safety): I agree that it is vital that we target people in the early years, and all the public health evidence bears that out. The structure of what we have been trying to do in Northern Ireland through Fit Futures and the further work that Rob Phipps outlined tend to corroborate that line of thinking.

1424. None of us is an expert on food legislation, so I am happy to get back to you on some of the details. I understand that the Food Standards Agency gave evidence to the Committee and informed you that most of the legislative issues relating to food and, particularly its content, are set by Europe and, to some extent, national legislation. Therefore, we are constrained about what we can do in Northern Ireland.

1425. Mr Phipps: There will always be an issue about food and nutrition. Dieticians and nutritionists always have issues about food and nutrition. Similarly, representatives from Sport NI and other colleagues will say that physical activity is also important. We acknowledge that, and we thought that the best way to ensure that we included that in the framework was to have experts from those two groups to raise those points. Mr Easton’s points may be discussed at the food and nutrition group, for instance.

1426. There is also an issue about consistent messages. Inconsistent or different messages going out at the same time, or at different times, annoy everyone. The education, prevention and public information advisory group is tasked with trying to achieve consistency. A point was made about the role of the Public Health Agency, public health campaigns and public campaigns. It is imperative to achieve consistency, and that advisory group has been tasked with that.

1427. The fourth group is concerned with data and research, which involves a roomful of researchers and statisticians who grapple with the big issue. The newsletter may state that. We also bring the chairpersons together. They are not independent to the extent to which they plough their own furrow, so we bring them together and have regular meetings, which is when the crossover occurs. That works well.

1428. Mr Gardiner: I ask for clarification because my mind is probably not functioning properly. The newsletter states that, in Northern Ireland, some 59% of adults have a weight problem, and 5% of children in primary 1 are obese, with 22% of children in primary 1 being overweight or obese. Does that mean that 17% of children are overweight?

1429. Mr Phipps: Yes, it does

1430. Mr Gardiner: That is not very clear.

1431. Mr Phipps: Thank you very much. The newsletter has not yet been circulated, so we can make that clearer.

1432. Mr Gardiner: Please do that because you are contradicting yourselves somewhat.

1433. Mr Buchanan: I welcome you to today’s meeting. I commend you for the ongoing work. This is a big issue that has come to the fore in Northern Ireland in recent years. Early-years intervention is vital. It is important to educate in the early years because prevention is always the best medicine. I assume that some of those groups work with schools, the education system and local authorities to establish incentives so that people are encouraged to try to tackle this serious problem. What plans are in place to treat overweight children and adults in the secondary sector?

1434. Ms Jendoubi: If they are older than 16 years of age, they will fall within the ambit of directed enhanced services (DES). There is always an opportunity for the surgical route, but we do not recommend that because people do not routinely go down that route. Many teenagers, particularly girls, want that route, which they see as being the easy way out. However, it is not a route that we routinely recommend because it is drastic.

1435. There are also normal dietetic services from the trusts. Youngsters will be referred when they present. If they go to their doctor with a problem, or if they turn up with any kind of health problem and their doctor feels that they have a weight issue, they will be offered a resource kit if they are old enough to avail themselves of it. They will be offered routine tests, and they will be followed up for weight measurement and routine monitoring as quickly as the doctor feels that they need to be. They will then be referred to a trust dietician for further advice.

1436. Mrs O’Neill: Are allied health professionals represented on the obesity prevention steering group?

1437. Mr Phipps: I would need to double-check that.

1438. Mrs O’Neill: A witness in Committee told us that allied health professionals were not involved, and they felt that they were not represented. They would have much to offer.

1439. Mr Phipps: Bear with me; I have the membership of the steering group, but I will have to go through my 3,000 documents. People say that various groups should be represented, and we say that that is great. We are inviting people. Just now, I cannot see a representative. However, I will take that point and ensure that there is an allied health professional by the next meeting.

1440. Dr Deeny: I am sorry that I was delayed.

1441. On the subject of exercise, I have worked in general practice for years now, and it is important to promote exercise. It is not only good for physical health and the prevention and tackling of obesity but for mental health. Some years ago, a couple from England who came into my area suffered a terrible tragedy and lost a family member through suicide. That couple has come on in leaps and bounds because they exercise frequently at the leisure centre. Their intake of drugs has gone down dramatically. I see that every day.

1442. In 2010, the cost of prescriptions will be reduced to zero. However, should it not be the case that, across Northern Ireland, GPs should pick appropriate motivated patients for exercise programmes? Motivation must be assessed for all types of conditions.

1443. Last week, representatives of the Department of Education were witnesses at the Committee. They told us that they would consider the Department’s guidance of two hours’ physical exercise for schools. I do not think that that is enough. Physical exercise should be compulsory, and it should be almost four hours a week. I suspect that some schools do not do physical exercise at all, and the focus is far too much on academic activity as opposed to exercise. For want of a better phrase, we are getting some obese Einsteins — children who are bright but not physically fit. Will the Department of Health, Social Services and Public Safety work with the Department of Education on that matter?

1444. With the advent of the new local commissioning groups (LCGs) — I must declare an interest because I am a member of the Western Local Commissioning Group — will GPs and elected councillors work together on commissioning groups and perhaps come up with exercise programmes to improve public health?

1445. Mr Phipps: The process that I described means that people can suggest such outcomes for the role of GPs and that of physical education in schools. Our physical activity group met yesterday, and the Department of Education was represented on it. They spoke about giving evidence to the Committee last week, so the number of hours of physical activity was a discussion point. We are keen to work on that area.

1446. I take the point about linkage with good mental health. One of my personal frustrations is that much of our work is about promoting self-esteem and good body image, which is excellent for mental health. It cuts across a range of lifestyle behaviours — alcohol, drugs and other issues. We are aware of those points. There is a potential for those to be built into the strategic framework, but we will then have to get the buy-in. There is certainly potential, and we are working closely with the Department of Education and the Department of Culture, Arts and Leisure on Fit Futures.

1447. Dr Chada: The point about local commissioning groups is extremely important. When the public health infrastructure matures at a local level, it will be important for local commissioning groups to work with partners such as local government and public health professionals. That will ensure a common approach so that people have access to exercise and leisure opportunities, thereby tackling the obesity issue. We need to examine that work carefully at a local level. Commissioners need to take that on board.

1448. Mr Phipps: It is a challenge; it is part of the regional vision, but it will be delivered locally. The framework will, I hope, enable that so that there is regional consistency. However, local bodies know their localities better than we do. The entire process is about that, and it can put in place those types of initiative. There must be consistency in what we are saying. One can go to area A and receive a certain message, and then go to area B and receive an entirely different message. People might say that we should get our act together. However, it is about how the issue of messages and information is managed. It is not unique to health issues. There is a range of issues, and it is about trying to manage a regional vision against local delivery.

1449. Dr Chada: What might be appropriate in an inner city might be completely different in a rural setting. We must consider all the initiatives to see how they can best be evaluated and in which setting they will be the most effective.

1450. Ms Jendoubi: We would expect local commissioning groups to turn their attention to that issue, and the fact that councillors and doctors are on local commissioning groups should make life much easier.

1451. When Barry Gardiner was Minister with responsibility for education, he had plans to increase the length of the school day and have two hours’ physical activity in the middle of each day. However, that did not go down terribly well with the teachers’ unions, and the plan was not pursued.

1452. The Chairperson: That concludes the oral evidence for the inquiry.

Appendix 3

Written Submissions

Obesity Inquiry Submissions

Organisation Page

Ofcom

OFMDFM Committee

Department of Employment & Learning

Conservation Volunteers Northern Ireland

Royal College of Psychiatrists

University of Ulster

Obesity Management Association

LighterLife (UK)

Northern Ireland Commissioner for Children and Young People (NICCY)

Centre for Obesity Research and Epidemiology

Banbridge District Council

Western Health & Social Services Board

North Eastern Education and Library Board

Dr Michael Ryan – The Northern Health and Social Care Trust

Fermanagh District Council

Health & Social Services Councils

Omagh District Concil

Department of Health, Social Services & Public Safety

Ards Borough Council

Action Cancer

Belfast City Council

Abbott

Southern Health and Social Service Board and Southern Investing for Health Partnership

South Eastern Health and Social Care Trust

Department of Culture, Arts and Leisure

Armagh City and District Council

Chartered Society of Physiotherapy Northern Ireland

Newry and Mourne District Council

Northern Ireland Environment Link

The British Dietetic Association

Belfast Health & Social Care Trust

Institute for Public Health in Ireland

Department for Regional Development

Public Health Alliance

British Heart Foundation Northern Ireland

Sustrans

College of Occupational Therapists

Ballymena Borough Council

Ajinomoto

Cambridge Health & Weight Plan

Western Education & Library Board

Department of Agriculture and Rural Development

PlayBoard

Northern Health & Social Services Board

Sport NI

Northern Ireland Cycling Forum

British Medical Association

Department of Finance and Personnel

Health Promotion Agency for Northern Ireland

Department of Social Development

Royal College of Nursing

Safefoods

Royal College of General Practioners

Department of Education

Southern Health and Social Care Trust

Western Health and Social Care Trust

NILGA

Queen’s University Belfast

Ulster Cancer Foundation

Food Standards Agency Northern Ireland

Diabetes UK

Dairy Council for Northern Ireland

NI Assembly Facilities Branch

Helping Hands Ltd

Dr Una Lynch

Public Health Authority

OFCOM

Introduction

1. This submission is in response to the Northern Ireland Assembly’s request for written evidence for its Inquiry into Obesity. It outlines the actions we have taken to limit children’s exposure to television advertising to food high in fat or salt or sugar (HFSS), on the basis of our findings 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.

Background

2. Ofcom was established under the 2003 Communications Act. One of our duties is to secure a wide range of high quality television services. Related to this, we must report on the extent to which the public service broadcasters (PSBs) have fulfilled the purposes of public service television broadcasting, and to make recommendations with a view to maintaining and strengthening the quality of PSB in the future. Advertising is clearly an important part of the funding system both for commercial broadcasters who have public service obligations and others that also offer alternative choices of channel viewing to the BBC, which is, of course, funded by the licence fee.

3. Ofcom also has statutory responsibility for regulating television advertising in the UK. Ofcom delegated responsibility for regulating the content of television advertising to the Broadcast Committee on Advertising Practice - BCAP (an arms-length offshoot of the Advertising Standards Authority) in 2004. However, Ofcom retains responsibility for approving changes to the rules. The rules for non broadcast alcohol advertising are the sole responsibility of the ASA (see http://www.asa.org.uk/asa/codes/cap_code/ShowCode.htm?clause_id=2152).

4. Clearly, any changes to the arrangements for advertising need to be carefully thought through in terms of their direct impact on the public’s viewing experience, and their indirect impact on the choice and quality of viewing available to the public as a result of the implications for advertising revenue. In all its policy work, Ofcom carries out detailed research and undertakes impact assessments to ensure that any regulation is evidenced based and proportionate.

Research into Obesity and TV advertising

5. A growing body of research has generated concerns in government and society about rising childhood obesity levels and ill-health due to dietary imbalance, specifically the over-consumption of high fat, salt and sugar (HFSS) foods and the under-consumption of fresh foods, fruit and vegetables. Both the Department of Health (DH) and the Food Standards Agency (FSA) have identified television advertising as an area where action should be considered to restrict the promotion of HFSS foods to children.

6. In December 2003, the Secretary of State for Culture, Media and Sport, asked Ofcom to consider proposals for strengthening the rules on television advertising of food aimed at children.

7. In response, in early 2004, Ofcom conducted research into the role that television advertising plays in influencing children’s consumption of foods that are HFSS. In publishing its research report in July 2004, Ofcom concluded that advertising 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 therefore concluded that there was a case for proportionate and targeted action in terms of rules for broadcast advertising to address the issue of childhood health and obesity. However, Ofcom also noted that one of the conclusions from the independent research was that multiple factors account for childhood obesity. Television viewing/advertising is one among many influences on children’s food choices. These other factors include social, environmental and cultural factors, all of which interact in complex ways not yet well understood. In these circumstances Ofcom considered that a total ban on food advertising would be neither proportionate nor, in isolation, effective.

8. In November 2004, DH published a White Paper reiterating the Government’s view that there was ‘a strong case for action to restrict further the advertising and promotion to children of those foods and drinks that are high in fat, salt and sugar’ in both the broadcasting and non-broadcasting arenas. At the same time the FSA published a consultation on a scheme which would identify HFSS food and drink products by means of nutrient profiling. This model was intended to help Ofcom reach decisions on the restriction of television advertising for less healthy foods. In December 2005, the FSA completed their work on a nutrient profiling scheme and delivered it to Ofcom.

