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Joining Forces to Tackle Obesity, 21-22 January 2002

Transcript : The Role of Education

Speaker

Professor David Hall, President, Royal College of Paediatrics and Child Health.

ANDREW HILL: Our next speaker is Professor David Hall and David is the President of the Royal College of Paediatrics and Child Health.

DAVID HALL: Thank you very much, Mr Chairman and thank you for inviting me. I wondered why they had so many College Presidents for these occasions and I can only think its because presidents go to so many dinners and functions that if they didn’t become experts on preventing obesity they would very quickly be unable to get up the stairs. Anyway this is a hugely important topic. I claim no special expertise either, except to say that this is now becoming such an important issue for the health of children of the next generation that I think no one who works with the health of children can afford to ignore it.

[Slide] Now the title I was given was ‘Why have Traditional Approaches Failed?’ And I thought well traditional approaches to what? We’ve actually not taken the prevention of obesity in children very seriously until the last few years, so we can hardly say that approaches have failed. So I am going to take a slightly broader approach and say what has failed in more general terms. But a more positive way of looking at this is to say, "Well, what has worked? Can we extract some lessons?" [Slide] And so if we look at the things that have worked, they tend to be things where there is an obvious connection between the action that the person is supposed to do or not do and the benefit they get. [Slide] And the simplest one I suppose in terms of output of effort versus benefit is immunisation and I’m not going to get into a discussion on autism today but leaving aside the strange fringe of opinion this is a wonderful benefit for a tiny effort.

[Slide] However there are a number of other examples as well. One of the greatest public health success stories in children’s work is to do with sudden infant death syndrome or cot death. Putting the baby to sleep on his back instead of on his tummy. This was an enormous campaign but the actual action required by the parent was really a relatively simple change of habit and didn’t actually have a very high personal cost. [Slide] Another example of a dramatic improvement from a public health perspective was structural or legislative change. In this case the safe packaging of tablets which dramatically cut down the number of admissions to children’s wards due to poisoning.

[Slide] If we take another example, smoking you might think is not a dramatic success story, but as Sian said over a period of many years we have seen a gradual fall in the amount of smoking and the reasons are complex. Firstly the public can understand how smoke might cause lung cancer, even if they don’t want to believe it. And then it has been a very long process of gradually building social pressure, taxation and so on. So it has been a difficult one but there really is, I think, visible improvement on a gradual change of opinion about smoking.

[Slide] Now I don’t want to be depressing but I think that we have to recognise that dealing with obesity is going to be more difficult than any of those other issues. [Slide] And the reasons I think are fairly obvious. First of all if you look at the clinical problem of obesity and you have a paper for example from Dr Penny Gibson in your pack, looking at how primary care teams might deal with obesity in children. Even in the most highly motivated child, who desperately wants to lose weight, it is extraordinarily difficult. More clinicians know this to their cost. It would not be surprising if youngsters who don’t perceive themselves as having much of a problem are going to find it even more difficult to make changes in their lifestyle. And I think the second reason why it is going to be difficult is that unlike smoking, or the other things I mentioned, there isn’t just one single action that you take or stop doing in order to become less obese or to reduce your risk. There’s a whole number of parallel and related changes, most of which are apparently very small in themselves, and are much more difficult, I think, to change one’s motivation and one’s behaviour. Now that sounds depressing but I think there are a lot of good things and we will come to those in a moment.

[Slide] Health professionals, I think, must have some of the blame for where we are at the moment. I suppose we always tend to blame ourselves or else we get hyper defensive, one or the other. But I think we must look back over the past ten or twenty years of preventive child health programmes and ask ourselves what exactly we have been doing all this time. [Slide] One of the things that we have not done always was to focus on prevention in general. Obesity is just one example and I think to be fair to ourselves, the enormous importance of this has only dawned on us in relatively recent times. Well we tended in the past, I think, always to have a very, sort of, medical approach, the medical model, the dreaded term. [Slide] But I think there is some truth in it and one example is the relative lack of attention paid to another aspect of diet and nutrition and that is the prevention of dental disease.

Now we know an awful lot about healthy outcomes in terms of dental disease. And yet the number of health professionals who see this as important, the number of paediatricians who examine the teeth, the number of health visitors at least until the last few years, who talk about the prevention of dental disease, I’m afraid, is very small. [Slide] And here is a picture of a little boy losing all his teeth in Manchester. Why they chose this poor lad or picked on Manchester, I can’t tell you but this is a widespread problem and a strongly social class related problem.

Another point about professional failures is we’ve had an incredibly neolistic attitude to breastfeeding. The perceived wisdom has been you can’t change people’s attitudes to breastfeeding, they’re bred in culturally, they’ve made up their minds long before they’re pregnant and it’s becoming patently obvious that really is not true. That it has been the attitude we’ve had until I think just the last two or three years.

