Paper for
Purpose
Date
Author
The Academy of Medical Royal Colleges investigation into the implementation of effective measures to tackle obesity – the steering group
To present the submission from the Faculty of Public Health
2 June 2012
The Non-Communicable Diseases Advisory Group of the Faculty of Public
Health
1.
Introduction a.
The Faculty of Public Health (FPH) strongly welcomes the Academy of
Medical Royal Colleges’ (AMRC) investigation into the implementation of effective measures to tackle obesity. Obesity is a life- limiting, life-shortening and life-long condition. It is one of the most acute public health issues facing the UK population and many countries worldwide and yet effective interventions are complex and hard won. b.
The Faculty of Public Health has submitted a response to the Dept. of
Health’s Call for Action (Appendix 1). c.
The FPH recognises that obesity is a highly complex issue, classically described in the Foresight report on obesity published in 2006. There is no single “magic bullet” that will impact on obesity. Instead it needs multisectoral, multi-professional, multi-service, multi-issue, concerted, consistent and long-term efforts. d.
Obesity needs to be everybody’s issue. e.
The AMRC is looking at 5 aspects of obesity interventions:
1.
Action that can be taken by individuals
2.
The environment
3.
Clinical interventions
4.
Fiscal measures
5.
Education
The FPH wishes to make a submission, in particular, on the 2nd and 4th of these points.
2.
The Environment:
 What do you believe are actions and/or strategy that actually work in preventing or reducing obesity?
Advertising: children are particularly vulnerable to advertising. The food industry spends large amounts of resources advertising directly to children because of its effectiveness.
Children need to be protected from such advertising in all media, including emerging technologies.
Whole school approaches: the evidence supports the effectiveness of a school tackling obesity through every aspect of its work, including food availability and education, physical activity (including active travel and non-sport activity) and mental well-being.
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Research is needed into whether this whole-system approach is effective in work places and care institutions.
Food labelling: The FPH strong supports “traffic light” front-of-pack labelling. There is strong evidence that effective food labelling helps people make healthy choices. There is also evidence that choices are made in a matter of seconds, so labelling needs to be consistent and easily understandable.
Promoting active travel: promotion of active travel (e.g. increasing information, increasing perceived and actual road safety, bike storage) enables people to build physical activity into their everyday life with the added benefit of reducing carbon footprints. 20mph zones in residential areas have been shown to increase active travel as well as reduce injuries and deaths and inequalities in these. Economic analysis has demonstrated the high value for money of investment in walking and cycling for governments.
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The built environment: Physical activity levels are directly related to the surrounding built environment but impact on health is not a compulsory part of planning considerations by local government. Obesity Impact Assessment needs to be a routine part of planning decisions in large scale developments.
 What is the evidence either from practical experience or relevant literature you have that these actions are effective?
The FPH refers the AMRCs to the Foresight Report, NICE guidelines and the National
Obesity Observatory.
 What do you think should be done regarding the environment and what should the
Academy be calling for from clinicians, Government or others?
The FPH regards the public health threat of obesity to be so profound that it justifies legislative measures. The FPH is concerned that DH is relying too heavily on the Public
Health Responsibility Deal and the Change 4 Life campaign, with a focus on the responsibilities of the individual.
In addition FPH would encourage government to:
Encourage local authorities to introduce 20mph speed limits in residential areas
Implement universal front-of-pack traffic light food labelling
Ban advertising of high-calorie low-nutrition foods to children (through all forms of media and at times where significant number of children would be exposed, e.g. during television programmes watched by children, even if not the primary audience),
Building health impact assessment into planning considerations
 Any additional issues we should be considering
1 Davis A. Value for Money: An economic assessment of investment in walking and cycling. Bristol: DH & Govt
Office for the SW, 2010
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There is an increasing debate about the role of sugar in obesity; whether it has addictive properties and as such whether its accessibility should be controlled in some way. FPH would welcome high quality research in this area.
The role of alcohol in obesity must not be missed – the population needs to be more aware of the calorie content of alcoholic drinks.
3.
Fiscal Measures:
There is increasingly strong evidence that fiscal interventions represent effective and costeffective strategies to improve healthy eating and prevent obesity.
 What do you believe are actions and/or strategy that actually work in preventing or reducing obesity?
- Fiscal measures that increase the marginal costs of driving private motor vehicles
(whether fuel tax or road charging)
- Investment in public transport
- Continuation of the employers’ bicycle scheme, that reduces the costs for employees to buy a bicycle for commuting with

