Joining Forces to Tackle Obesity, 21-22 January 2002
Transcript : The Global Epidemic
Speaker
Professor Philip James, Chairman of the International Obesity
Taskforce
ANDREW HILL: Well, we’ll have a short period
for discussion after our next speaker who is Professor Philip
James. Phil is currently Chairman of the International Obesity
Taskforce, and Phil is going to supplement Bill’s talk and "fillet
his slides", as he said to me beforehand. Phil.
PHILIP JAMES: Thank you very much. [Change of
slide] It’s a great honour to be here and to hear the outcome of
these astonishing reports from the government which, from an
international perspective, is a very unusual development and I’m
delighted to be here, returning to England to discover what’s going
on. My task is to tell you, in a sense, about the rest of the world
and, taking account of Bill’s analyses, I’ve at least gone halfway
and produced some data which simply amplifies, and stay away from
some of the issues that he has dealt with, so don’t -- I would
entirely endorse his sentiments, and what I’d like to do is, if you
like, to give you some reassurance that you’re not alone with the
United States in confronting this problem.
A few -- 1997, we produced in the International Obesity
(inaudible) Report, to which Bill Dietz has made a major
contribution, an analysis of the global problem because the World
Health Organisation, like all Ministers of Health and ministries,
did not believe it was important. And this came out about a year
ago, and I’m not going to summarise all its implications because
they are many, and last week some of those were at the Executive
Board of the World Health Organisation, where it’s now right up at
the top of their agenda. [Change of slide] The real point about the
report was we attempted to systematise a classification, which I
won’t go through, and the United States data. The issue now also
conform with this, as do most places in the world.
[Change of slide] What I’d like to emphasise however, is that as
you go round the world and you (inaudible) the system to be a much
more technical report input than we’ve heard in the general
messages from Bill Dietz. If you look at the BMI distribution of
the population, this is the sort of curve you get in the early
1980s in China, and this, I guess, is Bill Dietz’s curve in the
United States, and if you go across the world you see different
groupings. And everybody’s been talking in the medical clinical
world, about people with a BMI over 30, frankly obese. But what you
can immediately see is that it reflects an astonishing shift in the
whole of society, which is why it’s so marvellous that the Audit
Office has seen this conceptually as a societal issue.
Here’s the standard classification of overweight. You have a
vastly increased number of people, once you add the overweight to
the obese. And here, in dotted lines, is the new -- I call it the
neuroses -- of the Asian groups who believe that they have such
unusual susceptibility, to which I’ll come, that they in fact
should specify anybody over a body mass index of 23 as in danger
and in need of medical advice and care.
[Change of slide] Now, we had data this morning -- from the
whole question of looking at the women -- and it’s quite
interesting because it’s been a sexist issue for a long time. I’d
like to point out that, in these data we obtained a long time ago
from China in 1982, when nobody ever bothered about obesity,
characteristically you see the curve for women is different from
men. It’s broader and you have more women at both ends of the
spectrum. [Change of slide] And if you go round the world and take
different communities, and say, "How do we compare the proportion
of obese men with obese women", then almost every community in the
world -- and this is literally across the world -- you find, in
general, more obese women than men, and we now believe that this is
biological and not simply social. Of course it interacts with diet
and physical activity as well, as we discovered from studies in
Brazil.
[Change of slide] Now, what’s happening in the world? Well, way
back seven years ago, we published this data from a World Health
report which showed that, at that stage, we were concerned,
particularly in places like India, with chronic energy deficiency
or underweight. But to our astonishment -- and these are all
nationally representative data -- we found a host of third world
countries where they had really no problem of underweight -- these
are adults -- but they already had a sizeable proportion of the
population were already, in the early 1990s, overweight or indeed
frankly obese. So it looked as though something was going on
globally.
[Change of slide] Let’s come closer to home -- and this is much
more up to date -- and a collation of data that we’ve been
provided, not all of it meticulously representative, but it gives a
reasonable view -- and to our astonishment you can look at
different regions, and we’re currently working with WHO looking at
the massive epidemic -- and in different regions -- we specified
the regions, as I will shortly, as having particular problems, but
(several inaudible words), you see that in fact there’s an amazing
difference in the prevalence of overweight. But here we are, dear
old -- dear young England -- near the top of the league,
and you have to go to some unusual countries, such as the
Netherlands and Norway, before you see the striking contrast.
