Meeting date: Tuesday, December 6, 2016
Health and Sport Committee 06 December 2016
Agenda: Decision on Taking Business in Private, Obesity
Agenda item 2 is two evidence-taking sessions on obesity. For this first session, I will introduce myself and then go round the table to allow everyone else to introduce themselves. After that, we will crack on.
I am a Labour MSP for Lothian and convener of the Health and Sport Committee, and I welcome you all to today’s meeting.
Lorraine Tulloch (Obesity Action Scotland)
I am programme lead at Obesity Action Scotland.
I am the deputy convener of the committee and the MSP for Rutherglen.
I am the MSP for Renfrewshire South.
Professor Nanette Mutrie (University of Edinburgh)
I am professor of physical activity for health at the University of Edinburgh and lead our research centre there.
I am a Conservative MSP for Lothian.
Ian Findlay (Paths for All)
I am chief officer of Paths for All.
Claire Hislop (NHS Health Scotland)
I am organisational lead for diet and obesity prevention at NHS Health Scotland.
I am the Liberal Democrat MSP for Edinburgh Western and my party’s health spokesperson.
I am a Lothian MSP.
Professor Linda Bauld (Cancer Research UK)
I am chair of behavioural research for cancer prevention at Cancer Research UK and the University of Stirling.
I am the MSP for Uddingston and Bellshill.
Celia Nyssens (Nourish Scotland)
I am from Nourish Scotland.
Good morning. I am a Highlands and Islands MSP.
Joyce Thompson (British Dietetic Association Scotland)
Good morning. I am here on behalf of the British Dietetic Association.
I am a South Scotland MSP.
Dr Drew Walker (Scottish Directors of Public Health Network)
I am director of public health in NHS Tayside. This morning, I am representing the Scottish directors of public health network.
I am the MSP for Glasgow Provan.
Thank you all for that. I should say that Donald Cameron is likely to be late, as his plane is stuck on the tarmac at Stornoway or somewhere. I hope that he will join us in a wee while.
Alison Johnstone will begin the questioning.
I want to ask the experts who have joined us this morning why Scotland has the worst weight outcomes of all the United Kingdom nations and among the worst of any Organisation for Economic Co-operation and Development nation. That being the case and given the potential of action in this area to transform lives for the better and save the national health service a great deal of resource, can you tell us why this is not a national priority?
Who would like to begin?
We have seen some fundamental changes in our environment in recent decades. The Scottish Parliament has been very courageous about tobacco and alcohol; indeed, the changes that we have seen, particularly in smoking, did not happen because people decided not to smoke but because we changed the environment and the opportunities that people had to make healthier choices. What we have seen in Scotland in recent decades is very available and very cheap foods that are high in salt, sugar and fat and which people find that they can afford. As a result, our children do not have the diet that they should have. In addition, there has been no increase in physical activity—we do not have an active society.
Cancer Research UK is hugely concerned about all this, because obesity is probably our biggest future public health challenge. After smoking, it is the most preventable cause of cancer; for those who do not smoke, it is the single most preventable cause. This is a public health crisis, and our modelling shows that unless we take action we will have almost 700,000 additional cases of preventable cancers in the UK over the next 20 years.
You said that it was a future challenge, but is it not a present challenge?
I would argue that we need a comprehensive, long-term strategy, and I am sure that my colleagues in the room would agree. There cannot be change overnight. There is a current challenge, but I hope that the actions that members are considering will take us forward for many years so that children who are starting school now will not have potentially the same burden of obesity as those who have come in the past 10 or 20 years.
I echo what Linda Bauld has said. We know that Scotland has some of the worst statistics, but we are not alone in the world in facing the challenge. A lot of other countries face it, as well—it is not unique to us—but we know from the evidence that Food Standards Scotland has published over the past few years that our poor diet has been ingrained. There are 15 years of missing dietary goals. Indeed, there has been a challenge over decades. It is about the things that Linda Bauld outlined. The environment, poor diet and people’s physical activity levels are the causes of obesity.
We have policies, but we need to move further with the fiscal and regulatory measures. Action has been taken over a number of years, but Obesity Action Scotland firmly believes that now is the time for more fiscal and regulatory measures, which are needed to tackle Scotland’s poor diet. We need to take action to change the food environment so that the healthiest choice is the easiest choice for the consumer. We need action at the retail and out-of-home sector levels to see that change.
One of the reasons for the statistics that have been mentioned is that 40 per cent of adults in Scotland do not meet the physical activity guidelines. We believe that physical activity has a very important role to play in helping to prevent obesity and a complementary role in addressing it.
Over the past 50 to 60 years, we have done extremely well in designing physical activity out of our lifestyles and having much more sedentary lifestyles. We need to look at mechanisms for trying to incorporate more physical activity into our everyday lives, whether that is in leisure or everyday, short journeys.
It is a mystery to me, too, why that is not a priority, as it represents fantastic value for money. We are really talking about prevention and curing the cause rather than treating the symptoms. Spending a little now on physical activity and tackling obesity will save the nation a lot of money.
A recent report by NHS Health Scotland said that physical inactivity costs the Scottish health service £94 million per annum. By increasing physical activity, we could significantly reduce that amount. The solutions are very good value for money and quite easy. Why the matter is not a priority is a very good question.
I want to pick up on what Lorraine Tulloch said about making the healthy choice the easy choice. Currently, the unhealthy choice is the easy choice. We talk about an obesogenic environment—that is a bit of jargon that we use. That environment makes it very easy to overconsume calories and take too little physical exercise. We need to turn that on its head and make it much less attractive for people to consume too many calories and much easier for them to be more active more often.
Scotland’s record is worse than those of comparable UK nations. Is our environment particularly obesogenic? Last week’s report suggested that we had a pretty good environment for physical activity, but we are still not engaging. Is there more of a proliferation of easily accessible junk food here?
Forty per cent of foods in the United Kingdom are bought on promotion. That is the highest rate of any nation in Europe. If we start with the sales environment, there are very clear indicators that the options that are available to people are driving them in the wrong direction. That is just one example, but there are probably other specific examples. Because of some of the drivers, Scotland is worse than other European nations.
I agree very much with Lorraine Tulloch and Drew Walker. The issue is so bad in Scotland because of a combination of three very important factors. One is to do with inequalities and the quite high level of poverty in the UK as a whole but also in Scotland. It is proven that people on low incomes and with very small budgets for food will prioritise calories over nutrients. The excessive amount of calories that we eat is what is making us fat. Obesity is a social issue, and we need to look at it as that.
Another factor is the food culture. Scotland is not famous for its food culture. There is a lack of skills and of time dedicated to eating, and people do not have a habit of cooking a good meal with a lot of vegetables, as in Mediterranean diets.
A very important factor that adds to those other two factors is the food environment, which is extremely obesogenic. So far, we have not taken a comprehensive approach to changing the environment. It is still extremely difficult, even for people on higher incomes, to eat healthily, and we need to look at that.
I want to follow up on my colleagues’ comments about the importance of physical activity. I sit on the national strategic group for sport and physical activity. Scotland has an admirable strategy on physical activity and a very nice outcomes framework that is now monitored. However, we are failing to implement that at scale and with resources. We have a number of small projects, but they do not appear across the country. We have a great set of plans but no resources to push them forward to change the environment or to encourage the one fifth of people who are doing less than 30 minutes of physical activity a week. That is where we could do with improvement. That would undoubtedly help our obesity programming and agenda.
I am interested in international comparisons. I understand that here in Scotland and possibly in the whole of the UK we have an obesogenic environment, and I heard the point that 40 per cent of our food is bought on promotions. Why is that? Is it because we are less regulated than other countries, or do we just love a bargain?
That is because of our retail environment and some of the competition between retailers. To add to the points that Celia Nyssens made, it is also because of some of the traditional choices that we have made in Scotland on confectionery and some of the things that people perhaps prefer to eat. Those are available and we have children consuming them from very early in life, and even pregnant women have diets that are high in salt, sugar and fat. Those things come together—we have people’s choices or preferences, which are established very early, and then we have a commercial environment in which retailers are driven to sell things very cheaply. I talk about the four Ps, which are price, promotion, place and product. The price is something that we can take action on as a single measure.
I am keen to pursue the point that Celia Nyssens raised about inequality. Obviously, the link between obesity and deprivation, particularly among women and children, is well documented. I am keen to get the panel’s views on why that is the case. To what extent do existing strategies deal with that issue sufficiently? What is needed in any future strategy to tackle the problem?
I cannot speak about the physical or medical reasons for that, but one reason for the issue among children is that marketing is extremely aggressive and schools are surrounded by convenience food outlets. It is extremely difficult for children to ignore all that marketing and the convenience food that is readily available to them. School meals have a role to play, and free school meals have been very beneficial in helping children to eat healthily. Having free school meals across the board and looking at what children can eat outside school are very important.
Linda Bauld, I think, said that this is a crisis. Does any of the witnesses think that it is not a crisis? Are there any obesity sceptics in the room? No? It is very difficult to find such people, even in the media. On most issues, we normally get somebody who argues a contrary line, but I have never heard that on this issue. We seem to be in a crisis, and that requires a fundamental response.
When we look at the commentary on “Preventing Overweight and Obesity in Scotland: A Route Map Towards Healthy Weight”, we find
“that the number of interventions aimed at attitudes, values and behaviours outweighed those aimed at costs and regulation. This was at odds with the balance of international evidence on what would be most effective for obesity prevention.”
