Written evidence submitted by the Department of Health (IDH0078)

Introduction

1. The Department of Health has prepared this written evidence in response to the Health Select Committee’s invitation to contribute to its Inquiry on the impact of physical activity and diet on health.  The Department is grateful for the opportunity to contribute to this process and our note follows the sequence of issues outlined in the Committee’s announcement of its Inquiry.

2. The Department of Health sets national priorities for the health and care system, secures and allocates resources, supports our national bodies and holds them to account through transparent assurance processes. 

3. The delivery of national public health functions has been delegated to Public Health England (PHE), an executive agency of the Department.  As an operationally independent organisation, PHE will provide evidence separately. 

Background

4. We know that a third of men and half of women do not get enough exercise and almost two thirds of adults are overweight or obese. These patterns are influenced by, and in turn reinforce, deep health inequalities which can cascade down the generations.

5. Obesity is a leading cause of serious diseases such as type-2 diabetes, heart disease and cancer.  Obesity is also a major risk factor for non-alcoholic fatty liver disease (NAFLD).  This represents a huge cost to the health and wellbeing of the individual, the NHS and the wider economy. 

6. Internationally, obesity prevalence is increasing rapidly and does not only affect the richer nations.  Its causes are complex and no country has managed to solve the problem

7. Physical inactivity is an independent factor for a range of long-term health conditions; around a quarter of the population in England is still classified as physically inactive, failing to achieve a minimum of 30 minutes of activity in a week.

8. This is why increasing the levels of physical activity and reducing obesity is a key public health challenge and a priority for this Government. 

Evidence of the impact of diet on health and healthy weight

9. We know that around 62% of adults and 29.5% of children aged 2-15 are either overweight or obese[1].  We also know that the percentage of obese children in Year 6 at school (19.1%) is over double that of Reception year (9.5%)[2].

10. Alongside this, we know there is a link between obesity and lower income groups but that does not mean everyone who is overweight is from this group.  For example, though obesity prevalence among year 6 children attending schools in areas in the most deprived decile was 24.7%, there were 13.1% attending schools in more affluent areas.

11. Evidence shows that obesity affects men and women differently.  Compared with a healthy weight man, an obese man is five times more likely to develop type-2 diabetes, three times more likely to develop cancer of the colon and more than two and a half times more likely to develop high blood pressure – a major risk factor for stroke and heart disease.  Compared with a healthy weight woman, an obese woman is almost thirteen times more likely to develop type 2 diabetes, more than four times more likely to develop high blood pressure and more than three times more likely to have a heart attack.

12. Evidence also shows that Black and Minority Ethnic groups are at an equivalent risk of diabetes, other health conditions or mortality at a lower Body Mass Index (BMI)[3] than the white European population[4].

13. Although physical activity brings important health benefits – including stronger muscles and bones, improved cardio-metabolic health and enhanced psychological wellbeing – for those who are overweight and obese, eating and drinking less is key to weight loss.

Evidence of the impact of physical activity on health

14. Physical inactivity is as harmful as smoking[5].  In 2013 around one in six deaths (of adults aged 35 and over) were estimated to be caused by smoking.  We know that regular physical activity helps prevent and manage over 20 chronic conditions including coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal conditions. In addition, evidence shows that there is a link between physical activity and good mental wellbeing. For example, exercise is moderately more effective than therapy for reducing symptoms of depression. It may also help people with generalised anxiety disorder, panic attacks and stress disorders. There is a clear association between higher levels of physical activity and increased all-cause mortality.

15. Regular physical activity can increase bone mineral density in adolescents, maintain it in young adults, and slow its decline in old age. 80% of people in the UK experience low back pain at some point in life. In the UK, it has been estimated that low back pain is responsible for 150million days a year being lost from work. In older adults physical activity can help reduce the risk of falling, and therefore fractures, among older people. Physical activity can delay the progression of osteoporosis, but it cannot reverse advanced bone loss.  The UK CMOs’ guidelines stress the importance of physical activity through the life course for good bone-health[6].

