Health: Obesity

Lord McColl of Dulwich Excerpts

Monday 4th April 2011 Grand Committee

Asked By

[Lord McColl of Dulwich]

To ask Her Majesty’s Government what steps they are taking to reduce obesity in the United Kingdom.

[Lord McColl of Dulwich]

My Lords, the purpose of this debate is to draw attention to the most serious epidemic to affect many parts of the world. The obesity epidemic will soon involve half the population of this country. It is killing millions of people, costing billions of pounds and the cure is free: eat less and live. The results of obesity cause great distress and suffering and include cancer, arthritis—which often needs joint replacements—and type 2 diabetes, which leads to blindness, loss of limbs, heart attacks, strokes and very much more disability.

The best measure of obesity is the body mass index, BMI, which is the weight in kilograms divided by the square of the height in metres. In terms of body mass index, 20 to 25 is healthy, 25 to 30 is overweight, above 30 is obese and over 40 is morbidly obese.

How is it that intelligent, well meaning leaders of this country have allowed themselves to be hoodwinked into believing the false information about obesity that it is all to do with a balance between the calories that we eat and the exercise that we take? Of course, they have been aided and abetted by NICE—or, under its more recent name, the National Institute for Health and Clinical Excellence. In its document on obesity of January 2010, NICE stated:

“A person needs to be in ‘energy balance’ to maintain a healthy weight – that is, their energy intake (from food) should not exceed the energy expended through … exercise”.

There is its crucial mistake, because the real balance is between calorie intake and the total expenditure of energy in the body.

The simple fact is that only 20 per cent of the calories we eat or drink are used up in exercise, which means that diet is five times more important than exercise in controlling weight. Put another way, if we were successful in doing something which has never been achieved before—namely, getting the population to double the amount of exercise that they do in a day—it would increase energy expenditure only by 20 per cent. If, on the other hand, every plate of food was reduced by half, this would reduce the calorie intake by half.

We have to run 17 miles in order to reduce our weight by one pound of fat. Bearing in mind that as little as 20 per cent of the calories we eat or drink is used up in exercise, where does the remaining 80 per cent of the energy go? It is consumed by numerous activities over which we have no control: the heart beats 2.5 billion times in a lifetime, the kidneys filter 4.5 metric tonnes of blood and there are a myriad of activities in other organs of the body such as the liver, the pancreas, the bones and the alimentary tract. As regards those who believe that the energy from food is all used up in exercise, where do they imagine the energy comes from to run the heart, liver, pancreas, brain and so on? Perhaps they imagine that they run on air—perhaps hot air.

The sad thing is that there are politicians in all parties and people in many well meaning organisations who have also been misled. Most of their publications have adopted the mantra that exercise and diet are the solution to obesity but few, if any, emphasise that diet is five times more important than exercise. Politicians persist in believing that the issue is about having a balance between diet and exercise because that is what the quango NICE says in its publications.

When one examines what NICE published in January 2010, one sees that it recommends exercise and diet on seven pages and on three other pages it puts it the other way round, as diet and exercise. Nowhere does it state that reducing calorie intake is much more important and effective in reducing weight. On page 21, it recommends that obese adults should take more exercise even if it does not lead to weight loss. If treatment is not working, why not try another treatment such as eating less, which is five times more effective? But perhaps the most impractical advice in this paper was that people who have lost weight may need to do an hour and a half of exercise a day to avoid regaining weight. I must say that I would have been very disappointed if any of my medical students had produced a document such as this. But there is good news. I went to see the director of NICE, who has now admitted that the institute got it wrong. I look forward to politicians accepting this new advice that diet is five times more important than exercise.

Why are people willing to turn a blind eye to this problem while millions of people suffer as a result? By saying that taking exercise is the answer, we avoid upsetting the millions of obese people whose excessive weight often prevents them exercising and we give them a good excuse to stay as they are. We deceive them by avoiding the heart of the matter which is that we need to eat less. Of course, those in the food industry are delighted to hear that lack of exercise and sports facilities are to blame for the obesity epidemic as that lets them off the hook.

I have been asked not to be negative about exercise because all the political parties have been campaigning to increase activity and they do not want this momentum to be torpedoed. I understand that. I would never be negative about exercise because it is of great importance for the integrity of the heart and the control of the wrong sort of cholesterol. Exercise also gives a sense of well-being and high morale, but that does not alter the fact that what we eat is five times more important than exercise when we are dealing with weight control.

The subject of obesity is beset with a number of red herrings. Many people believe that obesity is due to genetics, hormones, brown fat, psychological factors, sexual abuse and so on. These factors may help to explain why people eat too much but they are certainly not the cause of obesity. Those factors were around during the war when food was rationed but there was no obesity then, apart from those miscreants who were indulging on the black market.

Over the years, I have had many obese patients who have assured me that they eat very little and sometimes they were speaking the truth. Their obesity was due to their alcohol intake. Noble Lords will perhaps know that three cocktails such as mai tai will contain 1,000 calories. That is another hazard for the unwary.

