Joining Forces to Tackle Obesity, 21-22 January 2002

 

Transcript : Implications of Obesity for the NHS and the Economy

 

Speakers

Imogen Sharp
Head of Coronary Heart Disease and Prevention, Department of Health

 

DR WILLIAM DIETZ: Our second speaker this morning is Imogen Sharp, who is head of Coronary Heart Disease and Prevention at the Department of Health. Prior to her arrival there, which was about a year and a half ago she was at the National Heart Forum. Imogen?

 

IMOGEN SHARP: Thank you very much, and can I also thank the National Audit Office for arranging this event in conjunction with the Public Accounts Committee report, and I think it’s a very significant and very welcome event. I think several of the speakers over the last two days have talked about the need to raise the profile of obesity. We’ve just been talking about the need to, sort of, look at it as something like smoking in terms of the profile it’s got and I’m sure that this conference, and the whole process that National Audit Office has gone through on this, will help achieve that goal.

The other thing, I think, that the NAO and PAC have focussed on, which I think is immensely useful, is the health consequences of obesity. Because, as most of you in the audience will know, over the years, I think over the past 10 to 20 years, we have read a lot about obesity. We have seen it in health strategies etc, etc. But I think one of the things the National Audit Office survey found, and we indeed have also found, that it isn’t high profile on a lot of agendas, including the National Health Service agenda.

I’m going to talk a bit today about the framework. The Minister, yesterday, talked about the broad framework from the Department of Health’s point of view in terms of that and, I think, again, what I hope you will have got from her presentation was her commitment to action this area and action on diet and on physical activity.

It is increasing on the government agenda. I regularly go to meetings across government where we are looking specifically at children’s activity patterns, about diet, etc. And those figures on obesity and rising obesity always help focus people’s thoughts. I think the fact that they’re out there, and that people are now responding is important. There were five government departments represented at Public Accounts Committee, again, which I think, as Edward Lee said, was unprecedented. But it did demonstrate the level of commitment to the whole thing.

 

The other thing, just before I start, I was just leafing through the paper at the weekend and The Guardian Editor magazine which sums up, sort of, the week’s news, etc. But they also pick an item from an overseas newspaper and, just coincidentally I think, they picked an item from The Washington Monthly where the headline in that was, "We’d better start treating obesity like an infectious epidemic". I think the main point they were making was, that in the US, which I would say comparably in the UK, we focussed for the past 20 odd years if not longer, about telling people what to do, about giving individual advice and a very strong focus on telling the individual or giving health education, etc. Whereas, what’s happened in the US and, indeed, here, is that obesity rates have tripled in that context. They point out that therefore it needs to be treated more strategically across government in the US and, I think, comparisons here. But the other thing they point out, a couple of nice examples, which I think, well we’re not there yet even though our rates are rising.

 

Vending machines in a New Orleans gas station recently, a petrol station, they discovered a coke vending machine on every pump island, so that drivers didn’t have to walk to the cashier for the 140 calories of dissolved sugar that they were getting from that. Another thing they point out is, if a person drives instead of walks for only 20 minutes every day they will store about 26,000 calories, gaining about five pounds over a year and, similarly, drinking a single can of coke every other day, will contribute enough calories to add about four pounds over that year. They also point out, even simply sitting talking to friends’ burns about 35 calories more an hour than just watching TV.

 

So, I think, just to echo what Will said, and what I know speakers have said yesterday as well, is that we are talking about a fundamental societal issue. It’s not simply an individual lifestyle issue.

 

So I’m going to talk about the context today and the context in which we are operating, particularly, in context of heart disease, cancer and diabetes strategies.

 

I’m putting up a slide that will be familiar from yesterday, familiar to all of us, but I don’t think it harms to remind, repeatedly, the threefold increase that we’ve seen and also the higher rate in women than among men, over a 20 year period, which mimics other countries across the globe.

 

The causes, which I suspect, Susan Jubb spoke about yesterday, is this blend of diet and physical activity - diet and exercise. But the point I want to make from this slide, because I think it’s often quite misunderstood, is what this shows is the energy intake and fat intake and then the cars per household and television viewing compared to the obese on the right hand slide. And as you can see the percentage cars going up and television viewer hours per week actually mimics the rise in obesity. But the point I’m going to go on and make is about this energy versus obesity prevalence, is that it’s quite often indicated people say, "Well it’s not down to diet, it’s not down to energy intake" and actually we talked a lot with the National Audit Office about this because I was particularly concerned that we were going to give out a message that said it was all down to activity and nothing down to diet and, I think, one of the problems with our figures around diet is that, until recently, we haven’t measured food eaten outside the home in our surveys. And therefore, actually all our surveys in the past have only looked at food consumption in the home so that doesn’t include snacks eaten on the way to school and, again, what I’ve recently seen is with kids, on the way to school, spent £365 million a year on sweets, crisps and fizzy drinks, just on the way to school. Now that sort of data isn’t measured here so they’re spending all this money, they’re consuming all these calories, but it’s not measured.