[Slide] Then there are various middle class, working class sort of issues about how professionals and their clients worked together. And perhaps the most classic example, if there are any health professionals here I am sure they will agree with me, one of the biggest causes of conflict between health visitors and their clients is on the issue of weaning. And a great many mothers, as we well know, actually lie to their health visitors about what they are doing with regard to weaning. We have different perspectives and this is a cause of conflict and of, I think, sometimes alienation between the professionals and their customers.

[Slide] We have had a lot of preoccupations too. Things that we worried about. A few years ago one of the commonest themes in health visitors and paediatricians was the message, "Your baby is too fat, fat babies make fat adults. You must get your baby thinner". [Slide] Anyone who has ever tried to get their one year old baby thinner will know that it is a pretty thankless task and I think it is increasingly clear that it is also one which is probably irrelevant and one we shouldn’t be getting into. It does perhaps illustrate the hazards of getting into a health promotion package without thinking through all the evidence first. But a lot of mothers have been made very distressed over the years by this kind of advice.

[Slide] Currently the latest fashion is, "Your baby is too thin. He’s failing to thrive". And we now have a whole batch of work appearing, some of which is very important and highly relevant but the focus is that your baby is not thriving, his weight is faltering on the chart, you’ve got to do something about it. I even know of cases where child protection proceedings have been taken. Sometimes on the grounds of a weight chart which anyone who really understood the weight charts would realise there is just normal variation. So we’ve had an obsession about little children who are too thin. And perhaps the thing that has caused me particular difficulties over the last ten years is a long running debate about short stature and the identification thereof. [Slide] Now actually children who’ve got otherwise unidentified causes of short stature, which are medical and treatable, is something like 1 in 2000 to 5000 children and yet I have a very fat folder of correspondence of how wicked I am not actively promoting a vigorous program of height monitoring. I do not have one single letter from that particular professional fraternity urging me to do something about the identification of obesity. Now that does perhaps indicate something about professional preoccupations. Perhaps I am being very hard on my profession and health professionals in general, but sometimes I think we are at risk of losing the plot and not seeing the big picture.

[Slide] I think a more genuine worry is that we do not have good evidence knowing what we ought to be doing in order to attack this epidemic of obesity. And one of the widespread fears is that if we start going on a bit more about obesity we may exacerbate the other epidemic that is running concurrently, of anorexia nervosa and related eating disorders. Now the evidence on this is complicated and conflicting. I think it is almost certainly true that a society that values the body beautiful and thinks obesity is undesirable will probably have more youngsters who have got anorexia. But whether that’s due to any professional campaigning or due to the sort of general social ambient climate, I don’t know. I suspect it’s the latter rather than being due to the professionals. But there is certainly a legitimate fear that if we got more aggressive on this issue we might also find that we are causing more trouble as well.

[Slide] The focus on the, what I call, the defect detecting model of school health originates right back at the start of the school health service in 1908. When it was begun because the government was seriously disappointed about the medical quality of the recruits that it was sending to be shot up in the Boer War. It was very keen next time we had a war the people who got killed should be healthier, that is to say, before they got killed. And so the government institute of the school health service, and this was very specifically designed to identify defects and to tackle sometimes very specific and very treatable medical conditions. And that sort of approach, where the main focus was on identifying things wrong with children, was really the predominant part of the school health service right up until the early 1990’s. And when we looked at this on a health economics approach, just two or three years ago, we found that still something like 60%-80% of school nurse time, in one way or another, was associated with looking for defects rather than the active promotion of health. So it has taken a very, very long time to shift in response to the changing patterns of morbidity in school children.

[Slide] There are also of course much wider issues in the question of obesity in children. I particularly want to focus on some of the pre-school issues for a moment. Poverty has been widely quoted, and Sian has given you some very good strong reasons why poverty is a powerful associate of poor nutrition in a whole range of different ways. But one that she didn’t mention perhaps, where children are concerned, is the impact on experimenting. [Slide] We now have a culture of many single parent families, working parents, long hours. And the effects of that inevitably is parents who are very tired, who don’t have the time and energy for joint activities, are probably too tired to make shopping for food an enjoyable teaching activity, a fun activity with the family. And the inevitable habit of relaxing and just buying fast food.

[Slide] This lovely book by Nigella Lawson has a chapter, which I commend to all of you, about feeding babies and young children. And what comes out of that is the sheer fun of talking about food and enjoying food with your children. And it brought back to me very happy memories of my own family when they were young. And food indeed was fun, buying it, cooking it, eating together, talking about food. But these are luxuries that go with having time and with having money to experiment. And what this does is create a very different attitude to food from the one if you grow up living on purely three or four different foods, all of them fast and all of them high fat.

[Slide] I think that we have to say that there is a lot we don’t understand about how children learn their eating habits. How do they regulate their intake? We have examples as I have already given you with health visitors nagging mothers about their babies being too fat or too thin. But all of us who have had children know how difficult it is to control intake. There is beginning to be some research in this field and I think it is an area that really needs developing. We need to understand the natural history of how different body builds evolve and how different eating behaviours evolve and why. And what the antecedents of those might be. There is a whole field of research there waiting to be done and I have a feeling that cross-cultural comparisons might teach us a great deal.