Consultation Process

9. In March 2006 Ofcom proceeded to consult on a range of different options for new restrictions on television advertising to children. Ofcom published a Statement and further Consultation in November 2006 which said that it had concluded that, in the context of its statutory duties, the aims of further regulation in relation to television advertising should be to balance the regulatory objectives set out below. In the light of the consultation responses and after considering all the available evidence, Ofcom extended the scope of the first regulatory objective to include all children under the age of 16, instead of children under the age of 10. We decided that the revised regulatory objectives were to:

10. The November Statement identified Package 1 as its preferred option, but sought views on whether a modified version of this package (Modified Package 1) would better fulfil Ofcom’s regulatory objectives. Modified Package 1 was set out in detail in the November Statement.

Conclusions

11. After a detailed examination of all consultation responses and the available evidence, Ofcom decided that Modified Package 1 should be adopted. Accordingly, it was agreed that the following package of measures to restrict the scheduling of television advertising of food and drink products to children would be applied:

12. Ofcom also decided that, alongside these scheduling restrictions, revised content rules would apply to all food and drink advertising to children irrespective of when it is scheduled. The full content rules are set out in the annex. Key elements of the content rules include a prohibition on the use of licensed characters, celebrities, promotional offers and health claims in advertisements for HFSS products targeted at pre-school or primary school children.

Implementation

13. The revised BCAP content rules came into force for new campaigns with effect from the date of the Statement (February 2007). Any campaigns that were already on air or in planning had to comply with the new rules from 1 July 2007.

14. The scheduling restrictions came into force in two stages as follows for all channels except children’s channels:

15. Children’s channels were allowed a graduated phase-in period, with full implementation required from 1 January 2009.

16. In accordance with the co-regulation arrangements put in place by Ofcom and its co-regulatory partners, responsibility for interpreting the rules rests with the Broadcast Committee on Advertising Practice (BCAP), while the ASA is responsible for securing compliance. All the new rules, both for scheduling and for content, will form part of and be included in the BCAP Television Advertising Standards Code.

17. The scheduling restrictions and revised content rules apply to all channels transmitted by UK broadcasters whether aimed at UK audiences or outside the UK.

18. In announcing the restrictions, Ofcom said that it would carry out a review in late 2008 to assess whether or not the restrictions were having the expected effects, in terms of:

a) the reduction in HFSS advertising seen by children;

b) use of advertising techniques considered to appeal to children in HFSS advertising; and

c) the impact on broadcasting revenues.

19. At the request of the Government, we brought forward the start of the review to July 2008.

Further Reviews

20. In conducting the 2008 review, Ofcom worked work closely with the Department of Health and the Food Standards Agency, both of which have also been conducting related reviews in this area.

21. In October 2008 the Department of Health published its report Changes in Food and Drink Advertising and Promotion To Children, which looked at the balance and nature of advertising for HFSS products across a range of media, including television, radio, press, outdoor and cinema advertising. The report found food and drink advertising attractive to children has fallen considerably on TV while increasing significantly in other areas.

22. The FSA has commissioned an independent panel to review the nutrient profiling model in the light of experience. The panel’s draft conclusions were to be reviewed by the Scientific Advisory Committee on Nutrition towards the end of 2008, with a view to recommendations being made to the FSA Board in early 2009. If the FSA decides that changes should be made to the nutrient profiling model, Ofcom would need to consider whether corresponding changes should be made to the model used to identify products that are subject to advertising restrictions.

2008 Ofcom Review Findings

23. Ofcom concluded a review in December 2008 assessing how the restrictions are working. It is important to note that Ofcom did not look to see whether the rules are having effects on child obesity – it would not be realistic to expect short term changes in obesity, and in any case, television advertising is only one of a large number of factors that affect obesity. Rather, Ofcom looked at whether the restrictions are working as intended. The findings revealed that :

24. Separate analysis carried out by Ofcom suggests that only about 40% of all food and drink advertising seen by children was for HFSS products likely to appeal to them. The remainder was either for non-HFSS products, or HFSS products such as spreads, cooking oil and drinks mixers.

25. Ofcom 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 (the last year for which we had comprehensive revenue and viewing data at the time).

Changes in the use of advertising techniques seen by children

26. Surveys carried out by Ofcom’s co-regulator the Advertising Standards Authority (ASA) show that broadcasters are complying with the HFSS content rules.

27. Children saw fewer food and drink advertisements using techniques considered to be of appeal specifically to children in 2007/8 than in 2005[2]. In particular:

Impact on broadcasters

28. In restricting the advertising that broadcasters could carry, Ofcom sought to avoid a disproportionate impact on the revenues of broadcasters, and to avoid intrusive regulation of advertising during adult airtime, on the grounds that adults are able to make informed decisions about advertising messages. Ofcom estimated that the restrictions would affect the advertising revenue earned by broadcasters, although some would be able to mitigate that loss to a greater or lesser extent.

29. The review found that restrictions on food and drink advertising have not been the most significant factor affecting broadcasters in the period under review. In particular, on the basis of data supplied by broadcasters:

Future review

30. The final phase of restrictions will be implemented on 1 January 2009, when children’s channels will be required to remove all HFSS advertising from their schedules.

31. Under transitional arrangements, children’s channels have been allowed to include a progressively declining amount of HFSS advertising in their schedules between April 2007 and December 2008. Unlike other channels, they have no scope to move HFSS advertising out of children’s airtime to other parts of the schedule. The purpose of the transitional arrangements was to allow them time to seek alternative sources of revenue to mitigate the loss of revenue from HFSS advertising.

32. In 2007/8, children’s channels accounted for 17% of HFSS advertising seen by children. If none of this advertising was displaced to other channels, we could expect a further overall 11 percentage point reduction in impacts since 2005 on top of the 34% reduction that we estimate has occurred.

33. The actual outcome is likely to be influenced by a number of factors, including the requirements of the advertising restrictions, the evolution of scheduling and viewing patterns, the changing emphasis of advertising campaigns, and the extent to which HFSS advertising displaced from children’s channels re-appears in adult airtime on other channels. Other factors that may influence the outcome include the extent to which product reformulation (a long term process) contributes to changes in the balance of HFSS and non-HFSS products advertised on television, and possible changes to the nutrient profiling scheme stemming from the FSA’s 2008 review.

34. For these reasons, we need to look at actual data from 2009 in order to gauge the full effects of the restrictions. Accordingly, we intend to carry out a further review in early 2010, once we have full-year data from both 2008 and 2009. As with the current review, the focus will be on whether the advertising restrictions are having the anticipated effects, rather than attempting to identify the direct impact of the restrictions on child obesity levels.

Annex

BCAP Broadcasting Code rules - HFSS products

7.2 Food and Soft Drink Advertising and Children

Notes:

(1) The rules in 7.2 must be read in conjunction with the other rules in this Code, especially section 8.3, ‘Food and Dietary Supplements’. For rules on the scheduling of HFSS product advertisements, please see the BCAP Rules on the Scheduling of Television Advertisements. References to food apply also, where relevant, to beverages.

(2) The spirit, as well as the letter, of the rules in this section applies to all advertisements that promote, directly or indirectly, a food or soft drink product.

(3) These definitions apply in rule 7.2:

7.2.1 Diet and lifestyle.

Advertisements must avoid anything likely to encourage poor nutritional habits or an unhealthy lifestyle in children.

Notes:

(1) This rule does not preclude responsible advertising for any products including those that should be eaten only in moderation.

(2) In particular, advertisements should not encourage excessive consumption of any food or drink, frequent eating between meals or eating immediately before going to bed.

(3) It is important to avoid encouraging or condoning attitudes associated with poor diets, for example, a dislike of green vegetables.

(4) Portion sizes or quantities of food shown should be responsible and relevant to the scene depicted, especially if children are involved. No advertisement should suggest that a portion intended for more than one person is to be consumed by a single individual or an adult’s portion, by a small child.

(5) Advertisements for food should not suggest that an inactive or sedentary lifestyle is preferable to physical activity.

7.2.2 Pressure to purchase

Note: Please see also 7.3 (Pressure to purchase)

(a) Although children may be expected to exercise some preference over the food they eat or drink, advertisements must be prepared with a due sense of responsibility and should not directly advise or ask children to buy or to ask their parents or other adults to make enquiries or purchases.

Notes:

(1) This extends to behaviour shown: for example, a child should not be shown asking for a product or putting it into the parent’s trolley in the supermarket.

(2) Phrases such as “Ask Mummy to buy you" are not acceptable.

(b) Nothing in an advertisement may seem to encourage children to pester or make a nuisance of themselves.

(c) Advertisements must not imply that children will be inferior to others, disloyal or will have let someone down, if they or their family do not buy, consume or use a product or service.

(d) Advertisements must neither try to sell to children by appealing to emotions such as pity, fear, loyalty or self-confidence nor suggest that having the advertised product somehow confers superiority, for example making a child more confident, clever, popular, or successful.

(e) Advertisements addressed to children should avoid ‘high pressure’ and ‘hard sell’ techniques, i.e. urging children to buy or persuade others to buy. Neither the words used nor the tone of the advertisement should suggest that young viewers are being bullied, cajoled or otherwise put under pressure to acquire the advertised item.

(f) If an advertisement for a children’s product contains a price, the price must not be minimised by the use of words such as "only" or "just".

Note:

Products and prices should not be presented in a way that suggests children or their families can easily afford them.

7.2.3 Promotional offers

Promotional offers should be used with a due sense of responsibility. They may not be used in HFSS product advertisements targeted directly at preschool or primary school children.

(a) Advertisements featuring promotional offers linked to food products of interest to children must avoid creating a sense of urgency or encouraging the purchase of excessive quantities for irresponsible consumption.

(b) Advertisements should not seem to encourage children to eat or drink a product only to take advantage of a promotional offer: the product should be offered on its merits, with the offer as an added incentive. Advertisements featuring a promotional offer should ensure a significant presence for the product.

(c) Advertisements for collection-based promotions must not seem to urge children or their parents to buy excessive quantities of food. They should not directly encourage children only to collect promotional items or emphasise the number of items to be collected. If promotional offers can also be bought, that should be made clear. Closing dates for collection-based promotions should enable the whole set to be collected without having to buy excessive or irresponsible quantities of the product in a short time. There should be no suggestion of “Hurry and buy".

(d) If they feature large pack sizes or promotional offers, e.g. “3 for the price of 2", advertisements should not encourage children to eat more than they otherwise would.

(e) The notion of excessive or irresponsible consumption relates to the frequency of consumption as well as the amount consumed.

7.2.4 Use of characters and celebrities

Licensed characters and celebrities popular with children must be used with a due sense of responsibility. They may not be used in HFSS product advertisements targeted directly at pre-school or primary school children.

Notes:

(1) Advertisements must not, for example, suggest that consuming the advertised product will enable children to resemble an admired figure or role model or that by not doing so children will fail in loyalty or let someone down.

(2) This prohibition does not apply to advertiser-created equity brand characters (puppets, persons or characters), which may be used by advertisers to sell the products they were designed to sell.

(3) Persons such as professional actors or announcers who are not identified with characters in programmes appealing to children may be used as presenters.

(4) Celebrities and characters well-known to children may present factual and relevant generic statements about nutrition, safety, education, etc.

7.3 Pressure To Purchase

7.3.1 Direct exhortation

Advertisements must not directly advise or ask children to buy or to ask their parents or others to make enquiries or purchases.

7.3.2 Unfair pressure

Advertisements must not imply that children will be inferior to others, disloyal or will have let someone down, if they or their family do not use a particular product or service.

[1] Commercial spin off services are ITV2, ITV3, ITV4, Men and Motors, Channel 4+1, E4, More 4, Film Four, Fiver, Five US and +1 time shifted versions of the channels

[2] Our analysis mirrors the findings of the Department of Health report which used a different measure (advertising spend) to establish the reductions in children’s exposure. Both pieces of analysis show a fall in impacts for all techniques considered to appeal to children.

The Committee for the Office of the
First Minister and deputy First Minister

Inquiry into Obesity

On 28 January 2009, the Committee for the Office of the First Minister and deputy First Minister considered your invitation to submit written evidence in relation to your Committee’s Inquiry into Obesity.

The Committee for the Office of the First Minister and the deputy First Minister sought in its recent inquiry into Child Poverty to develop a detailed understanding of child poverty in Northern Ireland and to use this understanding as the basis for the development of constructive suggestions to assist the Executive, and indeed future administrations, in developing a robust strategy to eliminate child poverty.