Is the general view that we have been following the wrong route?
I wanted to respond to Colin Smyth’s question about policies.
You can do that first if you want.10:15
I would just like to reflect on where obesity is. Is it a crisis? Yes, it is a crisis, but it has been a slow-burning crisis. If we had been sitting here 10 years ago, it would have been quite difficult to get support for a claim that we were in the middle of an obesity crisis, because people had not woken up to the problem. Joyce Thompson and I published our healthy weight strategy in Tayside 11 years ago, and I was criticised by my board for wasting my time and that of my colleagues and partners on something that was nothing to do with public health. It is inconceivable that that comment could be made now, because in the intervening years we have woken up to the crisis of obesity and of the threats to everything that is important to us, so things have moved on.
To pick up on the point that others have made, we have fantastic policies in Scotland. If we were to implement all the policies that we have we would be a long way down the road of tackling the obesogenic environment and all the things that are pushing us in the wrong direction. The issue is not a shortage of policies. The shortfall is in the implementation of the policies that we already have. I am not pointing the finger at anyone in particular. It is the responsibility of all of us.
Could you give us examples?
Others might want to come in on that point, but we have the route map, which includes a range of things that need to be done. Some things have been done but, as has been pointed out, things have not been done at scale. Lots of good initiatives are being taken all across Scotland, but the successful things are not necessarily being scaled up and adopted by everybody with the level of investment that is required across the country. There are lots of examples of that, but other colleagues might want to give more detailed examples.
The statement that you cited was in the evidence that we submitted, convener. The review on the obesity route map stated that a number of interventions were
“aimed at attitudes, values and behaviours”,
and, as Drew Walker has said, we have found that awareness of the issue has grown substantially over the past decade. That has contributed to the inequalities changes that we have seen, because we know that the least deprived people will respond to the health messages that they hear and will do something about it, so that may have been what has widened the gap. However, we need to think about other ways of addressing the issue to make it fair across the board and to help the most deprived people in society.
I wanted to highlight that because it is one of the reasons why we need to move towards interventions around cost and regulations. As Drew Walker said, it would have been fairly difficult to take forward such measures 10 years ago, because there would not have been the same level of support or acknowledgement of the issue, but now there is more recognition of the problem and more support. The original obesity route map recognised the need to change the food environment. That is not new. We went through a process of voluntary approaches to working with the industry over the years, but we now know that we have not progressed as far as we need to progress with those voluntary approaches, so we need to think about introducing regulation to tackle it.
I would be interested to hear the panellists’ thoughts on what regulation they think would help to tie in with some of the obesity strategies and to reduce overall weight.
I return to the four Ps: price, promotion, place and product. Ideally, we need to change all of those, and they are things that we can change.
The convener asked whether anybody disagreed with the need for action on obesity. The problem with promotion—the advertising of foods that are unhealthy—is that people are surrounded by the promotion of extremely cheap food on television, on billboards and so on, so initiatives that are designed to change people’s attitudes and behaviours are basically pushing against a tsunami of advertising. Through Cancer Research UK, we did some research with children, who talked about how they felt when they saw those ads. One of them said that they wanted to lick the TV screen—that kind of evidence is really compelling. It is difficult to push against that sort of thing.
We have talked about price, which is another driver. We could also talk about the product, with regard to reformulation—I know that Food Standards Scotland has talked about lowering the salt and sugar content of particular products. Place is the other important issue—we need to look at where products are promoted. For example, we know that sales of junk food can be increased by 50 per cent if it is placed on the rotunda displays at the end of the supermarket aisles. All those issues involve regulatory changes.
On the issue of public support, we know that about 80 per cent of the Scottish population agree with action on junk food advertising, and that slightly less agree with action on price promotions, so we can say that the public are in favour of the proposals. The industry will not necessarily be in favour, of course.
Things have changed, and I think that those are some of the mechanisms that we need to focus on.
We also need to recognise some of the successful policies that we have had in Scotland over the past few years. We have done a lot of work in schools and we are doing work in hospitals and various other areas. However, we realise that we have not all come together, and the changes that we are talking about involve choices that people have to make for themselves—they are individual behaviour changes. We need to start to think about how we can affect the population rather than relying on interventions that people must choose to take up. That is why some of the measures that people have been talking about will be more successful with regard to making wider change.
With regard to inequalities, we are less likely to widen gaps if we do things on a population-wide basis. One of the reasons why the gap has widened with regard to obesity is that, in the past, we have relied on interventions that are taken up only by those who can make that choice. For example, leaflets will be read only by people who are interested already.
As we develop the new strategy, we need to ensure that it is holistic and that we take into account all the approaches, including those around environment, and that we do not just rely on people’s individual interventions.
You asked for specific examples and I can give you two. The physical activity strategy has been in place for more than 20 years and is internationally renowned. A lot of good intervention has taken place within that strategy, such as the work that Paths for All does, and the walking schemes. We are seeing some hopeful signs with regard to walking—the Scottish household survey showed that there had been a 5 per cent increase in walking. However, I agree very much with what Professor Mutrie says about such interventions needing to be scaled up if we are to see more progress. That scaling up involves long-term and sustained funding, and leadership at all levels.
Another example is the national transport strategy. It has a hierarchy that puts walking and cycling at the top, followed by public transport and then the private motor car. However, as we all know, the reality in terms of priority and funding probably does not reflect that. Recently, Transport Scotland undertook a study into how to increase physical activity and how best to implement the physical activity and active travel policies that we have. That study reached the same sort of conclusions as I have outlined already—the solution involves long-term and sustained funding.
Those are two examples in which we have extremely good policies in place, but implementation needs to catch up. We are starting on that journey and there are a lot of hopeful signs, but implementation needs to be accelerated if we are to see a population-scale change.
We are good at writing strategies but not very good at implementation—is that what you are saying?
I will answer that with a tongue-in-cheek example. A number of partners in this area hold an active travel conference each year. Three years ago, we asked a policy guru from Europe to come across, have a look at Scotland, examine our policies and consider how we are implementing policies around walking and cycling for everyday short journeys. The person came across for a week and his conclusion to the conference was: “You must have a policy not to implement your policies.” He said that the policy framework was extremely good, but that we needed to focus on implementing the policies, which means ensuring that the leadership and resources are there to bring that about.
I will follow up on that. I have two points to make: one is about inequalities and the other is about potential regulation. The issue of inequalities affects physical activity differently from food consumption. The modes of activity that people do are critical. There is a lot of inequality in relation to sport, but that is not the case with active travel. We have just analysed the active travel data, and it is a good-news story for Scotland: active travel is increasing in urban and rural areas for men and women and across all social classes. However, it is not part of our outcomes framework—we are not monitoring adult active travel. What Ian Findlay and I are saying is that that needs to feature in our implementation.
The biggest inequalities for physical activity are age and gender. Our older population could benefit the most, but older people are doing a minuscule amount of activity compared with our younger generation. It is universally the case—Scotland is no different in this respect—that men are more active than women. We should try to close that inequality.
On regulation, there are tough choices to be made. It is not easy to find a regulatory mechanism to increase activity, but there could be such mechanisms on active travel. For example, car access to town centres could be restricted, we could have pedestrianisation or car parking charges could be increased. Those would be tough and unpopular political decisions to make, but we have seen from our European counterparts that such measures work. In Denmark, cycling is so much the norm that car usage is going down. Such decisions would help to create a more active and less obesogenic environment.
I will explore some data points, although I am tempted to talk about the planning system issue that you have raised, which I might come on to if I have time.
First, I will explore the existing trends. The data from the health survey shows a rise in the obesity statistics and in the number of people who are overweight throughout the 1990s and in the early 2000s, but there seems to have been a flattening off for the past number of years. Is that the reality? If so, is it a consequence of policy changes, or is it just a natural phenomenon—in other words, is it the case that the figures could not continue to rise at that rate for ever?
The second issue that I will explore is cost implications. Some numbers have been put out this morning, and you mentioned the impact on cancer. I would like to understand the implications now and in the future in a macro sense. The health service in Scotland spends about £13 billion. If we continue doing what we are doing, how much impact will increasing obesity levels have on the large-scale figures? I assume that someone has analysed how much an average-weight person costs the health service and how much a typical obese person costs the health service. Does anyone have any comments on those areas?
I will start with the cancer data; I am sure that colleagues can talk about other conditions. I mentioned the modelling that we did that indicated that obesity could lead to almost 700,000 additional cancer cases. If we had a 1 per cent reduction in obesity each year in the UK, there would be about 40,000 fewer cases of cancer each year, which we know would probably save the NHS about £40 million. Modelling has been done on that.
Are those figures for Scotland?
No—they apply across the UK. You could divide them by the relevant factor to get the figures for Scotland. We are clear about the cost savings that could be made.
The current trends are encouraging, but we should not be complacent, because there are issues with the data. In particular, there is underreporting of calorie consumption in some surveys. When we look at sales, we see that there is a big gap, so people do not necessarily feel comfortable about reporting what they consume.
Even though there has been a slight levelling off, which is particularly positive in some groups, we still have record levels of obesity, historically, compared with the levels in other countries, and we know what the cost implications are.
Absolutely. Is that levelling off a result of policy or is it a natural phenomenon? If it is a result of policy, we must have started to do something right.