[Slide] Turning now to school aged children, I think one of the most important messages is this one here. It comes from some work by Aggleton and the message is, the kids actually know what they are supposed to be eating. They know what’s bad for them, what is unhealthy and I think that is something we just often forget. We think all we need to do is pump in more information. [Slide] This lovely picture drawn by an infant school child - this one is healthy with his big bulging muscles, slim waist and broad chest and this one - well, no comment. Looks like the kids even understand that its actually (inaudible) obesity that’s particularly important. [Slide] This one is a slightly older child. There’s a whole string of unhealthy behaviours here. Fat is in bigger letters than all the others, where we’ve got sore throat, we’ve got ecstasy tablets. I don’t know what we haven’t got. The kids know what’s bad for them. It’s not a matter of pumping in more information. So we have to ask, why are they not doing anything about it?

[Slide] Mary Rudolph’s trial in Leeds, published in the BMJ last year, was an interesting attempt to change the patterns of weight gain in school children. Where she found that their knowledge increased, she could make some small impact on their eating behaviour, sadly the change in weight pattern over the years of her study was barely discernible. Clearly to have an impact on school children’s eating behaviour to the extent that they can change their weight gain pattern is something we still don’t really understand. This is a very important study and illustrates the quality of research we need to do if we are going to get answers that we can trust.

[Slide] The reality is of course that not withstanding kids knowing what they should do, this is often what really happens. They go to school on crisps and sweets. And we know from the evidence of breakfast clubs, which are increasingly becoming common in many schools in poor areas, that some of the kids come to school with no food at all. That they have lunch boxes because they’re getting free school meals and I think even more sad is what one teacher told me recently. Mothers who come in with their kids because they haven’t had any breakfast either. They haven’t got any food in the house for one reason or another and some of these mothers have to be shown the idea of making a piece of toast and sitting down with your child to eat together. Something they have never done before. So the gap between the rhetoric and the reality is a very big one in many parts of the country.

[Slide] Issues around the school. These are more generic questions and of course they apply to all sorts of things. But yet increasingly obvious is that the whole ethos and atmosphere of the school is important as indeed Michael Rutter told us in his book, Fifteen Thousand Hours, over twenty years ago. There are factors in the school, independent of social area, which make a difference to children’s emotional health and that in turn impacts on how they behave. You’ve already heard about the issue of getting to school, bicycling and so on, the type of meals available, the fact that a lot of children in school can’t even get to a drinking fountain or it’s put in the toilet, which tells us something I think about the British attitude to children. Fancy sticking the drinking fountain in the toilets. The net result is that they all bring sweet drinks to school and thereby stuff in some more calories. Playgrounds are often unsafe, a lot of hooliganism and violent behaviour in playgrounds and we know that facilities for sports and games are often sorely inadequate in British schools. [Slide] And playground bullying is drawn by another of these children, is a big issue for many kids who don’t want to go out. I commend you this excellent book by Berry Mail and Colleagues, 1996 which sets out a lot of the reality of what school children actually experience.

[Slide] Then there are wider community issues, which are important and we know from the work done by the Children’s Rights Commissioner for London, the things that children actually worry about. These are the top five things that children worry about, and that sets the climate in which they grow up and spend their early years. These are the big issues for children and of course all of those things impinge on the extent to which they go out and play in the streets. [Slide] And this was a comment in the review by Sarina Kurts and Rosemary Thorns on the health needs of school aged children. We’re the worst in Europe, that’s the perception of children. There’s so little to do outside the home in safe and especially affordable circumstances. And what we tend to do is blame the kids. [Slide] We say they sit in front of the telly, get off their butts, you know all they do is computer games. We’ve got to understand the circumstances that lead to that lifestyle.

[Slide] Playing in the streets used to be one of the ways that kids could let off energy and this is not the UK, sadly, you can see that this is pretty well traffic free. What we see occasionally in the newspapers is discussions about 10mph limits and what Ken Livingston might do. And I hope he wins this argument. But there is a massive motoring lobby that will try to kill it. [Slide] And of course bullying on the street has become a major issue since the sad death of Fanny Lola.

[Slide] So what have we learned then? Well I would say first of all let’s not kid ourselves there are going to be easy answers for this epidemic. There aren’t. The children know they cannot do, they don’t have the power, to make the changes needed. Health professionals still have a job to identify disease, of course. I don’t want to underplay that, but we do also need to start thinking about prevention. At least as much as the detection of disorders. There is clearly a challenge to the school system. Schools do make a difference and the different sorts of schools, the different ethos makes a difference to how children grow up.

And finally, the community as a whole, is it child friendly? I think my answer to that question unfortunately is all too apparent. Fixing obesity isn’t rocket science but maybe we need to apply a little bit more science to the methodology and not jump to any rapid conclusions. But what we do have to do is make this issue a top priority.

Thank you very much.

ANDREW HILL: Thank you very much David.