The Committee sought written and oral evidence regarding child poverty, and received several responses that highlighted the findings of the ‘Health and Social Care Inequalities Monitoring System: Second Update Bulletin 2007’ linking child poverty and obesity. The bulletin states that 5·9% of children in deprived areas are obese compared to 4·9% in areas that are not described as deprived.

Witnesses from Playboard; Eastern Health and Social Services Board; Western Investing for Health Partnership; Western Health Action Zone; and Derry City Council addressed obesity in their responses to the Committee’s inquiry. Among these submissions are examples of good practice to tackle the problem via improved play opportunities and programmes to educate families about personal development; physical activity; diet, nutrition and oral health; and to improve knowledge and skills for healthy lifestyles.

As you will appreciate, the Committee received a great deal of information in the course of its inquiry. In its summary, the Committee subsumed the issue of obesity into its conclusion on measures to tackle long-term disadvantage:

“In the long-term, improving the health and well-being and educational outcomes of families in poverty has a critical role in helping to address the cycle of deprivation. The Committee recognises the successes that there have been over the past decade in improving overall educational outcomes and in increasing life expectancy and reducing levels of preventable illness. However, the gaps in educational and health outcomes between children living in poverty and children from more affluent backgrounds remain stubbornly unaffected. The Committee is convinced of the importance of early intervention and family based approaches in seeking to break the cycle of poverty and wishes to see the Executive establishing specific objectives to increase the level of investment across government in early years services and to increase the number of places provided within Sure Start. The Committee has also identified the need for legislation relating to the planning of children’s services to be reviewed to ensure that there is a truly joined-up approach to children’s services planning in Northern Ireland."

Recommendation 41 of the report was as follows:

“The Committee considers that more attention needs to be paid to identifying and targeting the population groups at most risk of poor educational or health outcomes with specific, evidence-based strategies that will deliver real improvements for such groups."

The Executive response to this focused on the OFMDFM-led multi-agency Promoting Social Inclusion workstream and the overall Lifetime Opportunities Strategy.

I hope that these references will signpost you to the evidence relevant to your inquiry and that the Child Poverty Report provides useful background information about the health and opportunity costs, including obesity, that result from child poverty.

Yours sincerely,

Mr Danny Kennedy
Chairperson, Committee for the Office of the First Minister
and deputy First Minister

Department for Employment and Learning

Contents

1 Departmental Aim

To promote economic, social and personal development through high quality learning , research and skills training: and

To help people into employment and promote good employment practices

2 Department’s key areas of activity

3 Key Business Areas in DEL

Corporate Services: Minister’s Private Office/ Office of the Permanent Secretary/Central Management, Press Office, personnel, staff welfare, staff training, departmental records, [statistics / research and evaluation.]

Strategy and Employment Relations: Strategy and Equality covering compliance with S75 statutory duties and in particular the Department’s linkages with interdepartmental strategies; Employment and Industrial Relations, including responsibility for relevant legislation, and sponsorship of the Labour Relations Agency; the NI Certification Office; the administration of the Office of Industrial and Fair Employment Tribunals; the Industrial Court; and the Redundancy Payments Service; Migrant Workers Unit (facilitating the interdepartmental strategy); statistics/economists/research and evaluation.

Higher Education: Development of policy for the planning, funding and administration of higher education. Also, policy for student loans and awards, education maintenance allowances and for the payment of postgraduate awards.

Further Education: Development of policy for the planning, funding and administration of further education, including the reconfiguration of the Further Education Sector in line with the FE Means Business Review. Also responsible jointly with the Department of Education for the policy and curriculum for the 14-19 age group.

Skills and Industry : Responsibility for the NI Skills Strategy that sets out a vision for skills in Northern Ireland in 2015 and focuses on raising the skills levels of the workforce, enhancing the quality of those entering the workforce, and addressing the employability of those not in employment. This includes Careers Information, Advice and Guidance policy and delivery and the policy and administration of Training for Success, Apprenticeships, Bridge to Employment and Management Leadership programmes and also for sector development and the associated Sector Skills Councils.

Preparation for Work: Responsibility for the administration and delivery of the New Deal programmes; Steps to Work initiatives; the Disablement Advisory Service; Pathways to Work targeted at Incapacity Benefit recipients; Progress2Work (NI) to assist with overcoming major barriers to employment resulting from problems associated with homelessness and substance misuse, an offending background; and other community based employability initiatives such as LEMIS (Local Employment Intermediary Service) designed specifically to engage with unemployed and economically inactive people in Northern Ireland’s most disadvantaged areas, and help them equip themselves for work.

Employment Service (part of Preparation for Work Division): the delivery of the public employment service through frontline teams in the network of 35 Jobs & Benefit Offices and JobCentres. A pivotal function of the Service is its local engagement with employers and the availability of “online" vacancy filling services to assist business and jobseekers alike.

4 Context of DEL’s work

DEL’s Contribution to the Programme for Government is summarized as follows:

Priority: Growing a Dynamic, Innovative Economy

Actions: Increase by 300 the number of PhD research students at local universities by 2010

Introduce a new programme to increase the commercialisation of university and college research by 2010.

Goals: Increasing the employment rate from 70% to 75% by 2020

Ensuring by 2015 that 80% of the working age population is qualified to at least GCSE level or equivalent.

Increasing the number of adult learners achieving a qualification in literacy, numeracy and ICT skills by 90,000 by 2015.

Increasing by 25% the numbers of students, especially those from disadvantaged communities, at graduate and postgraduate level studying Science, Technology, Engineering and Mathematics (STEM subjects) by 2015.

Priority: Promote Tolerance, Inclusion and Health and Well-Being

Actions: Put in place by 2010 a careers advice service to meet the needs of people with disabilities.

In carrying out its business DEL will contribute to the following Public Service Agreements (PSAs):

In the delivery of its programmes and services DEL has a range of contractual and other arrangements with delivery partners. These include Universities, Further Education Colleges, training organisations – both private sector and voluntary and community organisations, and other organisations providing specialist support for DEL customers.

DEL’s Role in tackling Obesity

The Department for Employment and Learning 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. DEL’s direct influence in this regard is linked by its role and remit.

Further Education

The welfare of students in FE Colleges falls directly to the institutions involved.

FE Colleges are important institutions in which health can be promoted. Many students gain information about nutrition through their learning programmes. DEL has therefore issued guidelines on issues within the FE sector on physical activity, eating and health as well as drugs and substance abuse.

Most of the FE colleges have sporting/fitness facilities which are available for use by students. The Governing Bodies have ultimate responsibility for sport and facilities.

Within the FE sector, DEL funds a range of Physical Education and Sports Studies/Sciences across NI. Capital funding continues to be available for all curriculum areas, including sports facilities.

Higher Education

DEL supports innovation, research and development in universities including in the field of health. For example, the University of Ulster’s Sports Related Studies was placed in the top third of Sports-Related Studies in the UK in the recent Research Assessment Exercise. Among the research areas studied by the institute are:

In addition, our two universities are undertaking excellent work, in the field of diabetes, which it is widely recognized is often developed by people who are obese.

Queen’s University Belfast Diabetes Research Group

The Group is based on the Royal Victoria Hospital site of Queen’s University Belfast (QUB). There are active collaborations with local clinicians (diabetes), and with national and international groups.

The major work of the Group involves the vascular complications of diabetes and obesity, a major risk factor for the development of type 2 diabetes.

Of the successful projects recently awarded funding, through DEL’s ‘Strengthening the All-Island Research Base’; one is entitled ‘Diet, Obesity and Diabetes’. Its objective is to bring together the leading research groups throughout Ireland to provide a comprehensive all-island research centre to improve the primary and secondary prevention of obesity and diabetes. QUB will work in collaboration with the Institute of Public Health in Ireland and The National Research Centre for Diet, Obesity and Diabetes, University College Cork.

University of Ulster Diabetes Research Group

Since its formation in1989 the Group has built an extensive range of external networks being the founder of the European Association for the Study of Diabetes (EASD) Islet Study Group and playing a pivotal role in the establishment of the EU-funded Islet Research European and Latin-American Networks. The Group has also played a key role in diabetes research both nationally and internationally through senior positions in the British Diabetic Association/Diabetes UK, the EASD and establishing rich collaborations with numerous Centres of Excellence worldwide. The Group’s activities are expanding and the formation of a province-wide HPSS funded RRG in Diabetes and Endocrinology has strengthened local clinical collaborations.

Areas of research studied by the group include assessment of diet and lifestyle factors in gestational type 1 and type 2 diabetes. This research aims to assess what women with diabetes eat in relation to lifestyle and published dietary guidelines. A further element is assessing maternal diet and lifestyle factors in relation to gestational diabetes and pregnancy outcomes.

While DEL has links with teacher training colleges, the curriculum and supply of teachers is the responsibility of Department of Education.

However, regarding training for non-teacher coaches, SkillsActive (the Sector Skills Council for Active Leisure) is very much involved in determination of the skills needs in its sector in NI and works through a very robust network of employers and stakeholders. SkillsActive has a sector skills agreement for the industry which refers to coaching and identifies the needs of this sub-sector. They are continuing to seek employer and stakeholder views and work towards an action plan to address these needs.

With the exception of the Open University, all of the Higher Education Institutions in Northern Ireland have, or provide access to, dedicated sports facilities for staff and students to avail of. These include, for example, the Physical Education Centre (PEC) at Queen’s University and a range of leisure facilities at three of the University of Ulster’s campuses. UU also has boasts the Sports Institute for Northern Ireland at its Jordanstown campus and, in common with the other institutions, hosts a number of sports clubs and teams.

Sectoral Development

SkillsActive is the Sector Skills Council (SSC) responsible for upskilling the workforce in the sport and leisure sectors. DEL is providing funding support for projects including, Workforce Development Planning in Sport; Workforce Development Initiative; and Profile of the 2012 Active Leisure Workforce.

Skills for Care and Development is the SSC responsible for developing and training the social care and children’s services workforce. NI Social Care Council is the regulatory body for the Northern Ireland social care workforce. It is an independent public body, established to increase public protection by improving and regulating standards of training and practice for social care workers. This includes National Occupational Standards to Promote the Health and Physical Development of Children; elements include:

DEL Staff

Many DEL staff have benefited from attending the NICS Sports Association (NICSSA) Healthworks events over the past number of years. The core 2 day programme includes advice on nutrition, alcohol consumption and exercise. The course is available to all staff through the Centre for Applied Learning. There are also options for shorter, more specific sessions which DEL managers tend to incorporate into team time or other events.

The Lifestyle and Physical Activity Assessment programme is operated by the Occupational Health Service (OHS) with places allocated to each Department. The programme includes a lifestyle evaluation and assessment of activity levels. A physiological assessment includes measurement of blood pressure, cholesterol, strength, flexibility, lung function and stamina. On completion of the test, general advice on improving lifestyle is given and each participant gets a personalised fitness printout.

In relation to DEL staff, as with other public sector organizations, catering policies

are reviewed to ensure that healthy food options are available on their premises.

DEL Commitment

The Committee will wish to be aware that the Department for Employment and Learning 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 will continue to engage with the work of the various Groups on which it sits and do all within scope of its core business to address this important and widespread issue.

Department for Employment and Learning
3 February 2009

Conservation Volunteers Northern Ireland

Conservation Volunteers Northern Ireland has been a registered charity involving all sections of the community for 25 years. We’re aiming for a better environment where people feel valued, included and involved. Every year Conservation Volunteers Northern Ireland, which is part of BTCV, connects with 29,800 people who make positive differences to their local communities and their environments. Our mission is to create a more sustainable future by inspiring people and improving places.

Conservation Volunteers’ values are integral to all our work. They have been developed through two decades of a ‘hands-on’ approach to conservation activities. During this time we have adapted to meet the changing needs of communities, we care about people, the communities in which they live and the quality of their lifestyles and living environment.

Conservation Volunteers Northern Ireland aims to create a better environment where people from all ages, abilities and cultures feel valued, included and involved. This is achieved through the delivery of projects under four broad themes: Health, Environments for All, Direct Action and Biodiversity.

Welcome for the Inquiry

Conservation Volunteers welcomes this Inquiry by the Health Committee into this important issue facing the whole of society. Rising obesity levels, especially in children, is a serious problem that also reflects some more general problems in society and will have major impacts on public health and medical care for many years to come.

Across the UK the equivalent of £886 per head of population is spent per year in providing what amounts to a national sickness service and we spend £1 per person per year on sports and physical activity which could actually prevent a lot of that sickness."

Obesity – Lifestyle and diet

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 consuls, advertising and promotion of unbalanced diet, availability of convenience food, cost of healthy food options, inadequate cooking skills, and transport and planning decisions. British Heart Foundation statistics 2004 show Northern Ireland individuals spend on average 157.1 minutes per day watching TV and DVD’s, 3.5 minutes gardening and 4.4 minutes walking.