Ian Findlay’s and Nanette Mutrie’s comments in that regard were helpful. We have had strategies and there have been some very positive examples, but the take-home message is that the improvement has not been on the scale that is necessary.10:30
I will pick up on the plateauing of the data and expand a bit on what Linda Bauld just said. It is easy to be misled by the plateauing. It looks like good news that the numbers that were increasing some time ago have plateaued, but that is what we see if we look at the whole population. If we break the data down into socioeconomic groupings, we see a different story. The number of overweight and obese people has fallen slightly in more affluent populations over the past number of years. Conversely, the number of adults and children in our poorer populations who are overweight and obese has increased slightly. That should wipe out any complacency straight away, because we know that that is a significant contributor to the widening health inequalities that we see around us. Let us not be fooled by the average; we need to look at the different groupings within that average.
I echo that point, which I wanted to make as well. I also highlight the surveillance data that we have. We have the child health surveillance programme at school entry, which gives us data on body mass index in children, and we have the Scottish health surveys thereafter. It would be helpful if we had more frequent surveillance—for example, at secondary school entry—because we have limited data at the moment.
Drew Walker is absolutely right about the widening health inequalities, which relate specifically to children and women.
I agree with all the comments that colleagues have made so far. They highlight that the issue is complex and that we are talking about physical activity, sedentary behaviour and diet. However, in this country, we frequently talk about that without necessarily making the association with obesity. We do not recognise ourselves and particularly our children as being overweight or obese, which tells me two things. First, we definitely need to address the prevention side, which includes legislation. Secondly, we cannot ignore the fact that a significant proportion of our population already suffer from the condition, so we need to support those individuals.
Does everybody agree that we should monitor a child’s weight more often throughout their school career?
Yes—particularly in year 6, when there is routine weighing in England. That relates to Joyce Thompson’s point about monitoring at secondary school entry. It is fantastic that we monitor children’s weight when they start school, but we should also do it a bit further up the educational pathway, so that we have more data points and can be more confident about the monitoring.
To go back a bit, I have a response to make to a previous question, which was on regulation. One reason why we have not made much progress so far is that we have been working in silos and looking specifically at changing people’s behaviours without changing the wider environment. A framework that could be used to guide policy, and which the Scottish Government is already using to guide policy on climate change, is the individual, social and material framework—I do not know whether people here are familiar with that. It recognises that individuals are part of a social context, which is part of the material context, and that we cannot change individuals’ behaviour without changing the bigger context into which they are integrated. Looking at obesity through that lens would really help to guide regulation and policy actions.
I am struggling to understand why our commercial environment is so significantly different from those in the rest of Europe. I understand that it is much more competitive, but is there more regulation in other parts of the world? What makes buying items on promotion so attractive to the UK population?
Lorraine Tulloch can comment on some of the analysis that has been done.
The question is still being looked at, and we are trying to get a good international feel for it. It is less about the level of regulation and more about the food culture that exists in other countries around how and what people eat. As far as we can, we are looking for examples around the world, and some countries are bringing in other regulatory measures. You all know the examples from Mexico of the sugar tax and from Chile about advertising but, in relation to other European countries, the issue seems to be more about culture than about regulation.
Would you mind giving us a bit more information about the Mexican sugar tax? Would anybody else be interested in that? We did not get that in any submission.
Lorraine Tulloch and I agree on almost all of this. There are some good examples from other countries on action on price. I recommend the NOURISHING framework, which has been established by the World Cancer Research Fund. There is also a database that looks at what all countries are doing on food promotions and other food action on healthy diets. There are some useful comparators.
In Mexico, a 10 per cent levy or tax on sugary drinks was introduced, which resulted in a 10 per cent reduction in consumption over the period of monitoring. Interestingly, the intention was that the revenue from the tax would go back into public health measures, particularly to provide cleaner water in schools and other facilities that communities could use. That is really good.
There has been from commercial partners criticism of that policy and the interpretation of the data. That always happens in all areas of public health, but we can be relatively confident about the Mexican data that shows a 10 per cent reduction. Mexico had some of the highest levels of carbonated sugary drink consumption in the world but, unfortunately, we have very high levels as well, so the example is interesting.
Mexico is a good example; consumption there has gone down, and that has been sustained. There is evidence from year 2 of the tax there that shows a sustained fall in consumption. The interesting aspect, which Linda Bauld highlighted, is the reinvestment in the provision of water, which was a popular part of the tax.
I have been struck by the four Ps, which we have heard about today, and I will focus on two of them, which will relate to the discussion that we have just had on promotion.
In relation to place, we have discussed availability and access to healthier options. I did youth work in deprived areas of Glasgow where we talked about nutritious eating with the young people we were working with, but that fell on deaf ears, because no retail outlet in the young people’s roaming area stocked any of the healthy ingredients that we were talking about.
I would like to hear the panel’s reflections on promotion and particularly the targeting of advertising at children. As a parent who is trying to buy healthily for my kids, I often find myself being duped into buying things that say that they have no added sugar, but then I see that the sugar content is astronomical. Things vary in whether they show calories per 100g, per half portion or whatever, and I have to interrogate the back of the label to work out how many calories I am giving my kids, because that changes from product to product. There are also products that talk about providing one of the five a day, which I took as gospel until I saw a programme about how a lot of producers are variously swinging the lead on that.
I ask the panel to talk about the impact of advertising on children and how we can better educate parents to buy better for their kids.
I do not want to dominate the discussion, but I will give the example of one experiment that was done in Liverpool. It involved kids who were invited in and shown television adverts; some were shown adverts for toys and some were shown adverts for junk food. After that, they were allowed to go and have lunch in a room with a buffet, and the experiment monitored how much they ate. The children who had been exposed to the junk food adverts ate significantly more than those who had seen the toy adverts, and the levels of consumption were higher in kids who were already overweight or obese. That is just one example of promotion.
Cancer Research UK is calling for the Scottish Government to strongly press and encourage the UK Government to introduce a pre-watershed ban on junk food advertising on television. Even though people often say that it is all about digital media nowadays—that people are looking at small screens—TV advertising is still a major driver of consumption.
In Scotland, we could do other things on promotions in the retail environment by using some of the devolved powers that we have over advertising. We should look carefully at that and there should be an analysis of where action could be taken that is within the powers that we have.
A lot of really great evidence is coming from the work that Cancer Research UK is doing on how children respond to advertisements. We support a call for a 9 pm watershed on TV advertising of junk food.
As Linda Bauld said, there are devolved aspects of advertising, such as billboard and bus stop advertising, which we ask the Scottish Government to look at. Some controls could be implemented in Scotland that would have an impact on the type of advertising that children see.
We are very interested in labelling, which Alex Cole-Hamilton raised. There is a complex mix of legislative responsibility for labelling, and a lot of it is at the European level. Once we are clearer on where we are going with the European situation, we can look again at what labelling could offer us to improve people’s understanding. Part of that involves understanding portion sizes; there is a lot of confusion about what the label tells us about how much we should eat and the portions that are available.
I will pick up on the question about data and look particularly at costs. The important point is that although a lot of the interventions that we are talking about cost money, they produce a net saving. We are looking at preventative spend—at spending a little now to save money.
I mentioned that £94 million per annum is the cost to the health service of physical inactivity. Quite a bit of work has been done on cost benefit ratios and social return on investment studies. Dr Adrian Davis has done work on active travel cost benefit ratios and looked at the cost of walking and cycling infrastructure. He has come up with a cost benefit ratio of about 1:19 so, for every £1 that is spent on active travel, there is about £19 of benefit.
Dr Davis compared that with road infrastructure. I am not against roads and cars, which are important. However, for comparison, if a road development has a 1:2 cost benefit ratio, it is considered to be a really good piece of infrastructure.
I am aware of four independently verified studies of the social return on investment from walking and cycling infrastructure, which all show a ratio of 1:8 or 1:9, so every £1 that is spent delivers £8 or £9 of benefit. The top benefits in all four studies are health benefits from physical activity, tackling obesity and the like. There is some hard data to show that such interventions work, are good value for money and, taken over the long term, are a net saving to the nation.
The committee’s strategic plan highlights preventative spend, health inequality and cost-effectiveness as our priorities. All of those seem to match squarely with this issue.
A number of the things that people round the table have mentioned, such as sport—particularly local sport—or activity, local travel, active travel, older people’s clubs and walking groups, are or were funded by local authorities. How can we address obesity in a preventative way that tackles health inequality and gets value for money if local government is under so much pressure financially? Is it possible to address that under the current policy agenda on finance for local government?
The public sector more widely needs to play as full a role as it can. The least that we should expect is that the public sector should not add to the existing problem, but I wonder whether that is the case at the moment. For example, we should not expect people who attend health facilities to experience an obesogenic environment, but that is exactly what they do experience in far too many national health service hospitals in Scotland. Through the main door of a hospital, one of the first things is often a commercial outlet that is marketing heavily energy-dense food. In staff canteens, too, the choice that is on offer is too often high-calorie food of low nutritional value.
I do not want to say much about local authorities, because I do not know much about them, but we should expect the NHS to play a full role in at least not promoting obesity in the way that it currently does.10:45
On the point about cost-effectiveness, regulation is quite cheap, but it needs to be done well. It is important that policy makers take a comprehensive approach when they consider the issue. For example, a ban on TV advertising would be positive, but commercial resources would then be channelled to other means of advertising. Digital advertising is a huge issue. The World Health Organization recently published a report on digital advertising to children that was quite scary. Through social media and pop-up ads that appear when children are playing on their phones and tablets, advertising is everywhere. Regulators really need to look at that.