[Change of slide] And recently, at a Commonwealth Ministers of
Health meeting, we had to try to persuade the third world
ministers, many of them medical, who absolutely did not believe
that obesity was a problem. We’ve put together, for women, some
Commonwealth data. And here is a series of countries within the
Commonwealth. We put in the UK data there. We’re still outclassed
by Jamaica and, of course, the Pacific Islands have an appalling
problem with 75% of some populations obese and ½ of the population
essentially being treated for diabetes. And here’s rural India, and
up there is urban India. If you wanted to classify the biggest
concerns in the world, one would specify India, as I’ll come to
shortly.
[Change of slide] Now, what about the globe, as such? Well,
Marterel(?) did an analysis with a whole host of different studies,
and he took women and looked at the proportion of overweight and
obese in different societies. And Bill Dietz may be cheered up in
that the United States is not top there. The Middle East has an
appalling problem, as have the old central communal(?) economies,
the former Soviet Union, Poland, Romania, Bulgaria and so on. Then
comes Latin America, sub-Saharan Africa, and apparently very few
problems in South Asia because we are choosing the classic cut-off
point which I started with.
[Change of slide] If, in fact, you then go to Asia, you will see
-- and here are the different ethnic communities in Malaysia -- you
will see that if you look -- and this is very recent data,
published in the medical journals in Malaysia -- you will see the
different ethnic groups. Their average BMI is already climbing
rapidly almost to the 25 mark, to the average of the population,
and we think that this shows that there’s a major secular trend
going on, which you can show in some countries, and here’s
Mauritian data, where there’s been an epidemic of diabetes of
enormous proportions that people are very concerned with, and both
men and women have a similar increase. In Mauritius, however, they
are very focused on trying to introduce new public health policies
and are beginning to make some headway.
[Change of slide] Now, you’ve already heard that there’s a
parallel development of diabetes, and if you look at the
predictions of where we’re going to be, in diabetes terms, then we
find charts -- and this is quite an old chart from the World Health
Organisation -- showing that most societies are going to be
confronted with a huge medical burden from diabetes. And, of
course, what is now becoming recognised by diabetologists as well
is that the underlying factor is, in fact, the excess weight gain.
[Change of slide] Now, I’d just like to illustrate this with data
which were provided to me by the president of the Chinese Medical
Association, where they looked at the -- and I think it’s recently
been published as well -- where they’ve looked at the adult
diabetes rates in single ethnic groups -- and nobody can quibble
about specifics or susceptibilities -- and here in rural China,
diabetes rates are 2 to 3%. And as you go to Beijing, they’re
double, and you can then go to the Chinese communities in different
societies until you get to Chinese, 3% of Mauritian(?) to Chinese.
17% of them are diabetic, and the prediction that we’ve been
discussing with the Beijing authorities is that actually, they
already have about 35 million diabetics, and we predict they’ll
have 150 million diabetics within the next 10 to 15 years unless
some new developments occur.
[Change of slide] Now, forgive this slightly complicated graph.
The question is, are the Asians unusually sensitive to diabetes?
And the only data we’ve been able to obtain that are truly
representative, with meticulous analyses of where those people got
diabetes, comes from Japan and from Denmark. And here, as your body
mass index goes up, as you get heavier, up goes your rates of
diabetes, and as you get older you become increasingly susceptible,
which is why the graphs from the Japanese are different, with a
very high rate in the older, heavier Japanese. Here is precisely
comparable data from Denmark, which suggests that -- and these are
60 year olds -- if the danger is the same as the Japanese, the line
should be up there, so there appears, and there’s a big debate
about this, to be unusual susceptibility to diabetes, and that’s in
Asians and that’s actually been recognised here in Britain for many
years in terms of Asian immigrants. [Change of slide] And it’s for
that reason that the proposition has come from a meeting in Hong
Kong that, in fact, we should have different standards for perhaps
Asia and (inaudible) other developing countries.
[Change of slide] Now Bill noted that he’d produced this
fascinating paper last week, looking at the issue of abdominal
obesity, where one’s waist is increased and, if you look at
waist/hip ratios, you’ll have a high value. And the unusual feature
-- and this comes from Guatemalan data -- is that, if you look at
women or men, and you stand by the amount of fat that they have on
board, it looks as though some women and men have far bigger pot
bellies, even though they’re from the same community. And that
relates to whether or not those same individuals were stunted in
childhood. And there’s increasing evidence now that there’s some
mysterious link between early events in childhood and how one then
deposits the fat and accumulates, and we’re currently working with
the Mexican government, where I’m intrigued by Bill’s data because
we found the same in Mexico, comparing it with US data. And it
looks as though there’s a marginal increase in susceptibility of
diabetes and other co morbidities, that the dominant effect comes
from this abdominal obesity, which is so common in third world
countries.