 

The other point is that when we look at eating out we’ve seen a rise. And this is just in general restaurants this figure. It doesn’t include the quick service, the fast food, which there are now two billion meals served every year. This is just restaurants. The other thing we know about food eaten outside the home is that it’s higher in fat than food eaten inside the home. About 38.3% of our energy in food eaten outside the home comes from fat content. So it’s fattier food, higher in fat, and contributes a substantial proportion of energy to our diet, so I think it is a fallacy to think that it’s only physical activity and it’s not diet which some figures start showing.

The risk of disease - important and, as I said, I think what’s been invaluable from the National Audit Office report is doing these calculations, putting them, setting them out for all to see. The risk of disease, type two diabetes, hypertension, heart attacks, stroke, colon cancer, etc, the relative risk increased by up to 12.7% in women in type two diabetes - the one that is most associated with obesity. And, I think, those figures speak for themselves.

The other figure, which I suspect, and I’m sorry you may not be able to see further back, but this is a figure that looks at the interactions of body mass index of obesity with other cardio vascular risk factors. So, if you’re overweight or obese and you smoke, actually, it increases your risk further than simply the smoking. If you’re overweight and you’re hypertensive, actually, it has an interactive multiplicative effect, not simply an additive effect. Ditto, it has an effect on raised blood cholesterol and ditto, as I’ve talked about, on diabetes. But it interacts with smoking, it interacts with blood pressure and it interacts with cholesterol and actually raises the stakes in those.

 

Costs to the NHS - you’ve seen the figures, heard the figures again. I’ll repeat them - 28,000 heart attacks attributable to obesity in 1998; 6% of all deaths costing the NHS £0.5 billion pounds and 80% of those costs arising from heart disease, hypertension and type two diabetes. The other point about, if you manage obesity in adults and achieve a 10 kilogram weight loss you could be bringing about a 20% fall in mortality.

 

It is a government priority and what you’ll find if you look at the various documents, the national service framework for the cancer plan and the NHS plan, all of which frame the Department of Health’s work now, is that obesity is there in all of them. We have a target to reduce premature deaths in cardio vascular disease and cancer and also, I’ll go on, we have national service frameworks. We have a cancer plan but also a national service framework which shapes and sets standards and tries to level the playing field across the NHS and that’s the framework - the NHS plan and then a framework for the next 10 years.

 

We have a National Heath Service plan, which was published July 2000 - I’m going to talk a bit about the commitment there. And we also have, as I said, national service framework. But one, yet to come, which I’m just mentioning, is also one forthcoming on children and children’s services which I think will be quite important and I notice that our Ainsley Green, the chair of the task force was here yesterday. So, I think, that’s an important context.

 

The way I like to see these things is in terms of a twin track approach. Prevention, which we’ve heard a lot about, we’ll continue to hear about and the best long-term strategy, beginning from childhood. But also what I nominally call cessation. And the reason I call it that, and that’s treatment and management, is to align it with the sort of thinking around smoking that we have. We have the prevention or we have the cessation and so stop it starting or prevent it starting but also once you are overweight or obese, people actually can do something to stop that and reverse it.

And, I think, the discussion about the analogies with smoking is quite interesting. I think there are comparisons - that’s partly why I quite like this thinking about cessation strategies because there’s been a lot of investment in cessation of tobacco. But, I think, the thing we do need to think about is, whereas passive smoking has helped raise the profile of that, we don’t, at the moment, have passive obesity or any indication that actually you being fat can affect my health.

 

The important thing, also, around cessation or treatment and management, is that there is evidence on diets, exercise, behaviour interventions, drug therapy and surgical. And I’m going to talk a bit about those.