Nourish Scotland supports a sugar tax in principle, but we are not entirely positive about the approach, because a sugar tax tends to affect poorer families more heavily and because, if sugar in some drinks is taxed, people will just choose cheap drinks that contain aspartame and other fake sugars, which are not healthier than drinks that contain sugar.
We propose another kind of tax—a multiple retailers and caterers levy—which we think would be much more effective, albeit that we recognise that it is a long way off. It would apply to multiple retailers and caterers, such as Tesco, Asda, Greggs and McDonald’s, and it would be based on the difference between what was sold and what should have been sold for us to be fed effectively. We have the dietary goals that Food Standards Scotland has set, but we are not meeting them and we cannot meet them when everything in the shops is not compatible with them. Supermarkets and other caterers and retailers know their products’ free sugar and calorie content, and they could be required to report periodically on their sales and then pay a tax on the difference between what they sold and what they would have sold if they had sold us healthy diets.
Such an approach could be positive for retailers if they sold more fruit and veg than we needed to eat, because the tax would become a subsidy, but we are quite far away from that. Currently, what supermarkets sell contains free sugar that accounts for about 13 per cent of dietary energy, whereas the recommendation is that free sugar should account for only 5 per cent of what we eat. A levy could be applied to the difference, which would incentivise supermarkets and other caterers and retailers to look at how they market their food and consider reformulation so that what they sold us attracted less of that tax.
That would be a more comprehensive approach. The money from the measure could be used to fund fruit and veg vouchers, the healthy start campaign or other public health measures.
I would like to follow on from Celia Nyssens’s points. It seems to me that we have two food cultures in Scotland. We export some very high-quality seafood and meat, which many people in Scotland cannot afford, would not know how best to prepare—because of our food culture—and never eat. Three quarters of adults think that their diet is healthy, but if two thirds of us are overweight there is clearly a misunderstanding. Joyce Thompson made that point. I get the impression from the evidence that the witnesses think that reliance on individual behaviour change will not suffice and that we need a societal shift.
The Green Party manifesto proposed a levy on retailers and caterers, so I am interested to hear the panel’s views on that. I understand that the sugar tax has had success, but there are concerns about its potentially regressive nature and its impact on people on lower incomes. I suppose that the issue is that private companies are benefiting from the sale of unhealthy and potentially addictive food, which is impacting on people’s quality of life for which—at the end of the day—the public purse is picking up the health bill.
We could also look at our high streets. We need to discuss where we buy our food and what we are buying. There has been an impact on the number of small independent retailers to which people can go to buy fresh food and get great advice so that they understand what to do with it. I would like to hear from the experts what you think about supermarkets’ impact on the agenda.
We have been doing quite a lot of work on retail outlets. Our voluntary framework is called supporting healthy choices. We have been doing things on a smaller scale through the Scottish Grocers Federation’s healthy living programme, through which we go into retailers and encourage them to offer fruit. We also work in hospital settings. We have recently introduced a measure under which 50 per cent of food that is on offer in all hospital retailers will be healthier options. Again, that is about setting an example.
We are not doing all that across the board, so we need to think about how we can scale up those things to have a greater impact on the population more broadly. That might involve working with retailers on price promotion and even on product positioning and how they advertise—whether they use certain media to attract specific audiences. We need to look now at how we can change the balance in order to move up to the next step. We have had success—more than half the community retailers in Scotland are now in the healthy living programme—but we are still not seeing changes in obesity levels. We need to take the approach to the next level and do much more across the board to have an impact.
It is important to remember that no single intervention will solve the obesity crisis that we face: a whole package of measures will be needed. The McKinsey Global Institute recently did a report that looked at a broad range of interventions, nearly all of which were labelled as cost effective, in that they make a difference. We always need to remember and come back to that. We can talk about individual things such as the sugar tax and the retailers levy. There are all sorts of individual examples, and we need to look at the evidence behind them, but we need a whole package. Public Health England recently did a thorough review of the evidence on what is most effective and found that measures on price promotions and advertising and marketing are up there. We need to consider those measures and think about the evidence that is already out there, in putting together a package.
I want to go back to the point that Alex Cole-Hamilton made about the complexities and confusion in selecting the right products for children. That reminded me that I should say that we need to take cognisance of the significant issues with regards to health literacy. Even though we produce the best materials, it is difficult for a significant chunk of the population to utilise them, so we need to think about that. The Scottish Government has its maternal and infant nutrition framework and various education policies. I work in a very practical arena, so I acknowledge that the policies have undoubtedly helped us to help various populations by giving the practical support that they need in making choices.
From a nutrition and diet perspective, it is important that the information that comes through in the key messages is current, correct and consistent. Knowledge and understanding about food and nutrition across the piece not reflecting such information can result in mixed messages.
The convener mentioned the financial situation that we are in—in particular, with regard to local authorities and decisions that they are having to make. In my head, that points us again towards what is possible in our communities. For example, we have work under way with two parts of the community in Dundee to co-produce preventative actions on the obesity agenda.
I represent the British Dietetic Association. Dieticians are registered personnel who have a nutrition background, and many are considered to be experts in obesity prevention and treatment, but we also acknowledge that some interventions are, with our guidance, perfectly deliverable by volunteers or other individuals in the community. Perhaps that provides us with opportunities that are yet to be realised to utilise or work with communities, as opposed to doing things for them.
That is fair enough, but if active travel is reducing and fresh food and veg co-ops are closing at the same time, we are just scratching at a tiny part of the problem. That does not mean that we should not do those things, but we need to put them in perspective and look at the bigger picture. It is concerning when we see the rest of what is going on.
I want to make a point about cost effectiveness. Something that we have not touched on but which I hope the committee will note—it is mentioned in some of our written submissions—is the importance of primary care. Joyce Thompson made a good point about interventions that can happen in the community. In Scotland, an alcohol brief intervention programme that has been delivered by general practitioners and others has had some success, and we now have a very good randomised controlled trial that shows the benefits of brief advice for weight loss that is delivered by GPs. In that trial, randomised people who received the intervention lost double the weight that those in the control group lost.
We have done such things for smoking and we know that we can do them for alcohol, but we are nowhere near doing them for weight, in primary care, even though such interventions are highly cost effective. That is a another suggestion about what we could do.
I thank Joyce Thompson for picking up my point about parents’ awareness of what they should be buying for their kids and the difficulty that they face when they go into the supermarket, given—I am going to call a spade a spade—the duplicity and nefarious tactics of producers in trying to get round that awareness. I argue that, as a country, we do quite a good job of educating parents about what healthy foods look like. The information is available if people want it; getting them to access it is a different matter.
I bought a bag of toffee popcorn the other day because it said on it that a portion contains only 112 calories. I thought, “Bonus!”—but that was for a 25g portion. If you look at a 25g portion of toffee popcorn, it is utterly heartbreaking. You think, “That’s not a snack. That’s not a treat.” To get your fill, you have to absorb another 400 calories’ worth of it. We have to box clever with the producers, who have a responsibility.
I went into Sainsbury’s to buy a banana, but the frequently bought items section contained only cakes, buns and chocolate confectionery, so I tweeted Sainsbury’s and said that maybe it would be cool to start a trend in that. Will you reflect on that and suggest what we, as politicians, could do to stamp such things out?
That is a good question, but I do not think that there is a single solution to that. Alex Cole-Hamilton mentioned Sainsbury’s. Tesco, on the other hand, is giving away free fruit for children as soon as you go into the store, which is a positive move. It is a difficult question.
If you regulate, the retailers will respond. If there were restrictions on price promotions and other marketing initiatives whereby we would try to modify some of what retailers can do—we have seen this in debates around the sugar tax and changes that producers are making—they will think of alternatives, which might sometimes be healthier. The retail sector can be an important partner.11:00
I agree very much with the point that was made about the challenge that is presented by local authority capacity. If we accept that policy implementation, rather than the introduction of new policies, is the priority, the fact that capacity and skills in local authorities are reducing is a huge challenge. Most of the work that is done by Paths for All and a number of our partners including Sustrans, Cycling Scotland and Living Streets Scotland is delivered through local authorities, so the climate of reduced skills and capacity in local authorities presents a big risk to the interventions that we hope to deliver. That is a very important point.
Finding the solutions to that challenge will be difficult, but it is about prioritisation. Organisations that are getting fewer resources must prioritise more and more. The challenge for us all is to ensure that obesity and physical activity are higher up in local authorities’ prioritisation lists than they are at the moment.
Another very important issue for local authorities is that the agenda that we are discussing is not yet a vote winner. We are coming up to the local authority elections in May, and if what we are talking about does not feature in the mailbags of local councillors who are hoping to be re-elected, we will have a bigger challenge. We need to ensure that the subject is a priority with elected members, too.
And equally with MSPs, for setting budgets.
Yes. We had a panel of MSPs—not local authority councillors—at our active travel conference last year, and one of the questions that they were asked was whether walking and cycling featured in their mailbag. All five main parties were represented, and they all said that the issue did not feature strongly in their mailbags. There is an issue to address in that.