Linking the natural environment and health

Conservation Volunteers believe that there is a direct connection between quality of living environment and quality of life. We recognise that disadvantaged communities generally experience poorest quality built and natural environments, as well as poor health, poor education and poor employment prospects. Improving one aspect of these issues is not the solution. Increasing physical activity alone is not the answer, objectives need to include learning on wider health issues e.g. mental health, diet and nutrition, community involvement and cohesion whilst demonstrating how easy and effective it is to increase your daily exercise levels and sustain these over a period of time.

There is mounting evidence of the links between direct contact with the natural environment and the positive benefits to individuals and community health. In society, as a whole, there is an increase in sedentary, virtual lifestyles which is having a dramatic increase in very real physical and mental health problems. Extensive research has shown that physical activity can be an effective method of improving psychological well-being, reducing clinical depression, risk of depression, anxiety and stress, and improving aspects of mental functioning such as planning, short-term memory and decision making. It has also been mooted that people have a biologically-based attraction to nature (‘biophilia’) and that being in and connecting to nature can itself provide mental health benefits (Mental Health Foundation 2007).

Conservation Volunteers Green Gym Project has developed a flexible needs based approach which tackles overlapping issues of sedentary lifestyles, poor diet and nutrition, mental ill health, social isolation, poor living environment, lack of environmental and health awareness. As the Green Gym creates the opportunity to increase physical activity without exercising in the conventional sense of the term, Conservation Volunteers encourage individuals to be healthier physically therefore happier mentally. Direct involvement in the Green Gym address additional issues of community empowerment and ownership.

Help individuals and communities to develop skills to make healthier lifestyle choices.

The quality of life in disadvantaged urban areas can be significantly improved though raising awareness about how to make healthier lifestyle choices, e.g. by providing hands-on experience of growing, cooking and eating fruit and vegetables and measuring dietary changes through participants food diaries. The Green Gym assists participants to take the first steps to increase physical activity levels whilst incorporating healthy eating and improved nutrition, and equip them with the knowledge and confidence to sustain these on a long-term basis.

Green Gym Community Fruit & Vegetable Gardens

The overall aim of this project is to establish and sustain affordable healthy eating in areas of long-term deprivation. Through the direct involvement of local people the project increases knowledge and develops skills across a range of areas, e.g. growing vegetables, cooking for health and nutritional information. Conservation Volunteers Fruit & Vegetable Green Gyms are delivered in Partnership with Belfast Health Trust Community Dietitic Services, providing a holistic approach to healthier lifestyles. The physical activity of developing the community gardens is complemented by health eating and nutrition sessions.

Conservation Volunteers have six years of experience of developing community fruit and vegetable gardens through our Green Gym Project. This project helps achieve objectives outlined in a number of Regional Diet & Nutritional Strategies:-

‘Fit Futures: Focus on Food, Activity and Young People’

‘We are What we Eat - Future Challenges’

The Eat Well Model, formally the Balance of Good Health Model is an integral part of this project where indoor information sessions will be delivered in conjunction with the practical garden development and growing. The Cook it Model is also incorporated with sessions covering how to cook fresh produce from your garden, food hygene and cooking on a budget. Conservation Volunteers will expand this holistic approach to healthy eating into the two identified project areas.

Monitoring of existing fruit and vegetable Green Gym projects shows an increase in number of pieces of fruit and vegetables eaten per day after six months of regular involvement. On project day one 0-16 year olds consumed 0.97 pieces per day and adults 0.7. These figures increased to 4.28 and 3.8 respectively by project day 15 (NI Green Gym 2007).

Integrated Solutions to Obesity

As highlighted across a number of Health Strategies tackling the current issues including obesity lies beyond the capacity of the Health Service alone. Joint up partnership working is required of affective approaches are to be implemented and successful.

Adopting an integrated approach to obesity, addressing several causal factors while promoting more sustainable lifestyles and food consumption, will have many benefits for public health and for the health service, as well as additional benefits to the community through enhanced provision of goods and services which will facilitate people to adapt to the changes facing us all in the 21st century.

Conservation Volunteers would like to thank you for this opportunity to comment on the raising issues of Obesity in Northern Ireland. If you require any further details or clarification of the comments please do not hesitate to contact us.

The Royal College of Psychiatrists

Mr Hugh Farren
Clerk to the Assembly Health Committee
Room 412
Parliament Buildings
Stormont
Belfast BT4 3XX

12 February 2009

Dear Mr Farren

Thank you for your invitation to provide evidence to the Assembly Health Committee’s inquiry into obesity. The Royal College of Psychiatrists commends the Health Committee for its work in this area.

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. We therefore welcome the Health Committee’s interest in including this group of people in considering an obesity strategy for Northern Ireland.

As a College, we are committed to helping the Assembly understand the issues involved in psychiatry in Northern Ireland, and hope the Committee will continue to call on us as appropriate.

Yours sincerely

Dr. Philip Mc Garry FRCPsych
Consultant Psychiatrist
NI Division Public Affairs Officer

The Royal College of Psychiatrists is the statutory body responsible for the supervision of the training and accreditation of psychiatrists in Britain and Ireland and for providing guidelines and advice regarding the treatment, care and prevention of mental and behavioural disorders.

The College has 294 members in Northern Ireland, as well as younger doctors in training. These doctors provide the backbone of the local psychiatric service, offering inpatient, day patient and outpatient treatment, as well as specialist care and consultation across a large range of settings.

The College welcomes the Assembly Health Committee’s inquiry to examine the current approach to tackling obesity, and is grateful for the opportunity to contribute to this.

Why consider people with mental illness and learning disability?

It is widely acknowledged that people with severe mental health problems and/or learning disability are more likely than the general population to be obese, and have a higher level of associated physical health problems.

This is an international trend, not unique to the United Kingdom, and is associated with a complexity of factors including medication, disadvantage and lifestyle. However, research in England and Wales quantifies the problem.

The Disability Rights Commission’s Closing the Gap report on healthcare inequalities experienced by people with mental health problems and learning disability in England and Wales (2006) found people with mental illness are much more likely than other people to be obese (33% of people with schizophrenia and 30% of those with bipolar were obese, compared to 21% of the remaining population), and to have significant related health risks and major health problems such as heart disease, hypertension, stroke and diabetes[1]. They are twice as likely to die from coronary heart disease as the general population[2].

Both people with mental illness and people with learning disability are likely to die younger than other people. People with serious mental health problems are also more likely than others to get illnesses such as strokes and coronary heart disease before 55. Once they have them they are less likely to survive for five years.

A review of international research[3] found that children and adolescents with major depressive disorder may be at increased risk for developing overweight; obese people seeking weight-loss treatment may have elevated rates of depressive and bipolar disorders; general obesity is associated with major depressive disorder in women; and abdominal obesity may be associated with depressive symptoms in men and women. However, it found that most overweight and obese persons in the community do not have mood disorders.

Obesity can be a particular issue in inpatient settings, particularly where patients are resident for a lengthy period, for example when they are detained. One forensic mental health trust in England found that it is not uncommon for patients to put on 30-40 kg while in hospital[4].

Why do people with mental health problems and learning disability carry more weight?

Many of the reasons that people with mental health problems and learning disability are obese are the same as for the general population: eating too much calorie-rich food and exercising too little.

However, the reasons for this can be complex.

What could be done to address this?

All aspects of an obesity strategy are likely to apply to people with a mental health problem, but this group may be difficult to engage and require additional input and support.

People who use mental health services need to be educated about the physical health effects of food intake and obesity and encouraged to agree to positive changes to diet and exercise. Care planning should be used to support dietary modification, and encourage activity.

NICE Guidance on Obesity states that “Managers and health professionals in all primary care settings should ensure that preventing and managing obesity is a priority at both strategic and delivery levels. Dedicated resources should be allocated for action"[8]. It does not set out guidance specifically for managing obesity in people with mental illness.

However, NICE Guidance on Schizophrenia states that GPs and other primary healthcare professionals should monitor the physical health of people with schizophrenia. Physical health checks should be carried out at least annually and have results clearly documented by the primary care clinician and communicated to the mental health care coordinator and/or psychiatrist, and recorded in secondary care notes. Monitoring should include: weight gain and obesity (waist hip ratio or waist circumference); blood pressure; dietary intake; activity levels and exercise; blood levels of glucose; and lipids.

General practitioners may need to be proactive in helping people with mental illness manage their weight. This may be a sensitive issue, but should not be avoided. Mental health staff should also be proactive about addressing the issue, and where appropriate liaise with, and encourage contact with, the GP.

Diet can be problematic for people with severe mental illness. Health professionals should take this into account, and support and education should be provided to help people maintain a healthy diet. GPs should also ensure that advice on diet is given to people with severe mental illness, as included in the 2006 GP contract.

Mental health staff should be able to directly refer patients to community dieticians, and there should be a pool of dieticians trained to offer advice and support to people with mental illness. This could potentially be offered in community mental health settings.

People with severe mental illness may find shopping for food and cooking difficult, and should be provided with practical support to manage this. Mental health teams could take some responsibility for providing practical support to address these issues.

Keeping active is an important element of protecting the body from physical health problems, and can also be beneficial for mental health. GPs could consider prescribing exercise programmes for people with mental health problems who are becoming overweight. People with mental illness should be able to access leisure facilities at a concessionary rate.

In summary, the Royal College of Psychiatrists would encourage the Health Committee to consider how any obesity strategy will engage people with mental health problems, and how health practitioners can be supported to provide the necessary input.

Appendix 1

Key findings from the Disability Rights Commission

The rates of co-morbidity of severe mental illness and physical illness that are sometimes linked to obesity are higher than in the remaining population (unadjusted for differences in age distribution):

University of Ulster

Committee for Health and Social Care and Public Safety: Inquiry on Obesity

Thank you for asking the University of Ulster to comment on this very important public health issue. The University has a range of internationally renowned researchers in this field. In particular, I include the Northern Ireland Centre for Diet and Health (NICHE) where a number of important studies have been undertaken into the causes, effects and prevention of obesity. In addition, researchers in our School of Nursing have been funded to investigate the phenomenon of obesity in people with learning disability. Furthermore, staff in our School of Sports Studies have researched the effects of exercise on combating obesity. You could bring it to the Committee’s attention that the research quality of each of these disciplines was rated internationally excellent or world leading in the most recent Research Assessment Exercise. This is a measure of the expertise available in Ulster and if required, I am sure these colleagues would be pleased to provide you with further information. There follows our comments on the three terms of reference drawn up by the HSSPS Committee:

Introduction

Obesity is increasing at an alarming rate and estimated predictions suggest the numbers of adults and children who are overweight or obese shall increase dramatically, with over half the population in many developed countries being obese by the year 2050. The outcomes to health that can result from being obese include atherosclerosis, heart disease, diabetes, respiratory problems and a number of cancers. Problems are not restricted to physical illness with reports highlighting how obese children can face emotional issues such as low self esteem, poor expectations for their future and feelings of isolation because they are marginalised and stigmatised for being fat.

Diet, physical activity and behaviour modification have been integral to most health promotion intervention programmes that attempt to tackle obesity. But, to date no country in the world has been able to achieve sustained reversal of overweight and obesity trends.

1. Assess the scope and appropriateness of the current approach to tackling obesity and the promotion of lifestyle change

This is very difficult to determine for 2 main reasons:

1) Currently in NI there are so many different approaches: “Healthy Breaks", “Get a life get active" and “Eat well to keep well" to name just a few. The problem may well be that the public get a mixed message.

2) The approaches that have been undertaken have not been rigorously analyzed and so any useful information has been lost.

The most important factor when trying to achieving successful changes within a whole population is a uniform approach from all agencies. This will require one over arching body directing the strategy.

The Fit Futures undertook a consultation and reported in 2007 their priority approaches are:

Policies and strategies to tackle obesity should take adequate account of the importance of the role of parents and families in establishing and supporting good nutrition and active living, particularly during the first few years of a child’s life. One of the key messages to emerge from the Fit Futures consultation process is that parents have primary responsibility for ensuring the health and well-being of their children, but that action needs to be taken to support parents to fulfill this role effectively.

The development of the basic knowledge and skills necessary to encourage and support children and young people to be active and eat healthily, among those supporting and working on a daily basis with children and young people, was also identified as an important way of enabling children to make healthy choices. Policies and programmes also need to recognise the complexity of obesity and that a long-term commitment will be required if current trends are to be halted and then reversed.