[Change of slide] Let me skip this which highlights -- and come
to this concept. If you look at the third world community, with
their risk of short stunted children growing up to be short, with
pregnant women producing low birth weight babies. Currently 1/3 of
babies in India are of low birth weight. In Bangladesh ½ of all
babies born are small. And what seems to be developing is
subsequent rapid growth. The combination of some early nutritional
affect, and rapid changes in early childhood, appears to be making
children much more susceptible to increasing insulin resistance
and, if you like, the impending diabetes problem, as well as high
blood pressure, and that’s now been shown in Jamaica, in India, and
in South African studies, and they’re really very meticulous.
[Change of slide] So if we look, for example, at India, and we ask
how many -- even women in India -- have pot bellies at different
levels of their body weight, here we find that as soon as you get
over this cut-off point, the standard one, the vast majority of
women have abdominal adiposity with all its unusual complications
to which Bill referred. So we do seem to have a particular problem
in the third world with adults, and those who are coming here may
actually be, putting it crudely, programmed to be unusually
sensitive to the complications of unhealthy weight gain.
[Change of slide] Now what about children? We’ve already heard
about the increasing epidemic in the US. Here is a recent
publication that Bill was very involved with, getting standards
which are now being applied throughout the world. And when Bill
Dietz, with our colleagues, put together a set of data, [change of
slide] here are third world countries, where one wouldn’t imagine
for a moment that children obesity is a problem, and both girls and
boys are showing quite often remarkable rates. Here’s the Middle
East, and here is Latin America. It’s of immense concern in most
parts of the world. In China, ministers of health are suddenly
focusing on the major problem of ‘the little Emperors’ who are
tubby and on their way to early problems. [Change of slide] And
here is English data, using the same standard of criteria, compared
with Australian data over there. Here’s the epidemic occurring in
England -- boys and girls -- really a very recent kick-off. And
here’s Canadian data -- slightly different criteria but very close
to it -- and here in Australians. We do not have data for third
world countries on the secular basis, but there seems to be a major
epidemic underway already.
[Change of slide] Now, we’ve already heard a bit about the
burden of disease and we’ve highlighted the fact that both
nutrition and physical activity need to be considered. I thought it
might be useful, since we’re now currently working to try to find
out what the burden of ill-health is, to put together the factors
which we now recognise to relate to diet, and then specifies
physical inactivity separately. And if you look at the first report
on this, which came out recently from Australia, you’ll find that
high blood pressure, high cholesterol levels, lack of fruit and
vegetables, and obesity which was -- this contribution has been
halved to take account of physical inactivity. Those alone give you
about 15% of the total burden of ill-health in an Australian
society. Compare that with tobacco, which we all agree is a huge
problem and, in fact, those problems, without even considering
physical inactivity, exceeds even the burden coming from tobacco.
So I think we really need to re-gear ourselves and think in a
completely novel way, which is why the National Audit Office report
was so welcome. [Change of slide] And if one looks at the past -- I
won’t dwell on this -- as one looks at data from around the world,
many different countries have now highlighted the enormous problem,
and that problem of course increasing with age, and being
particularly a major problem if, in fact, one is obese. And so --
this data comes from Finland -- now there are data emerging from
different countries all coming up with the same story.
[Change of slide] Now, we’ve already heard about the
transformation of food practice. That transformation occurs very
early, and here’s (inaudible) recalculation of the old analyses
done 40 years ago, looking at what happens when societies develop.
As one becomes more affluent, the fat intake goes up -- and it’s
actually contrary to what I saw -- particularly animal fat, and the
complex carbohydrate, as it used to be called, goes down, with an
increase in sugar consumption result and there is a steady shift in
societal food patterns, but also in the macro-nutrient intake. And
I’ve deliberately chosen the rural areas because, if you take the
urban areas, as many of you know if you’ve been to third world
countries, you will find fast foods emerging as a major
contribution, as far as the people are concerned, in slum areas,
because of the problems of transport in fruit and vegetables into
cities in these circumstances. And it’s very frequent in Thailand,
in India, to see dramatic changes as villages enlarge.