I also make the point that—although it might be contrary to the concordat between national and local government—ring-fenced funding can be very useful. The cycling, walking and safer streets fund is incredibly useful at a time of limited capacity in local authorities, because that money has to be spent on walking and cycling. Finding a way of ring fencing funds could actually help.
I just wanted to make a point about the numbers that have come out—no one need respond to it. Someone mentioned £94 million as a potential saving, but if we look at that in context, I am shocked that it is such a low figure. Why? It is because that is only 0.8 per cent of the total NHS budget. Even if we take the £40 million and work that through, and assume that no one in Scotland is overweight, that comes out as a saving of about £250 million in the Scottish context, which is less than 2 per cent of NHS spend. Is it true that if no one in Scotland was overweight the NHS would save only less than 2 per cent of its total spend? I am struggling to make sense of that, and it might be interesting if the Scottish Parliament information centre picked that up and did some more digging into it. For the record, I would have thought that the number would have been 10 times that.
I kind of hinted at this before, but the thing that I want to quiz you all on is whether any stuff in the planning system militates against active travel. Anecdotally, I once asked someone very senior in a planning organisation why they were building housing estates of a couple of thousand houses but with no corner shops, and he said, “That’s not a problem. If people need to buy anything, they can just get in their car and drive to Asda.” Do you think that something in the planning system is causing problems?
The planning system has an awful lot to offer in tackling the problem. As I have said, we have been very good at planning physical activity out of our lifestyles and communities, and the motor car has tended to dominate how we plan our communities. The review of the planning system presents a huge opportunity to address that issue in order to make our communities more walkable and cyclable and to ensure that we tackle the issues of physical activity and obesity.
We did some work on that as part of the active travel alliance and we found that 50 per cent of the population either has no driving licence or no access to a car. If we are talking about inequalities and health inequalities, the private motor car is not an option for about half the population, which means that if we plan the way we travel, or if we design our communities, around the motor car, we instantly exclude about half the population. There is a big inequalities argument in that. I would not say that the planning system is the problem, but it is a big part of the solution. With the planning review coming up, we have the opportunity to ensure that the planning system incorporates walkability and cyclability in our communities, and that it places our services close to where people are.
On Ivan McKee’s point about the cost to the NHS, a thing that is entirely preventable and which is costing the NHS hundreds of millions of pounds every year should be a priority for us. We have to bear in mind that it is not just the NHS that bears the brunt of the costs; local authorities and other public sector bodies are negatively impacted, as is the economy. We know that productivity in our workforce decreases as obesity levels increase. There are therefore triple and quadruple whammies cost-wise.
It is important to consider the whole discussion around obesity in that wider context. There are other really important aspects to promoting healthier eating and higher levels of physical activity, and such a change in the situation might have impacts on the Scottish food industry. They are all entirely positive aspects. For example, the Scottish public transport sector could benefit from a change to more active travel. The impact on climate change is really important, and there would be an impact on pollution—we know that people’s health is negatively impacted by vehicle emissions.
We know that if we reduce health inequalities, it is not just people who live in our more deprived areas who benefit: the whole of our society benefits from having a smaller gap between the rich and the poor. There are wins all over the place not just in relation to obesity, but in relation to our entire social and commercial economy.
From what we have heard this morning, it sounds like you agree that there is a lot of good policy but it is not being implemented.
I specifically want to ask the panel about the cross-portfolio approach. When the committee was looking at the mental health strategy last week, we found that the Education and Skills Committee could have been pursuing a similar inquiry. To what extent do you think that when policy is produced, it is not picked up by schools and rolled out? We all have good examples of things such as walking buses and the daily mile happening in schools, but few schools are delivering them. Where is the problem with implementing the policies?
From my experience, the problem is a lack of resources. We have a framework, a plan and an implementation opportunity, but no resource behind that to move it out to local authorities or incentive for local authorities to pick up what is good Government policy. That is the gap that you are talking about.
I am not talking about needing a huge resource. The spend to save that we have been talking about to make this happen, at scale, at every imaginable delivery point in Scotland would be small.
Do you have an example of something that does not have the required resource?
We have a framework that says that we will try to decrease the number of inactive people in Scotland. There it is; that is what we must do. We have some ideas about how to do it, but the Government has given local authorities no money to spend on doing it.
The cross-portfolio point is important. One of the opportunities at the moment is the work on the good food nation. If we want to promote ourselves as a good food nation, and if the good food bill is coming out, we need to meet the health-based dietary goals for the nation. There are lots of opportunities for cross-portfolio work in this area—we have already talked about healthcare settings and education and so on.
I want to come back to some of the other issues that were raised earlier about the cost of obesity. There is some information in the SPICe briefing that was issued a number of years ago, but we need to gather more information to update that. However, it looks as though the annual cost to the NHS in Scotland to treat overweight and obesity is between £360 million and £600 million. Obesity is much more difficult to cost than other issues because it has so many health implications. A broad range of health impacts are associated with it—not just cancer but type 2 diabetes and complications in pregnancy.
Ivan McKee asked about stats on the costs earlier. We know that somebody with a BMI of 40 probably costs the NHS twice as much as somebody with a BMI of 20. That kind of information on costs is already available.
I totally agree with what you have said and I totally get that. We need to get that on the table because the flip side of the question is, if everybody in the country was fit and healthy, why would the NHS still need to spend 98 per cent of what it spends today? That is totally counterintuitive and we need to do some more digging on that.
The £94 million figure that Ian Findlay quoted is £18 per person in Scotland—that is the cost of inactivity. However, those are 2011 figures and Harry Burns, when he was the chief medical officer, thought that the cost was totally underestimated. One of the reasons for that is that when we do these calculations, we cannot include many of the things that Lorraine Tulloch mentioned—for example, mental health was not included in the cost because the data on that are not available in the same way as they are for other more standard things, such as cardiovascular disease. I think that the cost of inactivity that Ian Findlay mentioned is a huge underestimate.
I also want to raise the issue of individual and societal change. I completely understand that we need societal change but if we do not say that the mechanism is individual, we risk people not taking any action. Normative change happens when little groups of people start doing things differently and then it becomes the norm. We must continue to promote things that are proven to be successful individually focused interventions, provided that they can be done at scale. Then we begin to change the culture through those individual approaches.
To take that point further, politicians and leaders around the table can be champions for such change. The Scottish cancer prevention network has a lovely set of guidelines about how to conduct a healthy meeting. I would give you gold stars for providing water and fruit, but we have just ticked past 60 minutes and no meeting should continue for 60 minutes without an active break, because sitting as we are doing now expends close to zero calories—standing, as you might do for five minutes, doubles the calorie expenditure. People around the table are smiling, because that is so far from the reality of how we conduct meetings that it is amusing to hear.
However, that is part of the problem. People need to take the active opportunities that they are given. All the witnesses managed—against some resistance—to walk up the stairs to the meeting today, but initially we were taken to the elevator. You have a lovely building with lovely stairs and we must be the leaders of part of that individual change by conducting healthy meetings and avoiding the totally sedentary society of the workplace that we have managed to create.
I am glad that you mentioned that. There are so many ways in which we do not practise what we preach in this place. We have a gym in the Parliament that has no equipment in it and has never had equipment in it, because politicians do not want to spend the money and take the criticism from the public that that would incur. That is my understanding of the situation.
There is the way in which we conduct meetings—you are absolutely right about that—and the ways in which some of us travel here. In all of that, we are very hypocritical and I absolutely accept that.
Time to do 20 press-ups.
Remember never to use exercise as punishment. [Laughter.]
I agree with what Professor Mutrie just said but I want to highlight that as long as the environment is against people having healthy diets and being active, showcasing best practice and leading by example is not going to be scaled up, especially in lower socioeconomic groups—they are just not going to be able to change their behaviours because they are not in a position to do it.
To come back to Miles Briggs’s point, how we work together and make sure that the policies that we create are effective and enforced is a really important issue. Nourish Scotland has been trying to work with people with lived experience. We do that in the field of food insecurity, and there is huge potential to do it in obesity and nutrition and to talk to people who are struggling to change their diets and see what could help them to change the way they eat and their physical activity patterns. The good food nation bill is a huge opportunity for policy makers to work with social justice, rural economy and connectivity, environment and health departments to take a comprehensive approach to food and to see how we can bring together the different issues and create a good framework that enables us to act to solve this problem.11:15
We have just about run out of time, so I ask each of our participants to give us their 10-second ask. What should we be doing here and now with the powers that we have? What could we do? You have 10 seconds or so each.
We would ask you to support the need for regulation on issues such as price promotions, across advertising and marketing, and portion size, across the retail and out-of-home sectors.
I would ask you to implement our existing strategies at scale and with resource.
I would ask for sustained long-term investment.
We would want a co-ordinated approach across portfolios to prevent obesity, ensuring that we address inequality and do not widen the gap any further.
I would call for a comprehensive strategy that focuses on the individual and society. I talked about the four Ps, which are very much population-level interventions, but potentially we also need primary care and other interventions to support individuals.
We would ask you to work hard to make the good food nation bill a very ambitious piece of legislation that links food, farming and health and uses the industrial-social-material framework to look at all the different levels.
The BDA would ask you to lead an effective and joined-up approach across the life course and to allocate adequate funding to support research for and development, implementation and evaluation of the national plan.