 

The NHS plan, which is our framework, does set out a commitment, both to local action on obesity and physical activity, based on evidence of what works and, I know Caroline Mulvihill and, I think, Mike Kelly, are going to talk about the evidence in the next session from the Health Development Agency, but also a programme of action on diet and nutrition which I will go on to. But the context of the CHD national service framework is that throughout the system, whether it’s population and prevention, whether it’s primary care and identification of people with CHD or people with increased risk of CHD or NHS trusts in terms of cardiac rehabilitation. There is a commitment throughout that and all milestones to address diet, physical activity and obesity. It is a commitment; it is a standard that the NHS working with partners’ has to fulfil. The milestones range over the next two to three years but during that time we have been and will be offering advice and monitoring progress on that.

 

The Diabetes National Service framework standards, which were published just in December, also set out standards on prevention and reduction of overweight and obesity, including exercise and diet and also support for individuals at increased risk.

 

Another framework that we should think about within - Will talked about the social class difference but is tackling health inequalities which is a main government drive at the moment and it is a cross government drive. At the moment the Treasury is leading a spending review with the Department of Health on that to look at policies which impact on health inequalities. And we know that obesity contributes to those health inequalities, both in terms of the social class and the ethnic dimensions, Will talked about that. So a woman in social class five has double the risk compared to a woman in social class one of being obese. South Asians and Afro-Caribbean’s - particularly women - have high risk. And we’ve recently been through a health inequalities consultation with a view to developing an overall strategy. This indicates from left to right [Reference to visual aid], social class one to social class five, the patterns of obesity which are more clearly cut in women than in men, so the dark green -- ‘women’ shows the steady trend upwards to social class five.

 

I think the Public Accounts Committee said very clearly, the Department of Health cannot tackle this alone. We need an integrated approach, both with cross government work and local action, and already there is a substantial amount of cross government work but there is more, obviously, to be done. And one of the frameworks I like to think around is different prevention strategies; fiscal strategies. People talked about tobacco tax earlier but looking at strategies, for example, making healthy foods cheaper foods, for example, legal and regulatory setting nutrition standards for school meals, etc, providing information and education - but that is just one part of the border - and then service provision to the NHS. And I think if we think through those strategies and think through that framework, it guides us to think, "What are we doing in each of those different types of strategies"?

 

The NHS plan gives several commitments, which once implemented, should have an impact on obesity and, certainly, that is our intent. There is a reform of the welfare foods scheme, which currently gives milk and drink and formula to mothers and babes in low-income families and that has been under review and there is a commitment to reform that - to support mothers and babes with healthy options. Improved support for breastfeeding and Bill Dietz, yesterday, mentioned the importance of breastfeeding and certainly we’ve seen a major increase in breastfeeding from social class five from 50% to 62% over the past 5 years, so that’s something we’re working on.

 

A national school fruit scheme: Yvette talked about that, whereby every child aged four to six will be entitled to a free piece of fruit each school day from the year 2004. A ‘five a day programme’ to increase fruit and vegetable consumption and, I notice again, Bill, you put that as number four on your list yesterday, I think, in terms of fruit and vegetables. But I think these sorts of things will contribute to overall balance of the diet.

We also have a commitment to work with the Food Standards Agency, to work with industry to improve the balance of the diet and to reduce fat, sugar and salt. You will know that that will be a challenging goal. Obviously there’s a lot where we have seen reductions, for example, in change from full fat milk to semi skimmed milk, it shows it can be done. There’s a substantial shift, but there is further work to be done.

 

Hospital nutrition policy, as I said, tackling obesity and physical inactivity. We’re thinking about it as a life course approach whereby the locks fit together starting from pregnant women and infants through to children with also linking in with school meals and food in schools initiative and then the whole population. But, again, it’s working in partnership with those other government departments and other agencies.

 

In terms of exercise, you’ll hear more about evidence on it but I think we do have and, I think, Sian Griffiths made this point yesterday, is that we do have evidence on things that work and we should be focussing on what works rather than wringing our hands and saying, "Let’s wait for the evidence" which I think, again, public health, gets too trapped into that sort of scenario. We have evidence that we can improve walking to work and, as I said, that figure that just walking 20 minutes could have a substantial impact.

There’s recent research. I saw just a couple of weeks ago, on school playground size and time of recess linked with obesity amongst 4,000 kids in America. A research project that indicated the bigger the playground and the longer the play time the lower the rates of obesity.

 

Transport qualities can work to encourage walking and cycling and brief interventions and primary care can work.