What is the evidence either from practical experience or relevant literature you have that these actions are effective?
Many economic studies have shown that most human actions are price-sensitive, including decisions and choices made regarding food purchases and travel mode. E.g. the London congestion charge resulted in fewer motor vehicles and an increase in cycling.
A number of studies have shown that users of public transport walk more, on average, than those who travel by car (e.g. by Dannenberg and colleagues).
Appendix 2 lists references regarding fiscal interventions to improve diet.
Organisational travel plans have been shown to reduce car use and increase travel by other modes including public transport, walking and cycling. The plan needs to be developed and implemented in line with best practice, including consultation with employees / users; provision of necessary facilities, e.g. pavements, cycle parking, shower and related facilities; clothes storage; employers’ bicycle scheme; cycle training (e.g. Bike It for schools); availability of individual travel planning advice, e.g. TravelWise. 2

What do you think should be done regarding fiscal measures and what should the
Academy be calling for from clinicians, Government or others?
- Government should introduce or extend the fiscal measures listed above.
- The Government should consider the introduction of a “fat tax”
- The Government should require at least 5% of national, regional, and local transport funds to be spent on facilitating active travel , through infrastructure
2 Mindell JS, Cohen JM, Watkins SW (eds). Health on the Move 2. Policies for health promoting travel.
Stockport: Transport and Health Study Group, 2011. www.transportandhealth.org.uk
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- The Government should reintroduce national and regional targets and require regional and local government to have their own challenging targets for increasing active travel.

Any additional issues we should be considering
Population wide interventions tend to reduce inequalities rather than widen the gap.
The FPH particularly highlights the synergies between sustainable/’low carbon’ and healthpromoting transport, and thus the beneficial effects on averting climate change that widespread movement from cars to active travel would have. There is a debate about the benefits of a fuel tax as opposed to road charging. The advantage of a fuel tax is that it is an incentive to be more fuel-efficient, whether driving less or using more efficient, smaller engines over the longer term. Road charging is more equitable, in that it can be made more sensitive to the availability of other options, being highest where there is plenty of public transport and low in rural areas with limited other options – or could raise money to invest in responsive community transport.
A number of systematic reviews (SRs) and studies summarise the evidence for a range of fiscal actions (focussing on taxes, subsidies, economic incentives and price) to improve healthy eating of specific dietary factors: sugar sweetened beverages, refined sugars, saturated fat, total fat, fruit and vegetables, junk food and calories. These actions typically involve a policy, programme or strategy to improve people’s healthy eating.
Conversely, actions initiated by industry are generally ineffective while promoting the specific company. These ineffective initiatives include pledges, partnerships, corporate responsibility programmes and other public relations campaigns. There are clear parallels with the previous history of tobacco industry and alcohol industry initiatives.
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APPENDIX 1:
About the UK Faculty of Public Health
The UK Faculty of Public Health (FPH) is the leading professional body for public health specialists in the UK. It aims to advance the health and wellbeing of the population through three key areas of work: health improvement, health protection and health services. In addition to maintaining professional and educational standards for specialists in public health, and providing practical information and guidance for public health professionals, FPH advocates on key public health issues, influencing policy change at the highest level, and working closely with policymakers, professionals and the public to make a positive difference to people’s health and wellbeing.
1. Introduction a. In October 2011 the Department of Health published their “Call to Action on Obesity in England”. This short paper summarises the Faculty of Public Health’s response to that call to action. b. Obesity is a life-limiting, life-shortening, life-long condition. The Faculty of Public
Health welcomes the recognition, by government, of this hugely important and complex public health issue. The Faculty regards the Call to Action as making some excellent points and missing important opportunities.
2. Current Action a. Members of the Faculty of Public Health already lead the action that has been identifying and then tackling the growing threat to the health of the nation which is obesity. b. As the country’s leaders in public health issues they lead the population surveillance which identified the problem, and developed the methods of on-going surveillance in adults and, particularly, children. c. As leaders of local public health action our members already work in the NHS and in local government bringing together multi-organisational and multi-professional groups to find local solutions to tackling the problem. There are already many examples of these strategic approaches leading to real action on the ground involving strategic leaders, care and healthcare professionals, educators, planners, transport professionals, academics, community groups and individuals themselves. d. Faculty members lead the research that is vital to understand the cause of the rise in obesity and the effects of that rise on health and wellbeing. Our members ensure that robust evaluation ensures that when limited resources are used then the resulting actions are effective. e. All this action appears to be having some effect on a highly complex and highly important health need, as the annual child measurement figures begin to show a reduction in the rate of increase in obesity levels in our children.
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3. Excellent Points a. The Faculty welcomes the recognition of the continued relevance of the Foresight
Report of 2007 and of the on-going development of the evidence-base. The Faculty welcomes the recognition of the need to increase the evidence base. Government investment in health related research is distributed in such a way that public health research is minimal while the effect of public health issues is huge. The Faculty calls for a redistribution of government health research funding to increase the relationship between investment and the size of the threat to health. b. The “ambitions” of attaining downward trends in both child and adult obesity are to be welcomed. The Faculty urges the government to set itself and its partners (including
Faculty members) challenging and measurable numerical targets within this ambition to which we can all aspire. There are important targets within the overall measure of obesity levels, including physical activity levels and nutritional content that are important process measures for obesity and will also, in themselves, have proven public health effects. c. The Faculty welcomes the increased emphasis on the responsibilities and powers of local government in tackling the many causes of obesity. For many years Faculty members have been working with partners in local government on this issue. With the movement of public health resource and expertise into local government there is an opportunity to increase this partnership work.
4. Missed Opportunities a. It is right that the Call to Action was based on discussions that included Faculty members, experts in their field. However many are disappointed at the only partial recognition of those discussions in the final document. b. Throughout the Call for Action there is a huge emphasis on the responsibilities of the individual. While ultimately obesity is about the balance of calories ingested and calories expended by an individual there is a limit to an individual’s control about eating, drinking and physical activity when living in our complex and highly evolved society. There is a strong social gradient in obesity, with the most disadvantaged members of society faced with the greatest challenges in undertaking regular physical activity and eating a healthy diet, and suffering the greatest harms. An approach that is focused on individual behaviour risks entrenching and increasing these inequalities. c. The report as a whole places a disproportionate emphasis on diet while giving insufficient emphasis to physical activity, particularly incidental physical activity and how it can be encouraged.