I agree with all the points that my colleagues have made. I want to emphasise a point that Joyce Thompson made earlier about co-producing solutions. Too much of what we do is top down: doing things to people, rather than with people.
The second point is that we need to require the public sector to do what it can to reduce obesity in environments that are entirely within its control.
That was very interesting; thanks for attending.11:18 Meeting suspended.
11:23 On resuming—
I welcome to the committee Aileen Campbell, the Minister for Public Health; Fergus Millan, the creating health team leader in the Scottish Government health improvement division; and Derek Grieve, head of the active Scotland division in the Scottish Government. I invite the minister to make an opening statement.
Thank you for the opportunity to say a few words. I welcome the fact that the committee is taking time to look at probably the most pressing public health issue of our time. It is not unique to Scotland but, as usual, we appear at the wrong end of the league table. The Government’s approach to the issue is underpinned by a simple mantra that holds true even as our understanding and knowledge of how to tackle this complex problem grows: we all need to eat less, eat better and be more active.
Obesity can reduce people’s overall quality of life, create a strain on health services and lead to illness and premature death due to its association with serious chronic conditions, such as type 2 diabetes, cardiovascular disease—including hypertension and stroke—and a range of cancers. The cost of diabetes alone to NHS Scotland is estimated at around £1 billion per annum and much of that is avoidable.
Obesity used to be an exception to the social patterning seen in other non-communicable diseases. In essence, every zone in the Scottish index of multiple deprivation showed that its population was gaining weight. However, in more recent years, there has been some progress in reducing obesity in more affluent communities at the same time as the prevalence of obesity in more deprived communities has increased. That can be seen particularly in the primary 1 data, which highlights the divergence between the well-off and the poorest in our society that might well be behind the plateauing that we have seen in recent health survey data.
We published the prevention of obesity route map in 2010. That established a solid base, building on the foundations on diet and physical activity that previous Administrations laid, and we should recognise the progress that we have made in some areas.
For example, on food and nutrition, as well as physical activity, Scotland’s education system has a good story to tell. The food served in Scottish schools has to meet high nutritional standards and, together with the implementation of curriculum for excellence, we have made great strides in providing children and young people with the knowledge and skills they need to make healthy food choices. Coupled with that, the Scottish Government is delighted that 98 per cent of primary and secondary schools across Scotland continue to provide at least two hours or two periods of physical education, which we know can have a positive impact on a pupil’s health, educational attainment and life chances.
However, we are not complacent. The Scottish Government will continue to support schools and local authorities to drive improvements in school food and food education. Having good strategies is very important, but clearly not enough. We know that when we get our interventions right, they can be outstanding.
Our response to obesity cannot rely on just a few projects, no matter how impactful they might be. It is about reshaping the environment in which we live to make the healthier choice the easy choice and to change our ways of living to impact all the time.
In conclusion, the Scottish Government recognises that there are no silver bullets and that we must adopt an approach that focuses on a range of actions that will help to deliver and support a wider cultural change to our lifestyle. We recognise that there continues to be challenge in terms of seeing behaviour change on a scale large enough to make an impact. Tackling the obesogenic crisis and creating a cultural change cannot be delivered by the NHS or through public health alone: we need wider society to see value in this and we need members of this committee, and other leaders, to help reshape our relationship with food and activity.
I therefore welcome this chance to discuss those issues with the committee, as I prepare to consider how our policies should continue forward and how we in civic society can engage with the public in establishing the necessary culture change. I am keen to bring coherence and clarity to our messages on obesity and, again, I sincerely look forward to working with the committee on this agenda.
Thank you very much, minister. The previous panel unanimously agreed that there is an obesity crisis. Do you agree with that assessment?
As I outlined in my opening remarks, the cost in terms of diabetes alone shows how much of a challenge and a problem persist in Scotland. As the previous panel suggested, that is despite having had a number of policies in place to try to tackle that.
The scale of the problem that we face in Scotland is significant and we need to redouble our efforts to tackle obesity. That is not just for the here and now, in relation to the health benefits that that will create, but also in the preventative sense, in that tackling obesity will stop the impact that it is having on our health service and on public services more generally. Absolutely, Scotland has a significant problem to face.
I ask this not in any effort to embarrass you or anything like that, but if we all accept that there is a crisis, that will get us to a starting point at which we recognise the seriousness of the issue. Is “crisis” an unfair word to use or does it accurately reflect what you think?
Again, I am not trying to deflect from the seriousness of the issue. In Scotland we have a realisation, across a number of different professions and disciplines, that we need to refocus and refresh our work. That is why we have committed to refreshing the obesity strategy next year and why we are pleased that the committee is also looking at the problem. The range of evidence from the first panel will input into our thinking as we take our work forward.
As others have said, obesity is a significant problem in Scotland and the seriousness of it is huge. We also need to be mindful of our language because of the sensitivities around how people feel. Your earlier panel decided that there was a crisis. I think that we all agree that the problem in Scotland is significant and we need to refocus and refresh our approach, making sure that we bring together leaders, not just yourselves as committee members, but civic society leaders, to make sure that we focus and face the same way in Scotland, and recognise that Scotland has to unpick generations of overeating, low activity levels and less healthy choices.11:30
Before you took this brief, you were the Minister for Children and Young People, and we did a lot of work together over a number of years. I am very glad about that, because a lot of this agenda is about children and about prevention and early intervention.
We heard quite a lot from the previous panel about place and promotion. In terms of place, the issue is lack of availability, particularly in deprived communities, of access to fresh and nutritious ingredients and products; in terms of advertising, it is the targeting of our young generations. This Parliament is not entirely in control of the advertising agenda, but there are things that we can do.
Would you sketch out for us where you are coming from? What can we do in this Parliament to reduce the exposure of our young people to marketing, promotions in supermarkets, peer pressure and so on?
I wrote to the UK Government to see whether it would reconsider its position on junk-food advertising before the watershed. We have yet to get a response to that request. If the UK Government does not reconsider, we would like to open up discussions on whether the powers could be devolved.
Your point is a good one. It chimes nicely with the refocus and refresh of the obesity strategy as that will give us the opportunity in the broader sense to look at ways in which we can take a lead, some of which are tricky. That is where it is useful to have dialogue with the committee about where Parliament wants to see us take the refresh of the obesity strategy, where the parameters might be, where you would like us to focus our efforts and where we should be taking a lead. It chimes with public policy around minimum unit pricing or tobacco: Scotland took brave and bold decisions on those areas. Obesity has a degree of greater sensitivity. Often, people will consider smoking and the overconsumption of alcohol as something that somebody else does somewhere else. We all eat, and a cultural change is needed across the country.
Some of the bolder policies got a degree of kick-back. It would be useful to continue the dialogue to see where we should be pushing a bit more and where Scotland can take the lead. We are keen to make a difference on the issue. We cannot afford to plateau, as the statistics might be indicating that we have done. We need to consider everything as we look at the obesity strategy that we will bring for consultation next year.
I will focus on preventative spend. It was interesting to hear in your opening remarks that £1 billion is spent on diabetes. The Christie commission talked about up to 40 per cent of public sector spending being a consequence of issues that could have been prevented—that is a big number and I do not know whether I would buy into it. In the health budget, 40 per cent would be somewhere north of £5 billion, so the minister’s £1 billion is starting to get into the right ball park, which is good to hear.
I focused on that because it informs us of where we need to focus preventative spend. However, although we are happy to talk about how much more money we need when things are getting worse, if we turn the corner on obesity, in theory we will free up resources, which would be nice place to be. I want to reflect on what data you are aware of that would allow us to inform the debate about the financial consequences of reducing obesity.
Health is one of the departments that suffers as a consequence of what happens across society and Government. It picks up the poor health outcomes that result from things happening elsewhere. How much support do you have across Government? We spoke this morning about how decisions in planning, transport, education and regulation have a downstream impact on health outcomes and spend. Are things coherent and joined up at Government level?
The Christie commission published its report in 2011, I think, and it is still relevant. It challenged us all to work out how we move away from silo working—from progressing a stream of work in one area without reflecting on the crossover with other areas. That was as much a challenge for the wider public sector as for the Government.
We work across the Government, which is why there is significant investment in active travel and in organisations such as Sustrans, because we understand the need to be working across portfolios, disciplines and boundaries. It is why our national strategic group on activity also includes representation from Scottish Natural Heritage, Transport Scotland and others, and it is why the group that leads the walking strategy is chaired by the chair of the Royal Town Planning Institute.
We can point to areas in which we go beyond the usual suspects and ensure that we make inroads into areas that need to understand that they have an impact on the public health agenda. They might not be clearly associated with it, but that is part of why we need to build more momentum across the whole of civic society and the whole of the public sector, to make sure that we can all focus, face the same way and make inroads into that area in the best way that we can. It also makes sense for the public purse that we collect our resources together.
Can there be improvements? I have no doubt that there can be, and there have to be. I was listening to the previous panel as they were talking about the issues around implementation on the ground. There is still a job of work for us to do to make sure that it is as cohesive as we can make it. Likewise, we can always make improvements—and always strive to make improvements—in our work across Government.
The benefit of preventative spend is clear in relation to the £1 billion cost of diabetes. Some things are preventable, and if we can prevent them, that is a cost that we do not have to bear. At the same time, it is always easier to talk about preventative spend than to shift the focus—shift that tank—to ensure that that is what we are doing, because we still have to deal with the fact that, for now, people need to be helped to cope with their condition.
