COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

Inquiry into Obesity

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 ) Queen’s University Belfast
Dr Michelle McKinley )

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

We are happy to provide further details of any of our research programmes if desired by the Committee.

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.

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.

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.

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.

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.

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.

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.

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.

That is the research that we are carrying out at Queen’s University.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 weekto 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.

That is an overview of what is covered in the core curriculum and the student-selected components.

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?

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.

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.

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.

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.

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.

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 pupilsrecalled 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.

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.

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.

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.

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.

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?

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.

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.

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.

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.

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.

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.

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.

The Deputy Chairperson:

We will explore that further when the Food Standards Agency and the Food and Drink Association come before the Committee.

Mrs Hanna:

Good afternoon; you are very welcome. Thank you for your presentation. The research is important in giving us a better understanding.

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.

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.

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.

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?

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.

Mrs Hanna:

You also said that one should look at the people one has been keeping company with over 20 or 30 years.

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.

Mrs Hanna:

We walked to school.

Professor Kee:

We did. I remember walking a couple of miles to school.

Mrs Hanna:

We skipped, and we played rounders. We did not have computers or Game Boys.

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.

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.

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.

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.

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.

The Deputy Chairperson:

We need a cross-departmental approach, because that issue must be tackled by the Department of Education.

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.

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.

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.