There is a good deal of confusion about childhood obesity, which is now a very serious problem and getting worse. The organisation Change4Life has estimated that there are 1 million obese children under 16 in the UK, and around the world there are 2 million children under five who are overweight. We are beginning to see earlier and earlier the complications of obesity in these children, such as type 2 diabetes, heart disease, high blood pressure and cancer.

Again we are bedevilled by the obsession that exercise is the solution, but reliable long-term scientific research clearly shows that overeating is responsible and that it starts in the first five years of life. There was a misleading article in the Daily Telegraph on 8 November 2010 headed, “Exercise, not diet, key to obesity”. This was based on a Norwegian study which was fundamentally flawed. However, the same article mentioned the reliable work of Professor John Speakman of the University of Aberdeen, who presented unique data using state-of- the-art technology. He found that rising obesity levels were due to increasingly excessive food intake. The overall physical activity levels have been constant over the past 25 years while weight levels have soared due to the greatly increased calorie intake.

Professor TJ Wilkin of the Peninsula medical school has carried out a unique study, published in Archives of Disease in Childhood in 2009, that included annual measurements of physical activity and body composition over 12 years. This shows that obesity leads to inactivity, but inactivity does not lead to obesity. Furthermore it concluded that the pathway to obesity seems to be,

“set early in life, long before school age”.

This questions the rhetoric around school meals, computer screens, PE time, playing fields and physical activity, which, of course, is unstructured in early childhood. A recent meta-analysis incorporating 15 reports on over 13,000 children concluded that a nine year-old child subjected to intense pressure for 18 months would lose on average just three ounces, or 80 grams.

The obesity epidemic is killing millions, costing billions and the cure is free. Will Her Majesty’s Government embrace the essential fact that reducing food intake is five times more effective than exercise?

[Lord Addington]

My Lords, the noble Lord, Lord McColl, is consistent. I remember that we have crossed swords on this subject several times. The idea that exercise is a bad way of controlling weight is odd because fundamentally it misses the point. Exercise may make you gain weight. If you take exercise that uses muscle—for instance, my own sport of rugby union or rowing—you will get bigger. If you take these exercises your body will become more dense and solid; if you run, your body will become more solid and you will add extra muscle. The old adage is that if you go to the butchers and ask for a pound of fat and a pound of muscle you will discover which is the smaller unit—it is just there.

We can jump around here but the idea is that you are carrying too much fat. The body mass index is probably the worst measure of obesity and fitness because it throws up the anomaly of the sportsman emerging as the person who is going to die tomorrow. According to the body mass index, I did not make it to 30; neither did anyone else who played my sport at any level; and when Pinsent and Redgrave won their last combined gold medal they were heavily overweight and just missed being obese. These men are six foot five, so you can see how bad it is.

I am aware that I have an inferior medical knowledge but burning fat is probably the worst way to judge the way in which you use calories in exercise—I know I am sticking my neck out in saying this—because you burn up the calories when your body repairs the muscles, over a longer period of time, after exercise has put up your metabolism. This is fundamentally what your body does and different types of exercise will burn it at different rates.

It is also true that you have to take account of the number of calories going in and the number going out. If you live a sedentary life, it is absolutely obvious that you do not need extra calories. Exercise burns up calories, basically by rebuilding, reconditioning or changing muscle. You might burn off 15 calories by keeping fit in the gym but if, for example, you lift weights, you will burn off far more calories by rebuilding your muscles afterwards. However, if you are heavily overweight and eat far too much or eat the wrong thing sat in front of a TV screen, you are going to get heavier.

The fact is that, if we do not take exercise and we sit in front of a TV screen, the vast majority of us will eat or drink cups of tea laced with sugar. The same point applies to sugar in tea as it does to sugar in alcohol. If we spend a great deal of time being sedentary, most of us will consume calories at the same time. Many of us do not have the will-power to sit still for hours doing nothing without consuming calories. We live in a society where these no-need-to-cook, at-your-fingertips calories are easily available: you go to a supermarket and, after you have been good and bought the things that you have to cook, you buy lots of things that you do not have to cook. That is one of the barriers that we face.

How do we try to bring about a balance? The Government’s responsibility deal is a way forward, and I hope that we can get a bit more out of that than we have from some of the other schemes that we have had in the past. Primarily, we are not asking everyone to stop eating convenience foods, but we are trying to make those convenience foods potentially less lethal. However, how this will work, I do not know. Improvements have been made but are they happening quickly enough? There is no silver bullet. The previous Government tried hard to tackle the problem. They made people look at the problem but people still tend to be getting heavier, so which combination is right?

Total abstemiousness may be desirable but it is not something that we follow. Let us face it: we would not have to maintain sports grounds if we all did. Fast food is available to us and it has always been a part of our culture. History shows us that fish and chip shops and pie shops have always been there. All the things we like, such as salt and fat, are available and they give us a nice hit. We have to take that on board and try to educate people further. If people like these types of snacks, we have to try to make them less fatty.