The Christie commission is as relevant now as it has ever been. We need to be more disciplined in our focus and we need to ensure that we use the opportunity in the refresh of the obesity strategy to make sure that we bring people together across a number of different disciplines, to get the impact that we want and seek.
Minister, in your opening statement you acknowledged that there is a clear link between obesity and deprivation, particularly among women and children. To take the example of fuel poverty, if somebody cannot afford to pay their gas and electricity bills, they obviously cannot afford to cook or prepare a healthy meal. Why has the existing strategy failed to make inroads when it comes to tackling obesity, particularly in areas where we have the most deprivation?
There are probably a number of reasons. You alluded to generational issues, and there are probably educational issues and a whole host of other societal issues in play too. No one is pretending that it is a simple or easy thing to solve. Everyone recognises that the fact that our statistics indicate that there are particular problems in areas of deprivation shows that we need a much stronger focus on making a difference in those communities.
Likewise, on the fuel-poverty issue, the fact that people cannot afford to buy the food or to cook it either, is something that we need to ensure is part of the focus in future. It has been a focus; attention has been given to that, but clearly we need to demonstrate much greater improvement than we have seen. Does either Fergus Millan or David Grieve want to add anything?
Fergus Millan (Scottish Government)
I also look after health inequalities policy, and one of the big pushes that we made over the last few years was to get the Government to give more attention to tackling inequalities. I think that we can see that happening. A lot of the things that we do to tackle inequalities will impact on people’s health, generally, and on obesity; all those things go together. The work that we have done on inequalities will contribute, but we have changed how we are approaching that and I think that we will see the results of that over the course of the next few years.
The figures quite clearly show that this is not having an impact and that obesity levels in deprived areas are growing.
These sorts of figures do not change dramatically overnight; you have to follow the trend, because what you want to see is how the figures move over a number of years. When we first started writing the obesity strategy in 2008-09 for publication in 2010, inequalities were not, as the minister has said, deemed to be an issue. Everyone in Scotland was affected. There were some groups of people, particularly women in certain areas, who were probably outliers, but over the past few years, we have started to see the different SIMD zones separating. That has been particularly apparent with children; interestingly, however, the adults have not separated fully yet. That might suggest that although adults, particularly in well-off communities, have taken on board some of the messages and are doing things for their kids, they have not quite taken the messages on board for themselves. For example, they have not committed to giving up their glass of wine at night—or, indeed, eating more healthily, which is what their kids have committed to doing. In short, adults are not quite at the same place as kids with regard to inequalities.
In refreshing the strategy, then, do you see a need to change it, or is it just a case of implementing the strategy itself?
We always said from the outset that we would focus on inequalities and target our resources and activity on the most deprived communities. That is what we have tried to do, but this is a long-term thing and you will not see results very quickly. We are in this for the long game, because this will take decades to turn around.
On your point about targeting areas of most need, can you evidence where significant resource is being redirected from one area into an area of most need?
I cannot give you that evidence myself, because the resources go out to the health boards and local authorities, and it will be up to them to divert those resources.
We have policies that are continuing to make an improvement across the piece. Primaries 1 to 3 now get a nutritious free school meal, and the nutrition value of those meals is as good as it has been. We also have a number of areas of work to encourage activity, and we want to ensure that that is accessible to areas that suffer the most deprivation.
However, we also have to realise that, as I think your previous panel noted, those who live in areas of deprivation are far more susceptible to some of the more difficult decisions that have to be made in order to make their income go further or to being forced unnecessarily down a path where they sometimes take the unhealthy option. We therefore have to ensure that in this refocus and refresh, we tackle inequalities, understand the choices that families are having to make and find ways of helping them. I should also point out that the Government has invested in measures to allow people in more deprived areas to access fresher and healthier food. We have policies in place to address these issues; we are investing in them; and we need to build upon that to make the difference that I think we are all seeking.
A very good example might be the football fans in training project, which obviously focuses on football clubs. From the outset, we asked the project to focus on those in its fan base who live in the more deprived areas, which they are often drawn from. That is a very specific example of our helping people from a particular area, and the project itself is very successful.
We might come back to that.
Thank you for joining us this morning. As you will be well aware, Scotland has the worst weight outcomes of all UK nations, so I very much welcome the minister’s statement that this is a most pressing public health issue. However, I think that our previous panel would agree that it does not feel like a national priority at the moment. For example, Dr Drew Walker pointed out that, although this is entirely preventable, it is costing the NHS hundreds of millions each year, and Professor Nanette Mutrie said that we have lots of fantastic policy that we are simply failing to implement or invest in.
I would like to understand what is going to change. We have seen the complete removal of funding from jogscotland and we know that, last year, only 1.2 per cent of journeys in Scotland were made by bike. We have a vision for that to be 10 per cent by 2020. Given that the minister spoke of significant investment in active travel and that she has a cross-cutting portfolio, will she speak to Humza Yousaf and suggest that he invests more in active travel? Currently, he invests less than 2 per cent of a very big transport budget in walking and cycling. Are those changes that we can expect to be put in place while we wait for the refresh?11:45
We already invest significantly in active travel, with record investment of £39.2 million per year, and we will continue to invest.
Of course we will continue to have discussions with other policy leads and ministers with areas of interest that relate to tackling the problem of obesity. A lot of the evidence and the investment stacks up to confirm the cross-cutting nature of this work. Can there be improvements? Of course there can, and we will continue to need improvements.
However, there has been a great improvement through the focus on walking. We have seen an increase of—I think—around 5 per cent in walking and a reduction in the weight of people who are participating in walking, so that is a clear indication of where the Government puts a focus. We can expect to see quite quick results even though it will be a wee bit further down the road before we start to see the longer-term benefits and impacts across the country. We are investing in areas such as active travel and we are working across portfolios. We will continue to make sure that our policies can be implemented and that we can feel the positive impact of that across the country.
I am just making the point that ministerial colleagues are perhaps making this more difficult than it might be. The £39 million might be a record for this Government, but I suggest that it is far too low given that we know that 50 per cent of Scots do not have access to a car. Suitable and appropriate investment in this area could help to address inequality markedly.
We know from international evidence from countries where a lot of people cycle that those on the lowest incomes tend to gain the most advantage. Also, there is a lot of evidence that the jogscotland programme was very good at addressing inequalities. Lots of people who took part in it were women in their 40s who might not have been comfortable about attending a gym. They liked the fact that the costs were low and they could do the activity in their neighbourhoods. I would be—
That is exactly why we have had a focus on the walking strategy. Walking is free of charge and everyone can do it, but we have to make the conditions right for people to participate. It is positive that Scotland has seen a 5 per cent increase in walking as a result of a cross-portfolio focus on trying to improve on where we have been. As I said, the strategic walking group is chaired by the chair of the RTPI, which brings in planning as well. Nobody is saying that we do not need to understand and be cognisant of the fact that we need to continue to make improvements so that active travel is more keenly and routinely reflected in the planning decisions that are taken. We have to do that to benefit not just public health but wider civic society and public life more generally.
On walking, which is free of charge, we have invested in the paths for all partnership to ensure that more people can participate in that pastime, which improves their fitness and wellbeing and helps us to tackle some of the problems that we are facing.
Professor Nanette Mutrie said that she believes that there is a lot of very good policy out there. There have clearly been improvements, which I warmly welcome, but there was a feeling from the previous panel that things are not being implemented because of a lack of resourcing. It is clear that local authorities’ budgets have suffered. How will you enable local authorities to deliver these programmes given their reduced budgets?
Local government has been given a fair settlement, although I do not take away from the fact that everybody across public life is facing fiscal challenges. Going back to the principles of the Christie commission, I add that that means that we require a much more disciplined approach, in which we bring our collective resources to bear to make the improvements that we need to make.
In his earlier line of questioning Alex Cole-Hamilton talked about the early years work that we took forward when he had his role in the Aberlour Child Care Trust. The early years task force brought together local government, the NHS and the Government to pool our resources more effectively. That is one example of how we can bring about the differences that we need to see. That is why we need to push more and work more collaboratively with local authorities, the NHS and others, bring together our resources and work out where we will have the greatest impact.
Some of the things that we are talking about, such as walking and the football fans in training project, are incredibly cost effective. They do not cost a huge amount. Sometimes the answers do not cost a huge amount but the impact can be transformative. We need to work together more collaboratively with a common purpose and an understanding of what we want to achieve. The refreshed strategy will provide the opportunity to do that when we go out to consultation on the things that Scotland needs to do differently in order to make the impact that we need.
On local government fairness, is it fair that my local authority, West Lothian Council, which was named UK council of the year in 2006 for being a well-run local authority, has had £90 million taken from its budget, impacting on active travel, pensioners groups, physical activity groups and sport—all the things that feed into this very important issue? That surely cannot be fair.
The Scottish Government’s budget has been cut as well and we have managed to provide a settlement for local government that is fair, although that does not diminish the financial challenges that we all face. The Government has provided a fair settlement for local government against the backdrop of its own budget being cut quite considerably by Westminster.
The previous panel touched on the child health surveillance data and how that is used. As part of the refreshed strategy, should we record secondary school-level data as well?
On a separate point, you mentioned that 98 per cent of pupils are now receiving two hours of physical education in school. Is that quality PE?
