The long awaited White Paper on public health has been published (30/11/2010).
As someone working exclusively in the field of obesity, I had expected the paper to address the single biggest avoidable health crisis in the UK – obesity. The word obesity appears a dozen times in the 98 page document, but only to describe it as a problem, or to assign statistics to the scale of the problem – I could see no recommendations at first sight, other than a note under 3.53 that “employers have the opportunity to improve health outcomes.” I am sure employers will welcome this responsibility during the worst recession many have faced in their lifetime.
Let’s start positively:
There are some things that I like about the White Paper
1) Creation of a Public Health England – we have a Public Health Wales and with the right independence and leadership and remit this can be a positive force. However, there needs to be clarity of role. Each country has a Chief Medical Officer whose role includes public health, indeed majors on public health. As with all public bodies, roles and responsibilities need to be clearly determined with CAN DO (as I coined the phrase when I worked as an HR Director) Clear Accountability; No Duplication or Overlap.
2) The Professor Sir Michael Marmot work on health inequalities. I had the privilege of hearing the Cochrane lecture, delivered by Professor Sir Michael Marmot, at the Wales NHS conference on 11 November 2010. The comparative health and longevity and healthy years of life are indefensibly different for people from different income groups and this cannot be allowed to continue. However, I remain to be convinced if handing responsibility for this to local government will make any difference. It hasn’t for education or economic development, so what will be different to make this work?
Things I disagree with:
1) In the Foreword, Lansley says: “It is simply not possible to promote healthier lifestyles through Whitehall dictat and nannying about the way people should live.”
I completely disagree.
– We introduced a clunk click every trip seatbelt campaign. Robert Gifford, of the Parliamentary Advisory Council for Transport Safety charity, said seatbelts had saved 35,000 lives in the UK during the last 25 years.
– We introduced a smoking ban and an estimated 40,000 lives have been saved.
The UK government could and should introduce a sugar tax, as has been introduced in Denmark and Finland. Finland have also taken steps to get Pepsi out of schools by 2012 – still not soon enough in my view, but way ahead of the UK. The government could make an enormous difference to our health (obesity and diabetes especially) by banning food companies from advertising to children (as Sweden has done since 1991); banning sugary drinks and confectionery in school; banning cartoon characters in sugary cereal marketing and attempts by the cereal makers to get children (and adults) to eat more of their processed food; banning similar marketing by the fast food industry who want humans eating more burgers, more fries, more milkshakes, more white flour pizza, more chicken in ‘secret’ ingredients and so on.
This is the biggest outrage of the white paper – it is possible. Lansley doesn’t want to go this route because he is more concerned about the food and drink industry than the nation’s health. I challenge him to prove me wrong on this and take decisive action against the food and drink companies.
2) Lansley is doing the exact opposite to taking decisive action against the food and drink industry. He is meeting with them at Unilever house, with Unilever in the chair. His Foreword goes on to say: “All of this will be supported by work with industry and other partners to promote healthy living”.
As Professor Philip James, Chair of the International Obesity Taskforce, said on BBC Newsnight last week – this is utter madness. Food and drink companies have one purpose – to grow. They need to deliver increasing returns to shareholders and their ‘well being’ depends on them selling more of their food and drink. The biscuit companies need humans to eat more biscuits; the cake companies need humans to eat more cakes; the cereal companies need humans to eat more cereal; the confectionery companies need humans to eat more confectionery; the fizzy drink companies need humans to drink more fizzy drinks – human beings end up being nothing more than consumers in the food and drink companies’ pursuit of growth.
The food and drink companies love the current dreadful public ‘health’ dietary advice. They love everything being about calories and energy in and out. They will happily keep the focus on exercise – we need to exercise more; we’re fat because we’re sedentary kind of thing. Heaven forbid that the public stops eating processed food because they realise it makes them fat.
As I detail in my latest book “The Obesity Epidemic: What caused it? How can we stop it?” , many food and drink companies actually have the government “eatbadly plate” (I think it is supposed to be called “Eatwell Plate“) on their web sites. They love the box of cornflakes on there (branded Kellogg’s in earlier versions of the plate); they love the cola on there (yes really); the Battenberg cake, sweets, biscuits, white bread, sugary baked beans, fruit in syrup, fruit juice – and many more – all the processed food that they love to sell us and they want us to consume more and more of.
Our waistlines grow in sync with the growth in sales of processed food and drink. How on earth can we think that food and drink companies will lead a campaign to reduce waistlines and, inevitably, their sales in parallel. The cure to the obesity epidemic lies in returning to eating food – real food – the food we ate before two thirds of us were overweight. It does not lie in eating the processed food that we have eaten during the time in which obesity has increased nearly 10 fold – the stuff that Lansley’s partners make. It really is utter madness.