Obesity is not restricted to one sector of society and a population approach to obesity prevention should be adopted. However, particular attention should be paid to the needs of children and young people on low income or with a disability as they face additional barriers to healthy eating and active living. Activity levels in girls are also a particular concern. In addition, policies and programmes to tackle obesity in children should recognise that the most effective solutions are likely to be positive and focus on promoting and developing the self-esteem of young people and that there is significant benefit to be gained from making the healthy option the fun option. Above all, the Fit Futures taskforce recognises that policies and strategies to tackle obesity must take account of the available evidence in relation to what works and what doesn’t work when it comes to obesity prevention.

(http://www.dhsspsni.gov.uk/showconsultations?txtid=22125)

However, on area that is often passed over is psychology, in a mini review Malterud and Tonstand, (2009) outlined that Individual vulnerability and neurobiological mechanisms that may lead to weight gain must be taken into consideration, when developing strategies for health promotion. Prevention of weight gain is very holistic in its nature and must take on board, socio demographic, cultural and genetic characteristics. Also, when promoting interventions or strategies to overcome weight gain/obesity it’s important to avoid body weight control into a question of morality and social identity.

2. Examine the availability of weight management or other intervention services to tackle obesity and related ill-health

Some of the obvious strategies have been by using drug intervention; however, these are limited to obese individuals and the weight loss is minimal. An intervention looking at drugs (i.e. tesofensine 0.25mg, 0.5 or 1.0mg) which inhibit presynaptic uptake of NA, dopamine and serotonin appear to double the weight loss in obese patients compared to currently approved drugs (Astrup et al., 2008)

Some interventions have looked at eating behaviours related to obesity and it’s association with job stress (Nishitani, et al., 2009). It has been argued that obesity treatments should include therapeutic strategies that decreases body related worrying and sad mood, particularly for the overweight/obese who are high in negative affect (i.e. sad mood state).

Growing evidence suggests that obesity is not just linked to a weight problem but also neurocognitive outcomes. Positive affectively in obesity treatment is, therefore, discussed (Cserjesi et al., 2009). Results provide support for current cognitive-behavioural models of binge eating and have implications for treating binge eating and intervention efforts with children (i.e. 8-13 year olds). Also there is a discussion review on the need for practitioners and health care professionals to become involved in the evaluation studies that build on the limited base of current evidence (Wofford, 2008) (I forwarded this ref last week to the obesity group so you should have a copy).

A recent study in Barcelona highlights the need to consider socio-economic indicators when implementing strategies to improve public health; however, they don’t really relate this to obesity as such (Cano-Serral, 2009).

It is clear that the increasing concern about obesity trends (an consequences) have led to many initiatives (e.g. to improve nutritional quality of food in NI schools/promotion of health promoting schools) to try to tackle the problem. While such initiatives are to be welcomed evidence on the effectiveness of such interventions ranges from thin to non-existent (or impossible). In any case, given that obesity is a complex and multifaceted disorder such initiatives in isolation are unlikely to have significant impact unless part of a multi-sectoral joined up policy on obesity. The latter will be key to any successful strategy for tackling obesity.

Note: to date no country has such a joined up, comprehensive approach to obesity.

Currently there exist no official guidelines for prevention and management of obesity.

3. Consider what further action is required, taking account, as appropriate, of the potential to learn from experience elsewhere

We think this paper may be quite relevant to help address this question James F. Sallis, (2009).

Top five promising methods that can be used in research now:

1. Policy change evaluations that assess (1) implementation, (2) enforcement, (3) community acceptance, and (4) impact over time on rates of obesity or obesogenic nutrition behaviors;

2. Surveillance research to track changes in food-industry activities with the potential to influence nutrition behaviors (e.g., packaged portion sizes, reduced-calorie options) would allow researchers to (1) identify opportunities for natural experiments, (2) examine the influence of industry activities on nutrition behaviors and obesity, and (3) determine how industry activities shift in response to policy changes;

3. Observational multilevel studies, including research designed to examine interactions between individuals and food environments (e.g., what individual factors increase susceptibility to obesogenic food environments);

4. Studies designed to examine (or quantify) the influence of multiple environmental domains and their interactions on rates of obesity (or obesogenic nutrition behaviors);

5. Cross-disciplinary and transdisciplinary collaborations that incorporate complementary methodologies (e.g., qualitative and quantitative approaches).

Top five research priorities:

1. Conduct research in minority and low-income populations, such as the evaluation of policies to reduce/eliminate disparities in access to food (e.g., tax incentives for stores in low-income neighborhoods);

2. Develop standardized measures of food environment and nutrition policies (for various types of environments and contexts) to improve the comparability of findings across studies);

3. Examine motivations for food choices, including tensions between internal and external (environmental) factors on behavior;

4. Conduct research relating to home and family food environments;

5. Conduct research guided by systems theory.

All of which could be implemented although modified here.

Key issues for the future

Specifically with regard to the public sector

What needs to be done?

Finally the way food marketing contributes to childhood obesity is of importance, Harris, 2008, describes various mechanisms which may be implemented in order to change the current situation (Harris, 2008).

In the School of Sports Studies and the Sport & Exercise Sciences Research Institute we are involved in a range of studies relating to physical activity and health. Many of these have implications for both obesity prevention and management- although neither of these have been primary outcome measures.

For example our group has recently shown the beneficial effects of acute (single bout) and chronic (12 week training program) moderate intensity aerobic exercise on various cardiovascular, metabolic and physical indices of health in a group of obese subjects suffering from impaired glucose tolerance (IGT) or ‘pre-diabetes’.

This research was recently presented at the American College of Sports Medicine Annual Conference 2009 in Seattle, USA. 2 abstracts have been published in Medicine and Science Sports and Exercise Vol 41 no.5 May 2009 supplement : McClean et al pp S26 and McNeilly et al pp S511

We also have a range of publications on the role of exercise in altering health parameters in a range of populations which have a slightly more tangential relevance to obesity prevention - if you would like our Research Institute Director, Eric Wallace to forward these- please let us know

Obesity Management Association

This report is presented in response to the invitation by the Committee for Health, Social Services and Public Safety to submit evidence to assist the Committee to carry out an inquiry into obesity.

Executive Summary

Assessment of the Scope and Appropriateness of Current Approaches to the Prevention of Obesity and the Promotion of Lifestyle Changes

Until very recently obesity had been considered to be a lifestyle disease, but after a review by the United Kingdom Government’s National Audit Office, the accent changed and obesity is now regarded as a serious life threatening disease - the consequences of which cost the Government in excess of £6billion per year to treat, and this amount is rising. (This is the estimated cost to NHS in England and Wales only as both Scotland and Northern Ireland have independent health services).

These consequences include diabetes, high blood pressure, heart disease and cancer. They take up medical staff time, hospital beds, medicines and worry for patients and their families. In addition to the £6billion treatment costs, there is also a loss of earnings for the families and the value of lost workdays which collectively could add a further £1+billion to the eventual cost.

Historic and current policies to deliver long-term solutions for the treatment of obesity do not work.

The UK Government’s current anti-obesity policies focus on well meaning but ineffective practices which depend on the positive and continuous commitments from the patient;

These have failed to stop the crisis, and therefore a different approach is required.

The outcome is there is a major group of people who are overweight and obese due to poor diets, lack of exercise and an unwillingness to change their lifestyles and eating habits.

The socio-economic profile of the highest population group of obesity patients are C3 – D and E, namely low income households, poorly educated, low personal esteem who lack motivation and are dependent on the State.

The results of OMA’s 2007 survey of patients through its clinics confirm the above, and a genuine reluctance to engage with their General Practitioners. We believe this is largely due to time constraints and pressure on General Practitioners.

OMA recognises there are a group of patients across all socio-economic groups whose personal physiology results in them being obese.

The UK Government’s approach is to educate centrally using television press, outdoor and direct mail advertising supported with PR and to pass treatment responsibilities to Primary Care Trusts, so in practice there are hundreds of different ideas and ambitions without a common theme. [refer to the appendix on the latest programme introduced by the Scottish Government which confirms this positions].

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. Surprisingly none incorporate the use of private clinics which can offer lower cost in patient treatments thereby releasing pressure and demands on the NHS.

The current treatments of obesity in the UK NHS have the classic central Government philosophy;

Child Obesity

The loss of school playing fields and fear of children being abused causes many children to stay at home and undertake no exercise, which increases obesity. However, all football clubs should be encouraged to give exercise (and fun) to very large numbers of children and O.M.A. would be prepared to organise this.

The traditional home economic teaching in school would help children of poorer families to understand what is healthy and necessary, such as the five-a-day advertisement which has been successful. Add to this how to eat healthily within your budget would address the financial question.

In this vein, the use of Irish celebrity chefs heading up good kids and family food/diet campaigns locally and shown on national television can focus the mind of children and youths. This can be very cost effective and it is reality television, which is now popular with this audience.

The National Institute of Clinical Excellence (NICE) issued guidance regarding the treatment of children, but this excluded the use of medicines in the under-18 age group.

Dr Jeffrey Fine, OMA Board Member and Harley Street specialist in the treatment of overweight and obese patients has also produced guidelines on the treatment of obesity in children – an extract from his report follows;

Intervention Strategies

The treatment of obese and overweight children requires a different approach to that of adult treatment programmes.

Unfortunately many doctors consider this to be a “glandular problem" and simply check height and weight and conclude because of their age they lay down fat more easily – with respect this is a myth Obesity results from excess of food intake over output, one must of course exclude rare causes. Constitutional facts are not a cause.

Similarly, obese infants and toddlers do not always end up being obese adults “the bonny baby" belief is another myth.

The older the child the more likely the problem is to persist. This is a spectrum disorder. At one end a supportive family will take action to address the issues, sadly at the other end the behaviour problems by uninterested family obesity is the norm, and therefore little or no action is taken to rectify the problems.

The G.P. is well placed to manage the problem, compared to hospital doctors who are unable to establish any long-term relationship or solution.

B.M.I. (Body Mass Index) –is the normal measurement process to determine obesity; in addition Doctors should incorporate an additional and simple objective measure of waist/hip ratio when evaluating the patient’s condition and treatment.

Obesity in Children is Endemic in urban society, which results in the need to change national diet.

Experience shows the best results involve family members who must monitor and support the child in the treatment programme.

The National Obesity Forum is against the use of medicines except as a very last resort.

European Union law states that patients cannot be treated with drugs until their body mass index (BMI) is 30kg/m2 unless there are other reasons such as diabetes, high blood pressure or high cholesterol when treatment can start at BMI 27. As obese patients are showing the consequences of obesity they should be started on treatment at BMI 27, not 30, and the Primary Care Trust should make a special effort to treat this group urgently.

Professor M. Lean, Human Nutrition Faculty of Medicine at the University of Glasgow, stated in the BMJ 2008; 337:2408 that only drugs, diet, exercise and bariatric surgery aid will lead to permanent weight loss.

O.M.A. believes that in certain cases medicines should be included in the first line of treatment, together with diet and exercise programmes. It also believes that obesity can be overcome on a Doctor to patient basis with regular appointments and excellent close supervision of the patient.

Examination of the availability of weight management and other intervention services to take obesity-related ill health and to consider further action.

General Practitioners are normally the first clinical professionals to diagnose obese patients. As obesity affects 25% of the population and budgets are constantly squeezed, they are often reluctant to begin treatment of their patients with drugs. Instead they give the patients diet sheets, tell them to exercise, think about lifestyle changes, educate themselves and invariably none of these recommendations work.

O.M.A. believes the scope of the current UK Government approach is limited because:

Consider what further action is required

We understand the UK Government now recognises and accepts the NHS unable to deal with the size of the problem due to lack of services and increasing co-morbidity costs.

A programme of pro-active and preventative action is required which includes;

Appendix

Statement by the Scottish Government on its actions in dealing with its Obesity priority

What is the nature and extent of the Scottish Government’s action on this priority?

The Scottish Government has a twin approach to tackling unhealthy weight through an integrated implementation of our national Physical Activity Strategy ‘Let’s Make Scotland More Active’ and ‘Eating for Health: A Diet Action Plan for Scotland’. Additional measures in schools will be secured through the Schools (Nutrition and Health Promotion) Act 2007. We plan to publish an action programme covering healthy eating, physical activity and healthy weight in spring 2008. This will build on, rather than replace, existing delivery of the Physical Activity Strategy and Diet Action Plan. The strategic spending review 2007 has committed an additional £40 million over the next three years to delivering in these three interlinked policy areas.

LighterLife (UK) Ltd

Introduction

LighterLife welcomes the opportunity to submit written evidence to the Assembly Health Committee inquiry into obesity. We acknowledge that the factors that lead to obesity are multiple (as outlined by Foresight in Tackling Obesities: Future Choices, 2007). However, our comments will focus on the sector in which we are operating – that of community-based adult weight management services and in particular the use of very low calorie and low calorie diets.