[Change of slide] We’ve known for some time that, putting it
crudely, as the fat intake goes up above 15%, then the likelihood
of having obesity escalates. If one looks at whether or not we
inadvertently eat too much if we have a wonderful fat-enriched diet
[change of slide], the answer in the studies in here in the UK is
that we do not appreciate the fat content of our diet, and it’s
very easy to overeat a high fat diet, and accumulate an extra two
days’ supply of food, inadvertently without realising it, within a
week. So this episodic pattern of high density, high sugar, high
fat diets, which has not been looked at, as Bill highlighted, is an
extremely important problem. [Change of slide] Recently, in Quebec
a few weeks ago, (inaudible), in control of trials from Denmark,
showed that (inaudible) to reconsider the pattern in terms of soft
drinks, or intermittent intakes, because it may be that that has a
different effect from, in fact, just the macro-nutrient composition
that Bill emphasised.
[One slide skipped, change of slide] Let’s skip that. And let’s
come to -- the problem, therefore, is not that we should
necessarily blame the food area, or the physical inactivity area.
The problem is, how do we manage to put this together? And the
difficulty at the moment is to find coherent evidence, where you
take account of both factors. It would seem that, in fact, if one
is hopelessly inactive, you need to be on a very high quality diet,
low in fat and probably low in sugars, and with fruit and
vegetables, to be in energy balance and not gain weight. If one’s
physically very active, you can get away with a less appropriate
diet. [Change of slide] But how much physical activity do we need?
Here is the avoidance of obesity shown in, not US data which is
just coming out now, but in China, and in Sweden and Finland. If
you have people susceptible to diabetes, and you change their
activity, drop their weight and change their diet, you need both
factors, it would appear, and very modest weight losses.
[Change of slide] And, if in fact, one asks what are we doing
about it, we have to recognise that physical activity is dropping
markedly with age. You all know this and, therefore automatically,
we have to be eating less in terms of calories with age. That’s why
there’s a parallel between ageing, declining activity, and
increasing bodyweight in so many societies. [Change of slide] And
here is ITS(?) recent analyses, which will emerge shortly,
suggesting that if you actually ask, " How active should one be?",
with the physical activity level perhaps twice what you just burn
in basal rates, then and only then do you get, with your BMI,
reasonably down towards the normal level, if in fact one is on a
characteristic western diet. And James Ellison(?), who’s here, has
been heavily involved in that. Currently, our advice is that walk
30 minutes a day, and that will help cardiovascular disease, as
indeed it does. The new evidence in -- it’s actually, the more we
look at it, the more powerful it is -- suggests that unless we
change our diet, then in fact we’ll have to be very active
to in fact maintain bodyweight stability. And if we agree with all
of that, then I’m going to decide that I won’t put on
weight by being simply active. If I walk a dog, God help me, I will
need to go for 11 hours a week at this modest level of activity,
but even walking at a low (inaudible) pace, I need to do 10 hours
of extra walking. And it’s only when you become very
vigorous that you can get away with it on a short term base. So I
think we have to rethink the integration of food and activity.
And here, I’m just going to finish with one example where they
have not yet cracked the problem of obesity, but they’re on their
way to taking an integrated approach to societal change. Here is
Finland, where they had a major campaign with 19 guidelines, and
the whole society involved in trying to prevent cardiovascular
rates, which were horrendous. In 15 years they’d trebled the
vegetable intake. They also markedly reduced the fat intake, and
here’s low fat milks going down. A complete transformation of the
way in which they were eating and, in association with that,
despite some improvements in men [change of slide] on smoking,
they’d dropped the blood pressure, on average, by 10 units, which
is an astonishing change which would imply that every single
citizen had been on a hypotensive drug to bring their blood
pressure down -- no it wasn’t, it was changing diet with some
increase in physical activity. And here’s a huge drop in
cholesterol as well. And here’s the enormous drop in cardiovascular
disease. [Change of slide] The recent data, which will emerge
shortly, show that even the drop in the total fat intake of 34%,
the inactive men and women are still getting fat in Finland, but
even if they’re moderately active, then they in fact have
stabilised. So I think that we need the combination of food and
physical activity, and one’s not going to do this if one just
approaches it on a medical basis, which is why it’s so marvellous
to be in a forum where we can discuss the major precipitants of
this epidemic which, unless we do something, will actually escalate
with huge consequences for health. Thank you very much indeed.