Recent trends in statistics

16. The rising levels of overweight and obesity we have seen over the past 20 years or so appear to be stabilising, but at a very high level.  Health Survey for England (HSE) data shows that around 15% of children (2-15 years old) were obese in 2013 (down from 16% in 2011) and 29.5% were either overweight or obese (down from 30% in 2011).

17. For adults, the 2013 HSE figures show a decrease in the levels of obesity between 2012 and 2013 for women from 25% to 24% whilst the level for men increased from 24.4% to26%.  In total, 67% of men and 57% of women were overweight or obese (about the same as in 2012 and compared to 65% and 58%, respectively for 2011).

18. For children, data from the National Child Measurement Programme show over a fifth (22.5%) of the children in Reception year (4 to 5 year-olds) were either overweight or obese. This was higher than in 2012-13 (22.2%) but lower than in 2006-07 (22.9%).  In Year 6 (10 to 11-year-olds) around a third (33.5 per cent) of the children measured were either overweight or obese. This was higher than in 2012-13 (33.3%) and also higher than in 2006-07 (31.6%).

19. Alongside this, social and economic trends over decades have ‘designed’ physical activity out of life. Fewer of us have manual jobs. Technology is more dominant in home and work. Our reliance on cars and other motorised transport is another factor. Over one in four women and one in five men do less than 30 minutes of physical activity a week, so are classified as ‘inactive’[7]. Only 21% of boys and 16% of girls aged 5-15 in England take the physical activity they need to meet the CMOs’ guidelines.

20. We need to tackle the common risk factors for the big killer diseases and we have set national ambitions to reduce smoking, obesity and unhealthy diet, physical inactivity, and the harmful consumption of alcohol.  And we have put in place a clear and transparent outcomes framework to help us home in on areas where improvement is needed and focus on improving the health of the poorest fastest.

21. Through the Health Survey for England and the National Child Measurement Programme (a mandatory function for local authorities), we are equipped with robust public health data which helps to inform national policy and to provide local areas with information to enable them to plan services and monitor progress in tackling overweight and obesity.  On diet, we also have the National Diet and Nutrition Survey; and on physical activity, Sport England’s Active People Survey.

Costs to individuals and society

22. We know that obesity represents a huge cost to the health and wellbeing of the individual, the NHS and the wider economy.  The latest estimate of the cost to the NHS of overweight or obesity-related conditions is £5.1 billion each year[8].

23. In 2007 the Foresight team, which is part of the Government Office for Science, estimated the costs of overweight and obesity to society and the economy at almost £16bn, based on obesity prevalence at the time, with a potential rise to £50 billion in 2050 if increases in obesity rates were to continue unchecked[9].

24. It is estimated 40,000 deaths per year in England are attributable to being overweight or obese (over 10% of all deaths)[10].

25. Inactivity also creates significant costs for the wider economy through sickness absence. Physical inactivity directly contributes to one in six (16.9%) deaths in the UK[11], and costs an estimated £7.4 billion a year to the NHS and wider society[12].

The effectiveness of policy

26. We have a well-developed and wide-ranging programme of actions to tackle obesity and physical inactivity and have set national ambitions for a downward trend in excess weight in children and adults by 2020[13].  We also have a national ambition to increase physical activity for a year-on-year increase in the number of adults doing 150 minutes of physical activity per week and a similar reduction in those who are ‘inactive’.

27. A key element of our approach is giving people the tools and information they need to improve their diet and reduce physical inactivity, alongside working with partners to shape an environment where the healthier choice is the easier choice.  The Department, together with PHE and NHS England is tackling obesity and encouraging physical activity through a number of key initiatives. These include the Change4Life programme, Change4Life Sports Clubs, NHS Health Checks and the National Child Measurement Programme.