LighterLife – Who we are

LighterLife, founded in 1996, is a successful weight loss and weight management company. As well as the CEO and the Board of Directors, LighterLife benefits from the clinical input of an independent Medical Advisory Board. Our Chief Medical Officer is Professor Iain Broom, consultant in clinical biochemistry and metabolic science at Grampian University Hospitals NHS Trust.

LighterLife central office is based in Harlow in Essex. We have a network of over 280 EdExcel-accredited weight-management counsellors who operate across all four countries of the UK and the Republic of Ireland. Weight-management counsellors run single sex groups which typically have up to 12 patients. We have worked with over 100,000 patients.

Our programmes – What we do

The LighterLife Programme

The LighterLife Programme has been developed with two main components:

using a Very Low Calorie Diet (VLCD) for people who are obese (a typical VLCD patient comes to us with a BMI of 37).

The LighterLife Programme complies with COMA and NICE guidance. Alongside the Foodpacks, LighterLife provides behavioural therapy (cognitive behavioural therapy and transactional analysis techniques) specifically developed for the treatment of overweight and obesity to address the issues behind patients’ eating and levels of physical activity and the strategies they can put in place to prevent them putting on weight in the future.

The therapeutic package and the materials that accompany it are an important part of the LighterLife Programme – and are supported by evidence that patients are more likely to lose weight and maintain that weight loss if they do so as part of a group and have support.

LighterLife Lite

In November 2008, we introduced LighterLife Lite, a Low Calorie Diet (LCD) for patients who have a BMI from 25 to 29.9. This uses the same approach as the VLCD, except that instead of four Foodpacks, patients have three nutritionally balanced Foodpacks and one conventional meal a day.

What are the issues?

The key issues in tackling obesity

Obesity has become a major public health epidemic. In Northern Ireland 60% of adults have a weight problem and as many as 1 in 5 are obese. Prevalence of obesity is increasing at such a rate that on current trends it will surpass smoking as the greatest cause of premature loss of life. Obesity is associated and linked to many physical and psychological health problems, including coronary heart disease, diabetes, kidney failure, osteoarthritis, back pain, cancer and hypertension. Psychologically, people who are overweight or obese have lower self-esteem, higher levels of depression and increased rates of isolation.

Despite this, the response remains patchy and there is no coherent approach to tackling the causes of overweight and obesity and preventing the rise in overweight and obesity in order to reduce the number of people who are overweight and obese.

There is a need to have a good and clear understanding of the geographic prevalence of overweight and obesity and to understand its causes. Once these are established, it is important to ensure that action to tackle obesity is targeted at all ages, all communities and coordinated across all sectors.

We know that:

The health service response to date – what is working well

We welcome the way in which Governments have made a commitment to tackle the causes of overweight and obesity and to help those who are overweight and obese to lose weight.

We are encouraged by moves that some parts of the health sector have made to work with the commercial sector and to use its expertise. However, we believe that there is scope to develop this relationship further and to increase the number of private sector providers working in partnership with the NHS.

The evidence base and policy framework identifies that solutions need to be multi-pronged and need to focus on:

The traditional weight reduction pathway identifies four levels of intervention:

1. Primary prevention;

2. Commercial weight management services in the community;

3. Specialist obesity services in hospital; and

4. Morbid obesity services in hospital.

Primary prevention has been at the front of practitioners’ minds and there does not appear to have developed a clear patient pathway for those for whom general advice on healthy eating and physical activity are not working.

As primary care practitioners and patients become more aware of the risks associated with obesity, there is a need to ensure that they have the expertise they need to deliver primary prevention and at the same time to recognise that it may not work for all target groups. In these cases, there is a need to identify what options in secondary prevention are available.

The health service response to date – what can be improved

Whilst there has been an increase in activity in relation to primary prevention, drug therapies and bariatrics, there is an opportunity further to develop work on the use of the commercial weight management services in the community, particularly in relation to patients who are obese. There is scope to be more receptive to different approaches in any review Northern Ireland is making of its overweight and obesity services.

At a national level, there is a need to acknowledge the part community based interventions can play in combating overweight and obesity. This may be encouraged through the:

What the health service needs to do next (DHSSPS and Health Boards)

Given the extent of the problem and the predicted costs to the health service (and the rest of society) which will result from inaction, there is a need for the health service to expand its service provision and to revisit the traditional weight reduction pathway. Despite the development of pharmacological and surgical treatments, dietetic treatment is still the basic therapeutic tool against obesity (Ayyad, Andersen 2000).

The current weight reduction pathway implies that the boundary between service provision in the community and in hospital is drawn at the stage when a person moves from being overweight to obese. In other words, health care purchasers are being asked to:

There is a need to revisit this, not least because of the numbers of people who are overweight and obese and the costs of providing interventions for all of them in clinical settings. We do not think that it would be possible to provide weight management services to everyone who is obese and could benefit in a hospital setting (whether in the private or public sectors or both). There is also a need to recognise that VLCDs and LCDs are effective tools in weight reduction.

LighterLife believes that there is a strong case for ensuring that guidance provided by the Health Boards is comprehensive and looks at a wide range of ways in which overweight and obese patients can be treated in the community by a range of providers.

As noted in ‘Our Programmes’ (above) LighterLife is a leading provider of overweight and obesity management services in the community. The LighterLife Programme is clinically supervised and combines a VLCD with techniques from cognitive behavioural therapy (CBT) and transactional analysis (TA).

VLCDs enable patients who are overweight and obese to lose weight in a way that is safe and effective. It is recognised that for obese patients the rate of weight loss can be rapid at the outset (on average women lose 1 stone per month and men 1.5 stones). This initial weight loss can be an important motivator for patients to continue to lose weight. Over the longer term VLCDs offer a sustainable weight loss of, on average, 0.5 – 1kg per week.

The Route to Management Programme which follows the weight loss phase enables patients to successfully manage their weight in the future. Both our VLCD and recently launched LCD offer patients the opportunity to address the issues surrounding their overeating in the absence of all (or in the case of LighterLife Lite, most) conventional foods.

Working with the commercial sector – training needs

It is important to provide clear guidance and training for health professionals on how they can work with the commercial sector and how this needs to be considered as a necessary addition to current service provision.

This guidance needs to identify the range of providers and ensure that they are considered in the creation of:

It also needs to take account of the growing number of overweight and obese adults and the growing number and variety of weight management services (including VLCDs and LCDs) and the need to tailor approaches both in hospital and community settings that are going to be effective.

Need for more research to demonstrate the effectiveness of different interventions – a national need

The research in the field of obesity is vast. However, there is little research to identify the pros and cons of different community-based weight-management programmes and their success relative to that of, say, drug therapies and bariatrics in the medium to long term. This and associated areas (including training needs) are covered in detail in the NICE guidance (2006).

Conclusion

We are encouraged by this inquiry and the scope to identify a plan of action which will tackle the obesity epidemic. We believe that in order for this to be as effective as possible, there is a need for agencies in the public sector to work together and to coordinate action.

There is also a need to ensure that the mechanisms are developed for the local delivery of services across agencies, including the health sector, and that those managing the delivery of services have the expertise needed to identify the most suitable intervention for particular patients.

In the health sector specifically, there is a need at a national level, to recognise the variety of programmes available in the commercial sector and to acknowledge the contribution they can make.

The Northern Ireland Commissioner
for Children and Young People

1.0 Introduction

The Office of Commissioner for Children and Young People (NICCY) was created in accordance with The Commissioner for Children and Young People (Northern Ireland) Order (2003) to safeguard and promote the rights and best interests of children and young people in Northern Ireland.[1]

Under Articles 7(2)(3) of this legislation, NICCY has a mandate to keep under review the adequacy and effectiveness of law, practice and services relating to the rights and best interests of children and young people by relevant authorities. The remit of our Office is children and young people from birth up to18 years, or 21 years of age if the young person is disabled or in the care of Social Services.

In determining how to carry out her functions, the Commissioner’s paramount consideration is the rights of the child and NICCY is required to base all its work on the United Nations Convention on the Rights of the Child (UNCRC).[2]

2.0 Assess the scope and appropriateness of the current approach to the prevention of obesity and the promotion of lifestyle change

As highlighted by the Chief Medical Officer[3] in his annual report in 2007, “one in four girls and one in six boys in primary one are overweight or obese".

According to a press statement[4] from the Minister of Health “Figures from 2006/07 show that approximately 22% of Northern Ireland’s Primary school children are classed as overweight and obese".

The increasing number of children and young people in Northern Ireland who are obese illustrates that current approach to the prevention of obesity is not effective.

2.1 Barriers identified in the Review of Children Rights

‘Children’s Rights: Rhetoric or Reality, A review of Children’s Rights in Northern Ireland’[5] by NICCY launched on 17 February 2009 highlights just some of the difficulties that children and their parents face when attempting to lead healthy lives, these include;

These factors all have an impact on a parent’s ability to provide their child with a healthy diet and promote an active lifestyle. The review highlights that many of the initiatives such as healthy schools pilots and sure start healthy start vouchers are discrete initiatives and are not available in all schools or communities. While these initiatives are having a positive impact on some communities they need to be available across all of Northern Ireland.

2.2 Ten year strategy for children and young people

The ten year strategy for children and young people ‘Our children and young people - our pledge’ makes direct reference to the increasing rates of child hood obesity. This strategy contains a target to halt the increase of childhood obesity by 2010; the driver for change on this target is the Fit Futures Implementation Plan. Given that this target needs to be met by next year, the committee will need to closely monitor the implementation of Fit Futures to ensure that the appropriate actions are put into place.

2.3 Fit Futures Implementation Plan

A draft plan was put out to public consultation at the start of 2007, however 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. Many of the actions outlined in this draft implementation plan have a direct impact on the health of children, including play and recreation, early years, advertising and promotion of food to children and healthy schools. 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.

It is essential that DHSSPS prioritise the actions from this implementation plan; it needs to be monitored and evaluated to ensure that it is having a positive impact on the levels of childhood obesity.

3.0 Examine the availability of weight management or other intervention services to tackle obesity related ill health

In his annual report the Chief Medical Officer made reference to a programme ‘Fit Families’ developed by the Northern Investing for Health Partnership. This programme works with families to improve diets and physical activity. However this programme is only available in the Northern Board. Investing for Health Partnerships are carrying out excellent work in the community, but where an evaluation shows the positive impacts of a programme such as this, efforts should be made to replicate the programme across Northern Ireland.

In ‘Children’s Rights: Rhetoric or Reality, A review of Children’s Rights in Northern Ireland’ children and young people in some schools told us about ‘walk to school’ initiatives which aimed to get children and their parents walking to school as an alternative to car or bus journeys. These initiatives should be promoted and supported by DE and further developed so that all schools promote walking and cycling to school.

The implementation of the Department of Education (DE) guidance ‘New nutritional standards for school lunches and other food in schools’ is welcomed as it will have a positive impact on children receiving school meals, in particular on children who are in receipt of free school meals.

4.0 Consider what further action is required, taking account, as appropriate, of the potential to learn from experiences elsewhere

While NICCY appreciates that the remit of the Committee is Health, Social Services and Public Safety, we believe that many strategies from other government departments have a significant impact on obesity and therefore recommendations of this inquiry will be the responsibility of other departments. It is essential that the committee clearly notify other departments of their responsibilities, and liaises with them in tackling this important issue.

As highlighted in the Fit Futures report the focus of tackling obesity needs to be on early years, when attitudes towards food and physical activity are formed. The report highlighted that without significant intervention over 1 in 4 (27%) 4.5 to 5.5 yr olds will be overweight or obese by 2010[6] therefore we recommend that action needs to be focused on educating children and young people, and supporting their parents to enable them to live healthy lifestyles.

4.1 Play

While we recognise that the provision of play and leisure is not within the remit of the HSSPS Committee, it is central to tackling childhood obesity. A report from the Northern Ireland Audit Office[7] illustrates that children are not as physically active as they should be, with activity declining with age. Inherent to the ability of children to live active lifestyles is their access to play and leisure and activities.

The NICCY review of children’s rights shows that children and young people face multiple barriers when attempting to lead healthy life styles through active play. In particular they can not 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.

The Northern Ireland Play Policy was approved by the Northern Ireland Executive in December 2008. The next step involves the development of two implementation plans, one for 0 -11year olds and one for 12 - 18year olds. OFMDFM must develop and implement these plans as soon as possible, allocating appropriate funding to ensure that the actions can be implemented.