ANDREW HILL: Thank you very much Phil. We have
about five minutes before lunch to discuss the outcome of these two
presentations. If there are people who want to ask questions, would
you like to stick your hands up. It’s actually quite difficult to
see at the back but if I call out people, would they stand up, say
their name, where they’re from, and probably shout from the back so
everybody can hear. Yes?
QUESTION FROM FLOOR: (Several UE words) and I
could see you clearly Sir. I’m a (UE) overseas medical graduate,
thanks to the (several UE words) Health Service, and I must thank
the National Audit Office for bringing the director from the Centre
for SCDC to this country. Though politically we condemn the
Americans for their hegemony, here I must appreciate the Americans
for spending huge money in establishing such centres, and I am here
inviting them to condemn the European heads for failing to
establish the centres to quantify such problems, but particularly
the speed in which we are going to establish a European military
task-force. My (several UE words) solution, my ambition is that
(UE) at(?) the SCDC, in countries even like Afghanistan, so that in
the future we should spend all of the money wisely to prevent such
disease, so that we can (UE) ministers of health to the poorest of
the poor. Welcome, yes.
ANDREW HILL: Thank you. I think that was a
point, and I think the point there was that it would be really nice
if the SCDC in this country, and in fact everywhere, that’s a very
-- politically, I’m not sure that’s a vote winner but --
INAUDIBLE COMMENT FROM FLOOR
ANDREW HILL: Okay. Thank you, thank you.
Susan?
QUESTION FROM FLOOR: From the MRC in Cambridge.
Bill, the data you showed us on breastfeeding is something that I
think is only just beginning to be recognised as important in terms
of a prevention of obesity. Two things: can you be sure that that
is appropriately adjusted for all the other social factors which we
know co-associate with breastfeeding practices and secondly, if it
is, do you have any idea what the mechanism is? Is that through
appetite control or what do you think the mechanism might be?
WILLIAM DIETZ: Bless you. Those are both good
questions. Most of these studies, to the extent they’re code
adjusted for potential confounding factors like socio-economic
class but SES or income or education may not completely capture all
those factors. Regardless, I think we can argue that breast milk is
still the best food for infants, rather than -- that cows milk
should be reserved for calves. But it is possible that the
adjustments here don’t capture other variables. I was surprised
actually, in this report, that rates of the initiation and
sustaining of breastfeeding in England are actually lower than they
are in the United States. In the United States, about 60% of women
initiate breastfeeding but, at six months, only about 25% of women
continue to do so and I think that’s actually double the rate in
the UK, as I understood the NAO statistics.
The second question had to do with mechanism, and although there
are higher insulin levels associated in infants who are formula
fed, my own bias is that this is a parenting issue -- that when one
feeds formula from a bottle, what the gauge of infant satiety is
how much the infant has finished, not the infant’s cues about
satiety. And I think that even modest degrees of over-feeding or
urging children to eat more may be certainly as important, if not
more important than any physiologic differences which
exist between breast milk and formula.
ANDREW HILL: Thank you. We have a question at
the back, yes?
QUESTION FROM FLOOR: Yes, my name’s Dr
Bedes(?). I’m a doctor with an interest in the biology of
nutrition. We base our nutritional advice on the physical unit, the
calorie, but looking at the body biologically, the use of energy
that we metabolise is glucose, and if we extrapolate that back to
diet, it’s sugars and refined carbohydrates which are the high
energy substances in our diet which tend to increase with
westernisation. And Type 2 diabetes is a disease or malfunction of
carbohydrate metabolism. I just wonder what the panel thought about
refined carbohydrates as aetiology for obesity?
WILLIAM DIETZ: Well there has been increasing
interest in the glycemic effect of food on insulin responses and I
think that’s an intriguing area. The relationship however, for high
glycemic diets in the development of obesity is less well
established. I think that’s still a hypothesis. It’s certainly
reasonable to argue that foods with complex carbohydrate, as Philip
indicated, are probably a healthier diet, I mean particularly from
the prevention point of view, where we should be increasing
vegetable and fruit consumption. But I don’t think we yet have the
data to argue that a high glycemic diet is obesagenic.