 

I want to look briefly at the opportunities in exercise as well. You’ve heard about the new opportunities fund - £581 million, but we’ve got a very clear steer in there that PCTs - Primary Care Trust - and the NHS, are a key partner. There’s a target on sport and physical activity. The Prime Minister has announced two hours entitlement of physical education for kids. Transport policies - there’s a whole programme of urban renewal which we should be linking in with, and also there’s a whole network of healthy schools, school sports and travel plan co-ordinators on the ground, all of whom are working in the same direction. And one of the things we’re trying to do from the Department of Health is make sure they’re working in a joined up way to add value, rather than just replicate.

 

In terms of the specific action we’re taking, we’ve done a quality assurance framework for primary care but also we’ve recognised that the status of exercise within the NHS, it doesn’t have the profile it needs, so one of the things we’re doing is setting out the health case, a high level document for the NHS, for managers, for policy makers at local level, to say this is important, this links in and this has a major impact on heart disease, cancer, etc.

 

We’re also planning a conference for chief executives of primary care trusts to set out where exercise fits in the national service framework and, again, raise the profile of it in the NHS.

Looking at what I call bite size chunks which is, how do we convey this message of an hour a day for kids and half an hour a day for adults. Because I don’t believe the public responds to messages quite as general as that and we will need to look at what works for obesity as well as what works for heart disease. And we will be giving guidance to primary care trusts and developing with London School of Hygiene monitoring tools to monitor what’s happening.

In terms of local action also, the Health Development Agency, produced guidance on CHD Prevention which set out effective interventions on diet, physical activity, smoking, etc, but also they did with us an assessment of local plans on diet which clearly shows the need for integration, although the plans were patchy - they weren’t linked in that well to a lot of the frameworks, which are leading and driving the Secretary of State’s agenda. They weren’t necessarily co-ordinated and matched up with what was going on and also, there was a very clear need for them to look at the evidence base and look at implementation. So that’s something we are working with the Health Development Agency in terms of producing new guidance for primary care on this. The HDA is doing a new report for primary care, generally on effective action but also with supporting research and supporting charities like Weights’ Concern.

 

But the other point I want to make is the context of the NHS change and shifting the balance of power because, again, I think, this gives a huge opportunity for more work and more focus within the NHS on obesity. There’s a focus on patients in the front line but with the setting up of primary care trusts back to where the public health engine is going to be. There would also be public health in government office of regions, for a more strategic approach, for example, in food and farming. But at primary care, they have a specific obligation to deliver on health improvement and reduce health inequalities. Obesity fits in that and every PCT will have a Director of Public Health who should be driving this agenda.

The last context that I want to talk about is the Nice guidance. I talked about drugs and I think, again, that is often what drives the agenda of the NHS and of GPs and of health professionals. People know that there was Nice guidance issued but actually if you look at the guidance and look closely, it’s only to be prescribed for people who have lost 2.5 kilograms by diet and exercise in the previous month, therefore the guidance is, it shouldn’t be prescribed without that. In order to do that, training of practice nurses by dieticians will be needed, say Nice, and this is guidance across the field.

The other thing they ask for is local obesity action plans and, I think, armed with this knowledge that this is what Nice is requiring in primary care is quite important, that primary care trusts and GPs will have to set these up. They also ask for local audit data.

Now there’s a raft of policy framework, which set the scene at local level for NHS to deliver and help on obesity - both prevention and management. The last framework I want to talk about is the wider international framework because, again, we’re not operating, I think as we’ve all seen, the UK is not alone in these rises in obesity and we’re not operating just in a national framework and that’s something Will Hutton talked about - the multi-national globalisation.

 

Just last week the World Health Organisation executive board agreed a paper on diet and physical activity and to move forward on an action plan in these. And I know that the World Health Organisation’s keen that we take a more strategic approach - a bit like tobacco - to address these on a multi-national level and address the multi-national marketing and production of food, etc.

We have a European framework on nutrition. Now that’s gone slightly into abeyance and I think needs reviving and, certainly, I’ve been talking with the Commissioner about that. A world health day on exercise and a WHO action plan on diet and exercise. We can’t do this alone but I think that first slide and the top one actually provides a very nice framework for all countries in the world to come together and to drive on this one.

Just, in conclusion, it is chronic. It needs long-term action. It’s beyond the NHS, but the NHS can play an important part, particularly acting on evidence where it exists. We need an integrated approach but I think the main point I want to leave, is that actually Ministers are seeing this as a serious issue. Ministers across the board are taking it seriously. There is an opportunity for action and I think we should take it now. Thank you.

 

DR WILLIAM DIETZ: Thank you. I think we are going to go on to the next presentations. Imogen has to make it to another meeting at 10.00am, I believe.