Research completed by NICCY to be published later this year shows that out of 21 councils who responded to their questionnaire, only ten Councils had a play policy. This research recommends that all Councils should develop a play policy, as part of their statutory duty to develop and maintain play and recreation facilities. In advance of the changes to Local Councils through the Review of Public Administrations, the Department of the Environment should be working cooperatively with OFMDFM to prepare the new larger Councils to meet their duties relating to the delivery of play and recreation.

The draft Northern Ireland Strategy for Sport and Physical Recreation was published by the Department of Culture, Arts and Leisure (DCAL) last year for consultation. This draft strategy contains targets to increase the participation of children and young people in sport and recreational activities. This 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. As highlighted in our response to the consultation on this draft strategy, the costs of sport and recreation may be a barrier to the participation of some children; this was not adequately addressed in the strategy. In order for children and young people to participate fully in sport, it must be both accessible and affordable.

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.

4.3 Impact of poverty on obesity

In their report to the UN Committee on the Rights of the Child, the four UK Children’s Commissioners highlighted the impact poverty has on the increasing rates of childhood obesity.

“Improving the diet of children born into poorer families is more difficult due to inadequate income and restricted access to healthy food. We are also concerned about the growth in marketing to children, explicitly encouraging the consumption of unhealthy food products. In areas of socio-economic deprivation, opportunities to exercise are more likely to be limited; for example, there may be nowhere safe to play, no facilities for physical activities outside school, and a shortage of money to participate in such activities.[8]

The Institute of Public Health in Ireland report ‘Tackling Food Poverty: Lessons from the Decent Food for All Intervention’ details the impact that food poverty has on obesity[9]. This report from IPH shows that children living in poor household are more likely to adopt unhealthy behaviours in early life; this is due to poor information and skills; poor access to physical activities and poor finances.

Lifetime Opportunities, the Government’s anti poverty and social inclusion strategy is the policy framework to reduce poverty. In addition to this the Committee for First Minister and deputy First Minister carried out an Inquiry into Child Poverty in Northern Ireland. The actions from both reports need to be implemented without delay to ensure that parents on low incomes have adequate support to help them provide their children with a healthy diet and lifestyle.

However, the committee needs also to recognise that, while poverty impacts on children’s nutrition and health, it doesn’t always result in obesity, other evidence shows that food poverty can result in children being smaller in weight.

4.4 School Transport

In 2005, NICCY commissioned research into the views of children and young people, parents and carers and other interested parties on issues affecting safe travel to school. We launched a report ‘Safer Journey to Schools’[10] into the findings of this research in 2006. This recommended that the Department of Education reviews the current statutory walking distances for home to school transport, to identify the impact that changes could have on school transport provision.

The research made a number of recommendations to reduce car based journeys, including;

In order to reduce car based journeys to school, investment is needed to further develop and improve walking and cycle routes to make this a more attractive and safer alternative.

A part of increasing walking/cycling to school will require the Department of Education to ensure that road safety continues to be included in the curriculum of both primary and secondary schools, with an assessment of the impact of this awareness programme in schools.

5.0 Conclusion

As statistics in section 2.0 highlight Obesity is clearly a significant health issue for children in Northern Ireland. 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.

A number of discrete initiatives have been introduced across Northern Ireland to tackle childhood obesity; these initiatives have been developed by Investing for Health Partnerships, Health Promotion Agencies and individual Health and Social Care Trusts, however they are specific to one geographical area and usually funded on a short term basis. The initiatives which are having a positive impact on the rate of childhood obesity need to be supported by a comprehensive policy framework.

The Implementation of Fit Futures is central to tackling childhood obesity. DHSSPS need to make appropriate funding available to ensure all the actions of Fit Futures are fully implemented.

[1] Further information on the role and remit of the commissioner can be accessed at www.niccy.org

[2] The following articles of the UNCRC have a particular relevance to this inquiry:

Article 17- the right of children to access information and materials from a range of sources, especially those aimed at the promotion of their physical health and wellbeing

Article 24- the right to highest standard of health care, this includes education on and are supported in child health and nutrition

Article 27- the right of the child to adequate standards of living, with a onus on the state to provide measures to assist parents materially and through support programmes, particularly with regard to nutrition.

Article 31- the right of the child to rest and leisure and to engage in play and recreation activities.

[3] http://www.dhsspsni.gov.uk/cmo-annual-report-2007.pdf (access at 3rd February 2009)

[4] http://www.northernireland.gov.uk/news/news-dhssps/news-dhssps-131108 obesity_time_bomb.htm

[5] Copies of this report can be sent to committee members on or after 17th February 2009 on request.

[6] Department of Health, Social Services and Public Safety (2007d) Fit Futures: Focus on Food, Activity and Young People: Response from the Ministerial Group on Public Health including Consultation on Fit Futures Implementation Plan 2007.Belfast: DHSSPS

[7] http://www.niauditoffice.gov.uk/pubs/obesity/8100_Obesity_Diabetes.pdf (accessed at 3rd February 2009)

[8] UK Commissioners report to the UN Committee on the Rights of the Child

[9] http://www.publichealth.ie/files/file/Tackling_Food_Poverty_lessons_from_the_DFfA_intervention.pdf

[10] Research can be accessed at www.niccy.org

Centre for Obesity
Research and Epidemiology

In the Western world today, individuals who are underweight are vastly outnumbered by those who are overweight and obese. Almost one quarter of adults in the UK1, 2 and a third in the USA3 are obese and there is consistent evidence that the obese will continue to gain weight over time if not offered intervention.4 Obesity is a major public health risk, presenting a burden of obesity-related disease5, impaired quality of life6 and implications for medical care expenditure.7

The dual metabolic challenge of unlimited access to palatable food and greatly diminished physical activity both have a key role to play in explaining such disappointing statistics. The solution is necessarily multi-dimensional, and individuals exhibit different susceptibility according to genetic variation in control mechanisms which affect eating behaviour. Individuals are also variable in their capacity to respond to treatment by altering their behaviour.

Obesity is one of the most important and preventable causes of morbidity and mortality facing primary care today. However, the obese attend General Practice frequently8 and have additional prescribing compared to age and sex matched normal weight controls.9 Primary care prescribing costs increase steadily from £50.71 for men, £62.59 for women at BMI 20 kg/m2 to £198.66 for men, and £160.73 for women at BMI 40kg/m2 10

While the burden of obesity on NHS resource is well documented, there is a need to focus on what can be achieved from realistic weight loss from health and NHS resource perspectives. Consideration must turn to cost avoidance. Patients, General Practitioners and healthcare providers have held over-ambitious expectations for weight management which go beyond what is achievable, affordable or medically valuable. Research has demonstrated enormous medical gains11,12,13 and significant cost-avoidance from modest, and achievable, weight loss (5-10%) and more from long term avoidance of weight gain. Such expectations need to be addressed and refocused.

Despite clinical guidelines for obesity management14, 15 and related disease16, there is little evidence that obesity can be managed successfully in a primary care setting. Many weight management solutions offered to primary care lack evaluation and others have proven unsuccessful. Isolated weight management training events for primary care practitioners have been unable to demonstrate patient weight loss.17

Costs rise disproportionately with the disease progression10, and strategies which offer a modest reduction in body weight, may offer a more favourable health economic profile. The strategy which stands the greatest chance of success needs to be evidence based, culturally sensitive and locally delivered. It must address the range of levels of obesity, but focus on the majority of obese people, for whom a modest weight reduction can offer not only realistic targets, but tangible health benefits.

The Counterweight Programme was set up in 1999 to evaluate a structured model based on established weight management interventions using theoretical and evidence-based approaches, and to assess the feasibility of primary care as an appropriate setting.18 It is a novel approach which draws on theory and evidence relating to changing behaviours of health professionals and patients.19

Counterweight is based on a model of continuous improvement with closed-loop audit enabling on-going programme evaluation and refinement. An initial evaluation phase was conducted 2000-2005, demonstrating that if practice nurses are provided with training on a structured programme18, are mentored within clinical practice19 and results are continuously audited, they can achieve and maintain clinically beneficial weight loss in their obese patients.20 Mean weight loss in patients who attended the Counterweight Programme was 3.0 kg and 2.3 kg at one and two years, respectively. Weight loss of this nature results in multiple clinical benefits and loss of 5-10% has been previously shown to reduce progression to diabetes by up to 58% over 4yrs.11, 12

Counterweight Health economic analysis demonstrated that the cost of delivering the programme across the UK would be approximately £60 per patient entered and that prescribing costs should theoretically reduce by £6.35 per male patient and £3.50 per female patient over the first year alone (assuming the population has similar baseline BMI as in Counterweight (BMI 37 kg/m2)).10

Weight management advisers (WMA), all registered dietitians (or clinical nutritionists) facilitate programme implementation. They offer expertise in obesity management and provided protocols and training materials for staff. One hour of training is provided for GPs and a 12-hour training programme is provided for practice nurses (PN). Mentoring in practice is provided until practice nurses reach competency and confidence is achieved. The PN role is to deliver patient education through discussion about weight management, communication of information, and the transfer of “behaviour change" skills during weight management sessions.

The Counterweight intervention focuses on adults aged 18–75 years with a BMI over 30 kg/m2 or 28 kg/m2 with associated co-morbidity. The nurse-led intervention is delivered within a group or one-to-one setting in a general practice. The programme has also been implemented at a small level in a community and pharmacy setting. Intervention consists of six sessions over three months followed by quarterly follow-up to 12 months with annual review recommended thereafter.

Lifestyle interventions are a goal-setting approach, a structured prescribed eating plan or a group programme, all based on creating a 500 kcal daily energy deficit.

Goal setting involves the PN and patient working together to mutually agree goals for dietary and lifestyle change. Practice nurses are coached in the skills of negotiating goals to change lifestyle, as collaborative goal setting has been found to be more effective in weight management than health professional selected goals. The prescribed eating plan (PEP) is an individualised food portion plan with approximately 30% energy from fat.

The group programme is based on six one hour sessions run bi-weekly for a three month period. Sessions include discussions on weight loss targets, healthy eating, shopping, cooking, eating out, physical activity and relapse prevention. Each group aims to recruit 10-15 participants and sessions are based around the principles of adult learning, designed to encourage group interaction and active learning. Session plans, and teaching materials are provided to practices and the WMA typically facilitates the first patient group over three months with the PN observing. Following this the PN is encouraged to take responsibility for facilitating the group.

After 12 weeks of lifestyle intervention pharmacotherapy is considered where appropriate. The Counterweight model follows evidence-based guidelines and prescribing is usually led by local protocol.

In 2006, Counterweight was commissioned by the Scottish Government as the weight management option for the Keep Well Programme, an anticipatory care programme for the prevention of cardiovascular disease in areas of high deprivation in Scotland. In 2008 the programme was expanded and offered to each health board by the government. In England, the Counterweight Programme is commissioned by individual primary care trusts and the programme has undergone a smaller but steady expansion.

The Counterweight team have developed significant expertise in expanding the programme into new regions. The team offers support with practical facilitation of local implementation plan for Counterweight, identification of the preferred model of delivery according to local needs, protocols for data collection and ongoing programme evaluation, joint working with local stakeholders, and training of a local dietitian (Counterweight buddy) to continue expanding the programme in each area after the initial implementation phase.

An effective obesity strategy requires many interdependent strands, preventing the overweight becoming obese, and preventing disease progression in those who already are obese. Such a strategy needs to be evidence-based, delivering a service for patients which will dovetail with other public health campaigns and initiatives, and target resources where they have been shown to make a real difference. The Counterweight programme is currently the only primary care programme demonstrating clinically valuable weight change outcomes.20

The Counterweight Project Team includes eight leading obesity UK NHS physicians, as well as a team of 14 registered dietitians/nutritionists with more than 10 years experience in the field. Outcomes from the Counterweight programme have been published in peer review journals and presented internationally. Implementation of the Counterweight Programme in Northern Ireland will require funding for the Counterweight team, evaluation costs, local incentives for general practice and some commitment from dietitians, but offers a workable solution for the management of obesity, which is realistic, evidence-based, and effective in a similar setting.

References

1. Department of Health. Health Survey for England 2004.London: Health and Social Care Information Centre, 2005

2. Scottish Health Survey – 2003 results. See http://www.scotland.gov.uk/publications/2005/11/25145024/50251

3. Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006;295:1549–55

4. Heitman BL, Garby L. Patterns of long-term weight changes in overweight developing Danish men and women aged between 30 and 60 years. Int J Obes Relat Metab Disord 1999;23:1074–8.

5. Must A, Spadano J, Coakley E, Field A, Colditz G, Dietz W. The disease burden associated with obesity. JAMA.1999;282:1523-1529.

6. Lean ME, Han TS, Seidell JC. Impairment of health and quality of life using new US federal guidelines for the identification of obesity. Arch Intern Med. 1999; 159: 837-843.