INAUDIBLE QUESTION FROM FLOOR
WILLIAM DIETZ: Well I hope what I led you to
believe was that we need to understand why it’s different. The
problem with the Behavioural Risk Factor Surveillance System is
that it’s only 80 questions, and a good number of those questions
have to do with other behaviours other than diet and physical
activity, and I don’t think we have enough detail to understand why
Colorado is different. But people who live in Colorado tell me it’s
because there’s a greater emphasis on being outdoors and being
physically active, and I’m prepared to believe that, but in fact we
don’t have hard data that indicates that that’s the case.
ANDREW HILL: Okay, a final question, the man
with the microphone wins.
QUESTION FROM FLOOR: Thank
you. I’m (inaudible) Greene, I’m the National (inaudible) for
Children at the Department of Health. I’ve really enjoyed this
conference -- it’s so important, particularly the last two
speakers. There’s been repeated reference this morning to the
influence of advertising for children. I wonder whether the two
speakers could comment on what steps are being taken
internationally to influence food manufacturers in their
advertising, and then specifically looking at the impressive data
from Finland. Did that coincide with a change in national
advertising of foodstuffs for children?
PHILIP JAMES: The whole issue of advertising
for children is a major political issue. I understand that the
Swedish government tried to propose that there should be at least
an analysis of this, broadly they proposed that there should be
limitations when they had the presidency in the previous six
months, and that in fact was rapidly turned down because, as one of
the most senior officials said to me in Geneva last week, there’s
enormous power and industrial and commercial interests in actually
maintaining that advertising. Speaking certainly as a UK person,
we’ve put in with the Department of Health and Education’s
involvement, and the whole public sector received(?) the proposals
in 1997 after the election of the new government, which asked that
we should look at the issue of advertising to children. That was
seen to be a highly inflammatory analysis. It’s remarkable to me
that the Public Accounts Committee has asked for precisely the same
analysis, and what I think we’re going to find is that we are going
to find different approaches in Europe, and this is becoming an
issue. The Finnish data did not coincide with that. There were huge
changes in specifying the quality of food to be given to pre-school
children to school children. The restaurants were focused on the
dietetic. Food industry was heavily involved in transforming the
nature of their diet. We’ve got to confront the fact that if you
read the marketing analyses of those things that are advertised on
television, the marketers -- and you can see it in any economic
report -- focus on targeting children because it means that there’s
a huge opportunity. Britain is said to be lagging behind the United
States, so there are wonderful commercial opportunities for junk
food, as it’s called, and confectionery and soft drinks, and if you
talk to people in the UK, they’ve seen the Mediterranean world as
an enormous commercial opportunity to sell these products. So I
think we have a genuine dilemma and, rather than sort of ignoring
it we should actually engage and begin to sift through what is
appropriate because frankly, this is an epidemic and an issue
that’s emerging in most countries of the world.
WILLIAM DIETZ: I certainly agree with Philip’s
viewpoint, and we’ve taken a somewhat different strategy in the
United States in this area. What we know is that there’s a
relationship of television viewing to obesity. What we don’t know
is how that’s mediated, and although -- commercial speech --
there’s a history of the regulation of commercial speech in the
United States, I think it’s premature and unlikely -- an argument
that television advertising should be controlled is unlikely to be
terribly successful. Our strategy therefore has been to focus on
the time that children are watching television, as well as
the responsibility of parents for offering appropriate foods. We
have a protocol that’s now in a pilot status, in which we’re
looking at the effect of counselling around the division of
responsibility between parents and children around food choices,
and control of the television set on infinite(?) obesity in
susceptible 3 to 7 year olds. The (inaudible) for susceptibility
here is defined as a BMI between the 85th and
95th percentile, and/or one or both parents overweight.
The control of television is self evident. I think the strategy is
how to give parents alternative strategies, because I think
television does play an important role and, as I indicated, I think
that it’s pretty tough to recommend that television be controlled
if there aren’t opportunities for free play. The division of
responsibility between parents and children is what I think
mediates a lot of food choices, and the division of responsibility
means that parents are in charge of what children are offered and
children can choose to eat it or not, and how much. And I think
that television advertising blurs that division of responsibility
by putting children in the position of making decisions for
families. And, as I think I indicated, the decisions about where
families eat outside of the home are largely driven by children,
which is a consequence of television advertising directed at
children, and my view is that control of the television set is
going to reduce those requests and those types of behaviours.
ANDREW HILL: Okay, that’s a good reminder both
how industry should be responding and to the advertising for
children are two of the breakout sessions this afternoon -- if you
haven’t signed up, then you can go downstairs and sign up. Thank
you for your excellent questions.