28. We are also working closely with other Government departments.  For example the Department for Education on the School Sports Premium and the School Food Plan; the Department for Culture, Media and Sports on School Games; the Department for Transport on encouraging people to walk and cycle; the Department for Communities and Local Government on local planning; the Department for the Environment, Food and Rural Affairs on ensuring a co-ordinated approach to food policy and the food industry, and the Government Buying Standards.

Obesity and diet initiatives

Working with Schools

29. We recognise that tackling overweight and obesity in children is fundamental to reducing the long-term impact of heart disease, type 2 diabetes and some cancers, and schools have a vital role to play.  The School Food Plan, published by the Department for Education in 2013, is designed to increase the quality and take up of school meals, and inspire a love of good food in children to help boost academic performance and allow them to lead healthy lives.

30. The School Food Plan outlines actions to improve food and food awareness in schools.  These include: revising the existing school food standards; setting up breakfast clubs in schools with a high proportion of pupils entitled to free school meals; and including a separate strand for cookery in the new Design and Technology curriculum.  Alongside this, every pupil in reception, year 1 and year 2 attending a state-funded school is now entitled to a nutritious, healthy free school lunch.

Advice on Infant Feeding

31. We also provide advice for parents on maternal and infant nutrition through NHS Choices, Start4Life and the Start4Life Information Service for Parents.  In line with WHO recommendations, parents are advised that breastfeeding is the healthiest way to feed their baby; exclusive breastfeeding is recommended for around the first six months with babies introduced to solid foods at around six months of age.   Breastfeeding should continue beyond six months for as long as the mother and baby wish, while gradually introducing a more varied diet.

Working with the Food and Drink Industry

32. We are working in voluntary partnership with the food and drink industry to challenge businesses and other organisations to play their role in helping people to make informed, balanced, healthier choices. Partners are making pledges to commit to action. This work includes a focus on calorie labelling and calorie reduction.

33. The calorie reduction pledge has energised the food industry to deliver real progress in supporting people to eat less. Eight major supermarkets, along with fast food outlets, pubs and caterers, as well as the makers of household-name brands are taking a range of actions to help us to eat and drink fewer calories.  Examples of recent calorie reduction activity by supermarkets through the voluntary partnership include: Tesco removing two billion calories from their juices in 2013, following on from the one billion removed in 2012, and removing 600 million calories from its Finest and Everyday Value sandwich lines; and the Co-operative Group’s decision to take-out the added sugar from its high juices, which will remove 1.5 billion kcals per year.

34. Sugar is also being taken out of the food people eat and drink. For example Britvic has committed to stop selling full sugar Fruit shoot in the UK, removing an estimated 2.2bn calories from the children’s drinks market.

35. Alongside this, major high street names including KFC, McDonald’s, Pizza Hut, Starbucks and Subway are providing information on calories in the meals they provide. This represents 70% of fast food and takeaway meals and one third of all the meals sold on the high street.

36. Food retailers, such as ALDI, Lidl and Tesco have made significant commitments to remove sweets and confectionary at checkouts.  We will continue to work with the rest of the industry to build on this progress.

37. To help consumers understand the nutrient content of food and drinks and help them to make healthier and more balanced choices about their purchases, we are the first country in Europe to introduce a voluntary front of pack labelling scheme. The two front of pack nutrition labelling pledges were launched in June 2013, one focussing on adopting the scheme, the second on promoting it.  Businesses who have agreed to adopt the UK scheme and apply this consistent format account for two thirds of the market for pre-packed foods and drinks. They are all committed to introducing the new labels on all their products by January 2015.

Working with the Public Sector

38. The Government Buying Standards for Food and Catering Services (Food GBS) were implemented in 2011 as a means of meeting the "Greening Government Commitments".  The buying standards for food enable government caterers to procure healthier, more sustainable, food and catering services.

39. The Food GBS include nutrition criteria which reflect Government recommendations to reduce intakes of salt, added sugars, fat and to increase consumption of fruit, vegetables, fish and fibre. Encouraging healthier catering practice will contribute to reducing diet related illness and supports the Responsibility Deal. 

40. All Government departments should be procuring to the Food GBS and it is one of five food standards to which all NHS providers will have to comply.