7. National Audit Office: Tackling Obesity in England. Report by the Controller and Auditor General. London. 2001

8. Counterweight Project Team. The influence of body mass index on number of visits to general practitioners in the UK. Obes Res. 2005; 13: 1442-1449.

9. Counterweight Project Team. Impact of obesity on drug prescribing in primary care. British J Gen Pract. 2005; 55: 743-749.

10. The Counterweight Project Team. Influence of body mass index on prescribing costs and potential cost savings of a weight management programme in primary care. J Health Serv Res Policy 2008; 13 No 3: 158-166.

11. Diabetes Prevention Programme Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. NEJM. 2002; 346: 393-403.

12. Tuomilehto J, Lindstrom J, Eriksson J, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. NEJM. 2001; 344: 1343-1349.

13. National Heart, Lung and Blood Institute. The Practical Guide. Identification, Evaluation and Treatment of Overweight and Obesity in Adults. Nat Inst Health; USA.1998.

14. HTA 2004 Broom J, Avenell A, Aucott L, Brown TJ, Poobalan A, Stearns S, Smith WCS, Jung R, Campbell MK, Malek M, Grant AM. Systematic Review of the Long Term Outcomes of the Treatments for Obesity and Implication for Health Improvement and the Economic Consequences for the National Health Service (2004).

15. Health Development Agency. The management of obesity and overweight: an analysis of reviews of diet, physical activity and behavioural approaches. H.D.A. 2003.

16. Joint British Societies’ Second Report (JBS2): Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 2005; 91: (Suppl V): v1-v52.

17. Moore H, Summerbell CD, Greenwood DC, et al. Improving the management of obesity in primary care: cluster randomised trial. BMJ. 2003; 327: 1085-1088.

18. Counterweight Project Team. A new evidence-based model for weight management in primary care: The Counterweight Programme. J Hum Nutr & Dietet 2004; 17: 191-208.

19. Counterweight Project Team. Empowering primary care to tackle the obesity epidemic: The Counterweight Programme. Eur J Clin Nutr 2005; 59 (1): S93-101.

20. Counterweight Project Team. Evaluation of the Counterweight Programme for obesity management in primary care: a starting point for continuous improvement. Br J Gen Pract 2008; 58: 548-554.

Banbridge District Council

The followings outlines the steps that Banbridge District Council is taking in relation to the issue of obesity and its prevention.

Work with Food Businesses

EHOs have been involved in promoting the Food Standards Agency’s ‘traffic light scheme’ in food manufacturers in this area and are willing to work with them on other emerging initiatives such as their saturated fat and salt campaigns.

Appointment of Dietitian Specialist

A Dietitian Specialist has been employed with Southern Group Environmental Health Committee (SGEHC) for the period April 2008 - end March 2011, to work with Council EHOs and local food businesses on improving the nutritional quality of food sold from catering outlets. This does not include premises where nutritional standards already exist, for example schools, nursing homes, etc. The initiative is known as CHOICE (Choosing Healthier Options in Catering Establishments).

Between April 2008 and March 2011 the Dietitian Specialist will also be working alongside a Community Project Officer, who will be working on a community based initiative to improve the diet and nutrition among communities in the Southern group area. Both of these positions have been part funded by the SHSSB.

Community Nutrition Project

2 of our Environmental Health Officers have completed a Diploma in Nutrition, part funded by FSANI. This will assist them in delivery of the CHOICE initiative in this area and also enhance involvement in other forthcoming initiatives which the FSANI are keen to develop e.g. ‘Grubs Up’. Council may also provide nutrition training for local food business operators.

The Overweight and Obesity Prevention Group

The Principal EHO (Food Control/ Infectious Diseases/ Health Promotion) at SGEHC is a member of the SHSSB Overweight and Obesity Prevention Group. This group concentrates on initiatives to follow up on the Fit Futures report.

Investing for Health Joint Appointments

In 2003 joint appointments of three Investing for Health Officers were made in the Southern Group area, jointly funded by the District Councils and SHSSB. Part of their remit within the Southern Investing for Health Partnership is to tackle obesity as per the original Investing for Health Strategy.

Joint appointments of Health Improvement Workers

In 2009 three Health Improvement Workers will be appointed to work across the five Southern Group Councils and one of their key health improvement objectives is nutrition and the promotion of healthy eating in areas of social deprivation.

SHSSB Cook It programme Steering Group

SGEHC were involved in the steering group and hope to be involved with the new proposed Community Cooking programmes currently being set up by the SHSSB.

CEHOG Nutrition Sub-group

The Northern Ireland Food Liaison Group, a subgroup of the Chief Environmental Health Officers’ Group, is to convene a nutrition subgroup to look at how best EHOs can become involved in tackling the obesity issue in the general population and also to share ideas and initiatives that may be happening elsewhere in NI and the rest of the UK, etc. This group will also have membership from FSANI.

Recommendations for the future

Western Health and
Social Services Board

There are a number of key strategic documents that directly impact on the battle of obesity. They are the Investing for Health Strategy, Physical Activity Strategy and Fit Futures. In addition, you will be aware that there were plans to have a Diet & Nutrition Strategy and also a Life Changes Strategy to focus on obesity in adults. There are a number of other strategies that are led by other agencies and departments, which also contribute to opportunities to tackle the rise of obesity. These include strategies around sport, recreation and leisure and tourism, as well as regional development in respect of cycleways, walking paths and community safety.

In order to take a more strategic approach in the West, the Board has established the Western Obesity Prevention Group, which includes representatives from the five Councils, DOE Planning, Health & Social Care and the Community and Voluntary Sector. This group reviews activities within the West, but also feeds directly into the work that is being taken forward at a regional level through the group being led by the Chief Medical Officer.

A significant amount of work has been done in terms of developing priorities, based on research and consultation with stakeholders. The key areas that this Board is moving forward are:

It is acknowledged that there is a need for better collaboration around issues such as health policy, food policy and physical activity policy, to ensure that there is clarification in terms of the messages we are trying to get out to the wider population. Within this there is a particular key role for Local Authorities to take a leadership role in collaboration with professionals from Health & Social Care. This work is well placed to move forward within the Investing for Health Partnerships, which are already in place and are taking forward a range of initiatives.

There is a challenge in providing opportunities and access to real choice, particularly for those from disadvantaged communities, with a particular emphasis on children. There are initiatives in place addressing lifestyle and environmental issues and ensuring that information being fed out through the media is understood by the wider population. There is a wider issue around the role of the local food industry, and in particular around nutritional labelling, which still needs further work.

Early intervention is vital and this can be taken forward from breastfeeding through to education establishments. There are real opportunities where we can create healthier schools, but it is important that within the schools’ development plan, there is a clear mandatory requirement that schools must have in place the theme of improving health within the school setting.

Schools are not the only setting to be considered. In terms of promoting healthy communities, we need to see how we can reach out to more disadvantaged communities and those at risk of obesity, including people with disabilities, to ensure those individuals who are at risk of obesity are supported.

There is an ongoing challenge in terms of developing the evidence-base. One of the biggest difficulties is ensuring that the programmes available are quality assured and based on good evidence in terms of intervention. The gap in the evidence base has resulted in a range of initiatives from the Private Sector in terms of tackling obesity, which may not necessarily be approved by health professionals.

There are a number of key stakeholders that are vital. They are:

In order to make any sort of impact, it is important that the resources, which are very restricted, are targeted at those most at risk. Certainly in terms of adulthood obesity, the Western Obesity Taskforce has focused on those with a BMI between 25-30, i.e. those who are deemed to be overweight and at risk of becoming obese, so we can make a change to prevent further people from becoming obese.

In terms of the action plan, I have attached for your information, the Fit Futures Action Plan for the Western Board area, which highlights the significant range of initiatives that we are currently leading on. I have also enclosed details of how we would propose to take these initiatives forward. However it is worth highlighting a number of those projects that have proven very successful. Initiatives such as:

In relation to the availability of weight management and other intervention services to tackle obesity related to ill-health, it is acknowledged that there is increasing dietetic capacity within a community and secondary care service but the demand is continually growing. There are drug options, which have limited effect when diet fails – such as Orlistat or Sibutramine. 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 – this adds to the inequalities in health that we experience. It is acknowledged 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.

In terms of further action required, 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.

There is also a clear need to ensure we have a better evidence-base of what interventions actually do work which reflect the setting and target audience for which they are being designed. There is a necessity to ensure that there is the appropriate investment required, both in early intervention and prevention, as well as in treatment services.

There is a need for a better understanding in terms of the role that other agencies can take forward work that would contribute to reducing the burden of obesity and its subsequent ill-healths. There is a key role here for the Ministerial Group in Public Health to drive this greater collaboration that will support initiatives that are tackling the issue.

North Eastern Education
and Library Board

Current approach to tackling obesity and the promotion of lifestyle change

Curriculum:

The Curriculum Advice and Support Service of NEELB works with schools to support the implementation of the Northern Ireland Curriculum which includes statutory elements such as Home Economics, Personal Development and Mutual Understanding (PDMU) and Physical Education:

There are specialist subject officers available within NEELB CASS to provide specific and relevant advice, resources and training for teachers and schools in all of the above areas.

Partnerships:

The dietitian’s remit includes:

“To improve the health and life chances of children who are most at risk from Coronary Heart Disease, Cancer and Stroke in later years by encouraging children from disadvantaged areas to adopt and sustain healthy eating patterns at school, home and in the community and to create environments to facilitate this".

Big Lottery Fund allocation of £300,000 enabled the Healthy Breaks Initiative to target 28 Primary Schools in the NHSSB area. Funding enabled the initiative to run for three years ending in December 2007.

Physical Activity:

Extended Schools:

Now into its third year of implementation, the NEELB currently have 59 Extended Schools funded by DE. The majority of schools are operating activities and services within the Extended Schools Programme that contribute to the ‘Being Healthy’ High Level Outcome. During the year 2006-7, 105 activities and services were recorded as impacting on ‘Being Healthy’ and in 2007-8 this increased to 145. Activities include e.g. breakfast clubs, sports activities/clubs, cookery classes, healthy eating demonstrations. In 2007-8, 22% of extended schools reported an identifiable improvement in pupil health and fitness and 92% reported that the Programme was ‘very good/good’ at fostering health and well being and social inclusion.

Health Promoting Schools

The NEELB had 53 schools in the Health Promoting Schools Pilot from 2002 – 2006 with the majority implementing Healthy Eating and Physical Activity initiatives. Since 2006, NEELB has continued to provide support, training and resources, where possible, to the existing schools with the additional funding provided by the Health Promotion Agency (£10,000 in 2006-7; £20,000 in 2007-8).

NEELB School Catering Service

The Education Catering Service of NEELB has, for many years, been involved with Health Professionals across all sectors with the aim of improving the health and well being of pupils attending controlled and maintained schools within the Board’s Area:

Dr Michael Ryan
Northern Health and Social Care Trust

The ‘Fit Futures’ strategy (2006) rightly focuses on activity and young people. The ‘Fit Futures’ taskforce identified six strategic priorities which included the development of joined-up public health policies and the building of an evidence base. Services for young adults and the middle aged depend very much on the individual interests of the person themselves, and their primary and secondary care services. The lack of a comprehensive, strategically planned service for the overweight and obese adult is a major shortcoming of the current healthcare system.

The CREST report (2005) produced guidelines for the management of obesity in secondary care but has not resulted in the attraction of significant resources for the implementation of its recommendations.

The epidemic of obesity is well established and is not showing any signs of abating, particularly among the young. Currently, more that half our adult population is either overweight or obese. Their World Health Report 2002 estimated that over 7% of all disease burden in developed countries was caused by overweight, and that around a third of coronary heart disease and stroke, and almost 60% of hypertensive disease in developed countries was due to overweight. It is estimated that around 45% of patients diagnosed with cardiovascular disease in the UK are overweight. At least 75% of obese people will have one or more co-morbidity e.g. 80% of diabetics are overweight or obese.

Achieving weight loss is pivotal in reducing total cardiovascular risk. A modest weight loss of around 10% can result in a 20-25% fall in mortality, 30-40% fall in disease related deaths, a 50% reduction in the development of diabetes as well as a 40-50% fall in obesity related cancers. Figure 1 illustrates graphically the role of obesity in cardiac risk relative to conventional risk factors.

Obesity is also a significant risk factor for cancer. Among postmenopausal women, about 5% of all cancers (approximately 6000 cases annually) are attributable to being overweight or obese. For endometrial cancer and adenocarcinoma of the oesophagus about half of all cases in postmenopausal women are attributable to overweight or obesity.

Obesity and overweight are recognised priorities for action