3) I disagree with point 7 in The Executive Summary: enhanced nutrition is heralded as a “formidable public health achievement”. Our nutrition could be the best it has ever been, but it is far from this. I analysed the UK Family Food Survey (2008) with the following conclusions:
a) Vitamins: If you take the higher of the Recommended Dietary Allowances (RDA’s) for the USA and Europe, UK intake falls short for Vitamins A, C, D, E and Folic Acid. Interestingly the fat soluble vitamins (those delivered in foods with a fat content) are A, D, E and K. K was not recorded, but the deficiencies in A, D and E make it likely that our low-fat obsession is making us deficient in all the fat soluble vitamins. This should be of deep concern to our governments. Instead, when they present the latest annual food survey we are again told to eat less fat – and to become even more deficient in these vital nutrients. The vitamin E deficiency is both interesting and worrying – vitamin E is the body’s natural antioxidant and is known to repair damage in the blood vessels. I wonder if that has anything to do with heart disease?
b) Minerals: The average UK citizen is lacking in every mineral recorded by the National Food Survery, compared to the higher of the RDA’s for the USA and Europe. The UK is missing even the low European target in all but calcium. (No wonder so many people are now taking osteoporosis tablets with 500mg assumed to be adequate for calcium). Since so many of the minerals are not even recorded, we may be able to assume from the deficiencies in those that are recorded, that the overall picture is bleak.
A recent report confirmed that one in five middle class children are effectively suffering rickets – what was considered to be a disease of the Victorian period. This is a direct result of our negligent low fat dietary advice, telling people to avoid the health benefits of the sun and cereal companies ruling our breakfast choices, when we should be eating eggs. (Doubly ironically, on p11 of the white paper – bullet 1.1 says “once common conditions such as rickets” have been “consigned to the history books”. If only….)
This is not a formidable public health achievement Mr Lansley – it’s a disgrace.
4) Bullet 9 of the Executive Summary is, as a number of media commentators have already noted, “high on rhetoric” and “low on substance”. It is described as a “Radical new approach”. It is far from radical, although inviting food and drink companies to set policy may be new and catastrophic. A sugar tax would be new and radical; banning food and drink company marketing to children would be radical; using a tax on processed food to subsidise real food (especially directed towards people less able to afford real food) would be radical. All of these could have an enormous impact on obesity and health. Having a “ladder of interventions” and adopting “the least intrusive approach” is only radical and new in its certainty to be ineffectual.
A few other points:
In the main body of the paper:
1.6 – “People in England are healthier and living longer than ever”.
I disagree. I rarely see a healthy person. Two thirds are overweight; one quarter obese; one in three will die from a modern illness – heart disease; another one in three will die from another modern illness – cancer. Approximately three million British citizens are suffering diabetes – another modern illness. The average person that I see walking around the UK is fat and sick; tired and depressed – all, I would argue, as a result of the appalling dietary advice that they have been given over the past 30 years. We are keeping people alive longer, as a result of modern medicine and pharmacology (not always in a good way), but there are too many people “existing” rather than “living”. As point 1.10 says, and surely this is contradictory, “some 15.4 million people in England have a long standing illness.”
1.30 – “only 3 in 10 adults eat the recommended 5 portions of fruit and vegetables a day”.
This is bad science. 5-a-day has no scientific foundation whatsoever. It was a marketing campaign started by the American National Cancer Institute and c. 20 fruit and vegetable companies in California in 1991 – the influence of the food industry in demonstration. Nearly 20 years later, this marketing slogan still has no evidence base (see reference 278) and yet it features in government, Department of Health, documents as if it is scientific. A 5-a-day marketing slogan, which could have had a significant impact on the health of English people, would have been liver, sardines, eggs, sunflower seeds and a green leafy vegetable. The fruit juice that mums are trying to get into their children, thinking they are following sound government advice, is fuelling the obesity epidemic and damaging our children’s livers. (There is more nonsense implying that 5-a-day is sound in point 3.31).
There are then 5 questions for consultation on which public comment is invited:
a. Are there additional ways in which we can ensure that GP’s and GP Practices will continue to play a key role in areas for which Public Health England will take responsibility?
b. What are the best opportunities to develop and enhance the availability, accessibility and utility of public health information and intelligence?
c. How can Public Health England address current gaps such as using the insights of behavioural science, tackling wider determinants of health, achieving cost effectiveness and tackling inequalities?
d. What can wider partners nationally and locally contribute to improving the use of evidence in public health?
e. We would welcome views on Dr Gabriel Scally’s report. If we were to pursue voluntary registration, which organisation would be best suited to provide a system of voluntary registration for public health specialists?
– nothing about should we have food and drink companies writing our obesity and drinking strategy. Just the usual vacuous ‘consultation’ questions that are designed to only invite comments on the least contentious areas in the secure knowledge that consultation won’t change the government’s plans anyway. As for evidence in public health? 5-a-day?!
I await the obesity paper in the spring.