COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Inquiry into Obesity -
British Medical Assosiation Northern Ireland
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 ) British Medical Association Northern Ireland
Dr Theo Nugent )
Mr Ivor Whitten )
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?
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?
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
It is simple, uncomplicated stuff: The BMA and GPs would welcome any move towards a public mindset of encouraging exercise at a simple level.
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.
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.
Dr C Hamilton:
I have not seen any menus recently. I have paid attention to —
Mr Gardiner:
You made a statement to the fact that they were the biggest offenders.
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.
Mr Gardiner:
Are you saying that healthy food is not based on five portions a day of fresh fruit and vegetables, and so forth?
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.
Mr Gardiner:
Confession is good for the soul.
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.
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?
The Deputy Chairperson:
We can do that.
Mr Gardiner:
If the Committee can take any action, it will.
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.
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.
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.
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.
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.
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.
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.
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?
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.
Dr C Hamilton:
Precisely. Salt does not occur naturally in many basic foodstuffs. Therefore, it must be added somehow or other.
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.
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”.
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.”
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.
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.
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?
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.
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.
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 —
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.
Mrs McGill:
I repeat: we need up-to-date figures rather than figures from 2003 or 2002.
Dr C Hamilton:
I have no problem with that.
Mrs McGill:
I think that those figures come from the Department.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?
Dr C Hamilton:
Theo will answer on the primary care side, which includes family health issues.
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.
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.
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.
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.
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.
Dr C Hamilton:
The important points about the role of the family should not go unheard.
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.
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.
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.
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.
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?
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.
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.
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.