National Government d. The Faculty welcomes the recognition of a role for national government. The Call for
Action gives a great emphasis to the Responsibility Deal at a time when there is no evidence whether this form of engaging with the food and drinks industry will have any effect on obesity levels. The Faculty is working with the government on the
Responsibility Deal, and repeatedly emphasises the experimental nature of the Deal and the need for robust evaluation to gauge effectiveness. e. Meanwhile there are actions that only government can take for which there is already evidence of a positive effect:
- on the intake of high calorie foods
 legislation on advertising to children[http://www.iaso.org/news/obesity-news/];
 taxation of sugar in sweetened drinks & sodas[http://www.nature.com/nature/journal/v482/n7383/full/482027a.html]
- on the expenditure of calories through regular physical activity
 20mph speed limits in residential areas
[http://www.transportandhealth.org.uk/?page_id=32]
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 the planning of public open space to support increased levels of walking and
 cycling[http://guidance.nice.org.uk/PH8]
In not taking such actions Government is actively pursuing obesogenic policy while calling others to abandon obesogenic actions. f. The Call to Action states that the government “continues to be committed to statutory nutritional standards for school meals” and yet the Minister for Education has removed the obligation of Academies to abide by the standards set by The School
Food Trust. The Call to Action also mentions the Healthy Schools scheme while removing national funding for the coordination of this scheme. g. The Faculty regards the national government as reneging on its responsibilities while urging others to act on theirs. The Faculty echoes the Health Select Committee in urging national government to be willing to take stronger measures, including legislation, alongside the Responsibility Deal. While understanding the political preference for interventions from the less intrusive end of the Nuffield ladder the
Faculty would suggest that until the obesity epidemic is under control more effective measures are necessary. Although these may be more intrusive initially they can then be relaxed if the ambitions for sustained reductions in obesity levels are met. In addition the evidence from work on tobacco consumption suggests that it is these very actions that will have the greatest effect on the health inequalities aspects of obesity. h. The Faculty urges the government, in its recognition of the advancing evidence base in tackling obesity, to reflect its responsibilities by asking NICE to review its Obesity
Guidelines. These guidelines are now over 5 years old and need refreshing. i.
England does not have time to wait to see of the Responsibility Deal alone works. The need is too great, the problem too complex and the effects too critical to restrict the actions of national government in this way.

Local Government j. The Government is to monitor progress of individual councils against the new Public
Health Outcomes Framework and reward improvements in health inequalities through the Health Premium. Obesity varies with deprivation and other community characteristics. The government needs to take into consideration the effect of its own actions (or inactions) on different local government areas and population groups within them. The Government's own actions (invested mainly in the Responsibility
Deal) are likely to affect some groups more than others and the impact on health inequalities needs careful investigation to enable interpretation against outcomes in the light of these effects. k. While the support offered to local government in the form of data and building local capability is welcomed local government also needs national government to act on its own responsibilities to do what only national government can. These actions will then empower local government to achieve more.
5. Conclusion a. The Faculty of Public Health welcomes the recognition of importance of the public health effects of increasing obesity levels demonstrated by the publication of this report. b. While the actions described show a positive intention. However the Faculty is concerned and disappointed by the over-emphasis on both the responsibility of the individual and the lack of action by the Government itself. The approach taken is contrary to the evidence available, which supports a much more comprehensive approach with robust action by central government. c.
The government has a duty of care to its citizens, particularly children, and a moral duty to reduce avoidable inequalities in health. It would be a dereliction of these
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APPENDIX 2: duties to pretend that the bulk of the actions to tackle obesity need to be confined to local levels. Upstream actions can be powerful, rapid, more effective in reducing inequalities and cost-saving. They need to be driven by central Government. We should not pretend otherwise.
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