I heard the comment made in the previous evidence session—and the consensus among panel members seemed to be—that it would be a good idea to embark on the monitoring at secondary school level of young people’s weight. That is something that we will commit to look at and consider.
On quality, we have come from a base of 10 per cent in 2004-05 to 98 per cent now. That is a huge and significant increase that we should not take away from. That has been work in progress among active schools, sportscotland and the Scottish Government. The quality is there.
Derek Grieve (Scottish Government)
In rolling out the delivery of the physical education target, Education Scotland has worked very closely with schools so that, as well as increasing the volume, there has been a lot of work in schools to drive up quality.
The minister said earlier that the public had accepted several laws that the Government has brought in over the past couple of years, for example on minimum unit pricing, which is an on-going issue, and on smoking. The previous panel suggested that we should regulate the food industry, especially the big names such as Tesco and Sainsbury’s, and that we should introduce taxes, which I do not think they are going to like too much. Should we regulate or should we educate people about this crisis, as some people want to call it.
We should certainly educate, regardless of any views on regulation. We strive to do so through the curriculum for excellence and through a host of other areas. That extends beyond the school classroom into youth work and a host of other areas that take their responsibilities for children and young people seriously.
On regulation, you touched on an issue that shows how complicated this problem and this area of policy are. Minimum unit pricing was not wholly supported by some elements of the industry, so we can see how tricky it is to move forward in these areas.
Therefore, what we need to do—and what the strategy of refocusing and refreshing will allow us to do—is to have a wider debate about where civic society wants to push us; where the committee wants us to go; what committee members, as leaders in their parties and their communities, think; and what areas the Government should be looking at as we try to find solutions for this problem, which is significant for Scotland and costs our public services a significant amount of money.
As a starter, we should ensure that children are not exposed to junk food advertising before the watershed. That would be quite straightforward and it has been called for not just by the Scottish Government but by our counterparts in other areas of the UK and by health professionals across the UK. I hope that the UK Government can reconsider that and that we can make progress on it.
What role does Food Standards Scotland have in challenging the food industry, the shops and the big grocers and in formulating and promoting a better, healthier way of eating?
Food Standards Scotland has a national leadership role as well in providing authoritative sources of advice and evidence and in working with other partners to ensure that there is clear guidance around people’s approaches to purchasing or to food more generally. It is also well placed, through its position separate from the Government, to provide challenge to industry, so it has an important role to play.
I have one last question. We were talking about the sugar tax on drinks. What do you think about having a levy on unhealthy foods?
Again, some of those issues will no doubt come out through the consultation. What was clear from your previous evidence-taking session was that there is a desire for Scotland to be bold on this issue. Where we have seen that boldness on tobacco and alcohol, we have seen the health benefits come through as well. Therefore, this is an opportunity to flush out what people think we should be doing; where we need to increase our efforts; what more we need to do; and how we properly implement some good policies that we have in place. We also need to be mindful of some of the sensitivities that exist. It is not going to be an easy journey to embark on, but the consultation gives us a chance to talk openly about what tools we have, what tools can make a difference, and how we should proceed in dealing with the issue that Scotland has with obesity.
Thank you for joining us this morning. We heard the concern of members of the previous panel about price promotion on higher-sugar and higher-calorie foods. I was staggered by some of the figures in the Cancer Research UK submission. For example, it said that 53 per cent of regular soft drinks were purchased as a result of price promotion. Could the minister give us her thoughts on price promotion? The Scottish Government has looked at price promotion particularly on alcohol and multibuys. Perhaps it could consider that for sugary drinks and high-sugar, high-fat and calorie-dense foods.
Absolutely, we will consider that as part of the strategy and the consultation that we will embark on. Even talk of the sugar levy has begun to lead to some changed behaviour in industry. Tesco is starting to reformulate products, as is Lucozade, I think. There are already changes in industry because of the notion of the sugar levy. We will absolutely consider that as part of the refresh of the strategy.
I will draw on Miles Briggs’s question. In your answer, you might again want to reflect on your experiences as the Minister for Children and Young People.
It is fair to say that the SNP is to be applauded for what has happened in PE, which draws cross-party support. Some 98 per cent of pupils are now getting two hours of PE a week. Arguably, however, the Government has given with one hand and taken away with the other, given the decline in the access to youth work that children and young people have in the crucial times outside school hours, including access to physical activity.
For example, the decline of the community education department at the University of Strathclyde means that we are no longer churning out qualified youth workers in the way that we were, and we still have the repeated barrier across our communities of brilliant facilities being inaccessible at weekends because they are tied up with club events or because opening them is financially prohibitive. What steps will your Government take to mitigate that and to promote and boost access to youth work?
Scotland takes a lead in comparison with many other parts of the UK in our approach to youth work and our youth work strategy. From memory, I think that participation in a number of uniformed groups, for instance, is going up.
As ever with youth work, the problem lies in enticing volunteers to come forward so that such opportunities can be provided, and we have to do what we can to ensure that volunteers continue to come forward. We have quite a good story to tell on youth work.
I absolutely agree. We have a shiny youth work strategy but, unfortunately, because of the cuts to local government, paid youth workers are being laid off and access is diminishing. Last week, we had a really good meeting in Muirhouse in my constituency with a number of youth work providers, all of whom are uncertain about whether they will still have contracts this time next year, because of local government financial uncertainty.
I admit that such decisions are taken at the local level, but that is about the Government’s funding priorities as well. The strategy is brilliant, but delivery on the ground is not meeting it.
We can point to increased participation in some youth work organisations as well. We have a good strategy in place and we have seen great improvements in youth work. Participation in youth achievement awards, which are accredited by the Scottish Qualifications Authority, has gone up exponentially, and in my portfolio we have the active schools network, which is providing greater opportunities for young people in the community.
We have exceeded our target for community sport hubs, which are being taken forward by sportscotland. As it tries to further increase the number of hubs, we will be looking to areas of increased deprivation and considering how we can enhance and increase the opportunities that young people have to participate in sport and in activity more generally. We have some of the best facilities that we have ever had across the country. Now, we have to make sure that we break down the barriers so that everybody gets an opportunity to use the facilities.
We have a good story to tell on youth work and an equally positive story to tell in our active schools network. That has been enhanced by the community sport hubs, which have had significant investment from sportscotland and the Scottish Government to ensure that young people in areas across the country have access to a variety of sports of their choice.
In looking at the evidence that was submitted, I was struck that slightly different strategies are required for preventing and tackling obesity. In treating the obesity and overweight problem that we have, it is more significant to reduce the number of calories that people eat, which involves affecting their diet rather than their activity level. I accept that physical activity can be part of the treatment strategy, but we get a much bigger bang for our buck from policies to tackle what people eat. I would be interested to hear your thoughts on that.
I was also struck when we spoke with the previous panel by the point that previous strategies might have increased health inequality, because many of them were targeted at individuals’ responsibilities. Is it time to think seriously about population-level approaches, fiscal strategies and regulation, so as not to broaden inequality further?
Physical activity has to be part of our approach. There are a lot of different views and opinions, but the wider benefits that physical activity provides for mental health and general wellbeing are generally agreed on.
Much of the focus is on young people and girls, but there are also benefits for the older cohort. Activity can help with fall prevention, muscle tone and many other things. We continue to work with the Care Inspectorate and others in relation to care homes. We need to have a focus on work for other age groups, too.
Physical activity has to be part of our approach, as does looking at what people eat. Physical activity is not in itself enough to compensate for the calorie intake that people consume. You are right that there are good policies and pockets of good practice in different places. How we scale that up has to be part of our approach.
The 5 per cent increase in walking was the result of a lot of collaborative work and focus on an issue where we know that we can make a difference. That difference has happened quite quickly. While some of the benefits will be felt in the longer term, we can make inroads and have some quick wins. We need to move forward with short, medium and longer-term goals in the strategy refocus.
You wanted the committee’s views on how we take this forward, and I am keen to hear your views on that, too. Governments took brave and bold decisions on smoking and alcohol and took on vested interests to move the agenda forward. To tackle obesity, we need to take on some of those vested interests again.
Some of the responsibility lies with the UK Government, but some of it lies within the powers of this Parliament. With the powers that we have, will you take on the vested interests to make an impact on some of the issues that we have discussed today, while continuing to lobby elsewhere when that is required?
The opportunity that we have for dialogue and consultation in the refresh of the obesity strategy is important because it will allow us to look for ways in which we can be innovative and bold and make the differences that we seek to bring about. That will be quite a challenge, which is why I suggested that the committee could come forward with its views and opinions.
At this point, we are open minded, but we are determined to make a difference. We will need to roll up our sleeves and look seriously at any ways in which we can bring about changes to address the problems that Scotland faces on obesity.
The whole Parliament came together behind the bold decisions on minimum unit pricing. That is where we need to be, and we should be mindful that we need to win hearts and minds not just in the Parliament but in wider society. Such topics are difficult and challenging; there are sensitivities around looking at bulk buys and pricing, for example.
We have a collective determination to make the improvements that we need in Scotland and to address the issues that the public purse is facing. The consultation on the strategy gives us the opportunity to raise the debate about what we do as a country to respond to the obesity problems that Scotland faces.
Does anybody want to make any final points? No.
Thank you very much for your attendance, minister.
I was expecting another question. [Laughter.]
We will move into private session.12:10 Meeting continued in private until 12:44.