41. We believe that every hospital should provide the highest level of care possible for their patients, including the quality and nutritional value of the food that is served and eaten, and we are introducing legally binding food standards in the NHS Standard Contract. 

Work to reduce sugar and salt

42. The Scientific Advisory Committee on Nutrition, which provides advice to Government on nutrition and related health issues, has published its draft report ‘Carbohydrates and Health’.  The final report is expected to be published in late spring 2015; and this, together with other advice, including from PHE, will inform our future thinking on sugar.

43. The UK is among the world leaders in reducing salt in the diet. Around 75% of the retail market and 60% of major high street restaurants and contract caterers have committed to reduce salt through the voluntary partnership with industry.

44. To help keep the momentum on salt reduction, two new pledges and sets of targets were issued through voluntary partnership with industry in March 2014. Both pledges commit signatories to support and enable people to consume less salt through reformulating a wide range of foods. The overall aim of the salt targets is for a gradual, stepwise reduction in the levels of salt in food with the ultimate goal of reducing people’s intake to 6g per day.

45. The salt reduction programme has so far reduced population average salt intakes by 15% (from 9.5g in 2000/01 to 8.1g in 2011). The National Diet and Nutrition Survey are due to publish an updated salt intake figure for adults in summer 2015.

Work to reduce alcohol consumption

46. Alcohol can be a significant source of calories in the diet. We know that alcohol consumption per head has fallen in recent years. 

47. Alongside this, since April 2013, an alcohol risk assessment has been a mandatory component in the NHS Health Check, so that people will be given brief advice on cutting down if their drinking is putting their health at risk.

48. The Department is also working through its voluntary partnership with the alcohol industry to help people to drink within the CMO’s guidelines.  Around 130 companies have committed to do just this.  Independent research published in November shows that just under 80% of bottles and cans of alcohol on shelves now have the correct health labelling: clear unit content, the CMO’s lower-risk drinking guidelines and a warning about drinking when pregnant. This fulfils an industry-wide pledge on labelling.

Physical activity initiatives

49. In 2012, the Secretary of State for Health launched a National Ambition for a year on year increase in the number of adults doing 150 minutes of exercise per week and a similar reduction in those who are 'inactive' (less than 30 minutes a week). The National Ambition is mirrored in the Public Health Outcomes Framework through a specific indicator by which local authorities can demonstrate how well they are doing in promoting physical activity to their local populations.

50. To strengthen action, in February 2014 the Government published “Moving More, Living More”, a cross-Government campaign to deliver a physical activity legacy from the 2012 Olympic and Paralympic Games.  This campaign is aimed at everyone who can help to get the nation more active: departments across Government, local authorities, businesses and employers, and the local community groups and individuals across the country who know how to get people moving.

51. Alongside this, we have established a cross-Government Ministerial group on physical activity, which reports into the Olympics Legacy Ministerial committee. This helps to ensure that we are now working across Government to make the nation more active. This Ministerial group is supported by a regular officials’ level group which continues to make the links across Government departments to ensure that identify opportunities to get the nation more active.

52. In addition, the Department is contributing to help deliver the Government’s legacy commitment to “Inspire a Generation” and is working closely with other Government departments to ensure all children and young people have opportunities to be physically active and enjoy sport – particularly the least active. 

53. The Department plans to contribute almost £222m of funding to support the Primary PE and School Sport Premium, School Games programme and Change4Life Sports Clubs to help achieve this aim. The Change4Life Sports Clubs, delivered in schools, continue to successfully engage the least active children in physical activity and sport. An independent evaluation shows that the clubs are effectively engaging the least active children and leading to changing attitudes to sport and they have higher levels of physical activity.

54. The Responsibility Deal Physical Activity Network was established by the Department to tap into the potential for business, local authorities and delivery partners to improve public health and counts more than 300 partners from across the business and voluntary sector to promote physical activity in the workplace and wider community.

55. In October 2014, Public Health England published, Everybody active, every day with full ministerial involvement.  Building on Moving More, Living More, this framework aims to increase the levels of physical activity in local communities by identifying key areas where more action is needed.  PHE is writing to the Committee about Everybody active, every day with further detail.

56. The Public Health Minister has asked Public Health England to develop a “5-a-day” style of message for physical activity, to ensure that we improve the effectiveness of the messages of the Chief Medical Officer’s recommendations to members of the public. CMO has also re-convened an expert group to help translate the physical activity guidelines into simple messages for health professionals to use with their patients.

The new system approach to improving physical activity and diet and accountability structures

57. As steward of the health and care system, the Department sets national priorities, secures and allocates resources, supports our national bodies and holds them to account through transparent assurance processes.  It is accountable to Parliament for the proper stewardship of all the resources allocated to the Department.

58. The delivery of national public health functions is the responsibility of PHE, including campaigns such as Change4Life, the National Child Measurement Programme and NHS Health Checks.  PHE is ideally placed to provide the public health system at the national level with strong leadership and make evidence-based contributions to the policy debate. From evidence into action: opportunities to protect and improve the nation’s health, published in October, sets out its seven priorities for the next five years (including tackling obesity, particularly in children) and it commitment to support partners. 

59. We believe it is important that people who are overweight or obese get the support they need. That is why funding and responsibility has been put in the hands of those closest to the individuals.  Local authorities are now responsible for tackling public health issues and have been given a ring-fenced budget of £8.2 billion over three years (2013/14, 2014/15 and 2015/16) to help them tackle issues like obesity and physical inactivity. 

60. Local authorities – working with Health and Wellbeing Boards, and local and national partners across the health and social care system – have responsibility for the assessment and provision of preventative and lifestyle-based obesity treatment and services, and services to improve physical activity. 

61. The Public Health Outcomes Framework Indicators help to provide robust data on excess weight in children aged 4-5 years and 10-11 years, and excess weight in adults. This enables local authorities to make decisions about where to target population level interventions to tackle obesity.

62. Local authorities are supported by national bodies, including PHE, to help with evidence and advice to make a difference to their communities, and create social marketing campaigns to support behaviour change. 

63. NHS England’s focus on prevention in its Five Year Forward View is welcome, recommending a more engaged relationship with patients, carers and communities so that they can promote wellbeing and prevent ill-health.  We also welcome its determination to set a national example in the support it offers to its own 1.3 million staff to stay healthy, including keeping a healthy weight, and serve as “health ambassadors” in their local communities.

64. We believe GPs and other health and care professionals have a key role in “making every contact count” by identifying overweight children and adults, and supporting them with an appropriate intervention or referral and on-going management.  The Quality and Outcomes Framework indicator incentivises GPs to identify their patients who have a BMI of 30 or over.  This encourages GPs to work with those patients to offer advice and referrals if appropriate.

65. Alongside this, health and care professionals are encouraged to implement their local obesity care pathway to ensure that patients receive the support they need to manage their weight and increase physical activity.  The National Institute for Health and Care Excellence (NICE) has a suite of guidance for practitioners on tackling obesity and increasing physical activity, including the recently published Obesity: identification, assessment and management of overweight and obesity in children, young people and adults.

Conclusion

66. The rates of obesity and overweight in the population are too high, and the levels of physical activity are too low. There is no single action that can solve the problem of obesity and physical inactivity. We need collective action by Government, businesses, health professionals, and individuals. 

67. The Government is fully committed to playing its part, working closely with our partners to help deliver our national ambitions for a downward trend in obesity and more physical activity in adults and children.

68. We keep the international evidence about tackling obesity and increasing physical activity under review and we continue to learn from research and academic studies and take appropriate action. 

69. We believe the actions we are taking are delivering results. Obesity rates in children and adults in England are stabilising. But they are still far too high and we have much further to go.  We welcome the Health Committee’s focus on this issue and the opportunity to explore the challenges and build consensus on the priority actions.

18 December 2014