Exercise plays a very important part for many people. If you are active and a reasonably keen amateur sportsman, then, apart from anything else, you are probably going to take slightly better care of yourself. Why would you not do so? Even if you only want to get from the third to the second team in your particular sport, then losing a couple of pounds and eating slightly better may have a part to play in that. When you are playing or running around training one, two or three nights a week, you are not sitting on your behind in front of a TV screen or in the pub. We must look at the issue in the round. The incentive to control your diet is increased by exercise. If you do not eat a great deal and are not carrying an extra few pounds of fairly soft tissue or fat, then, even if you just want to walk gently up a hill on a Sunday, it will be easier and more fun. Everyone enjoys the view more when they are not gasping for breath at the end of their walk and do not have incredible pain in their muscles. That is a fact.

I repeat: we have to look at things in the round. Physical activity and access to physical activity will help, if only as an incentive to eat better. Unless we make sure that that there are incentives to take part in social and physical activity and to think about the foods that we eat and the amount we eat, we are going to miss our targets. Let us make sure that, when we talk about diet, we talk about it in terms not just of consumption of calories but of the correct cycle of calories for activity.

I leave noble Lords with this. Everybody is gobsmacked by professional athletes—not by the amount they train but by the amount they eat. An Olympic gold medallist—I think it was Phelps in the last Olympics—said that he had to eat 4,000 calories a day. That is eight gold medals-worth of burgers. It means that people can actually eat a great deal and be very fit and healthy. I suggest that we need to look at this in the round and not get obsessed by any one activity.

[Lord McColl of Dulwich]

Before the noble Lord sits down, would he recognise that I did not actually run down exercise? I specifically said it was a good thing. Also, how does he explain the scientific fact that only one-fifth of the calories we eat are expended in exercise?

[Lord Addington]

My Lords, quite simply, if it is expended in exercise, it is not expended in the rebuilding of muscle. Rebuilding muscle is an important part of exercise—not the actual taking of exercise.

NHS: Global Health

Lord McColl of Dulwich Excerpts

Monday 20th December 2010 Lords Chamber

[Lord McColl of Dulwich]

My Lords, I, too, congratulate the noble Lord, Lord Crisp, on initiating this debate, and I admire the outstanding work that he has been doing on this vital subject. His natural modesty precludes him detailing his extensive work. He is, in fact, joint chairman of the Global Health Workforce Alliance, which is giving a new impetus to the subject nationally and internationally. His report, entitled Global Health Partnerships, graciously gives credit to the many initiatives in this field, especially to THET, which was set up by that pioneer Professor Eldryd Parry.

Medical students have for years spent several months of their clinical training working in developing countries and gaining valuable insight into global medicine. King’s, Guy's, St Thomas's, St. George's and UCL are already running courses on the subject. A great deal is going on, but much more could be done. We can encourage more partnerships to be set up between medical schools in the UK and developing countries, for instance the new medical schools in Ethiopia. The medical schools and hospitals here need to make it easier for our graduates to go to those countries for longer periods, not only to enjoy invaluable new clinical experiences but to help medical students abroad to achieve their goals. They can increase their help to the medical students out there by demonstrating physical signs, new ways of teaching, how to get the best out of their libraries, data collection and so on.

There is unprecedented interest among medical students in helping to develop this field, and good organisations are at work, as outlined by the noble Lord, Lord Crisp. The Royal College of Obstetricians and Gynaecologists recently drew attention to the need for the NHS to help to plan the work abroad of junior doctors. In Guy’s Hospital in 1972 we set up a comprehensive surgical training programme involving a large part of the south-east of England. One of the years of the seven-year programme had to be spent abroad, and that proved very popular.

With the hospital ship part of the charity Mercy Ships, we not only provide free surgical treatment to the poorest of the poor but we teach the local surgeons the kind of operations that are appropriate in their country given their available resources. For instance, in Togo this year three Togolese eye surgeons were taught the best way of removing cataracts without the need for the expensive equipment that is used in the West and cannot be afforded in Africa. Now one surgeon is at work in the north of Togo, one in the south and one in between, so they cover the whole country.

An example of the excellent work done by many of the doctors in global health is a junior trainee at Guy’s Hospital called Abigail Boys. She works for Mercy Ships intermittently and has done so for the past six years. She came across a 13 year-old girl in Ghana whose tumour of her face was too complicated for Mercy Ships to cope with, so she raised thousands of pounds to bring her to the Royal London Hospital, where she had an amazing 11-hour operation, which was carried out successfully by the distinguished surgeon Iain Hutchison, whose wife enhances the Benches opposite. So long as our future surgeons are going to be like this young lady Abigail Boys, who is so passionate about helping the developing world, we can look forward to an ever-increasing participation in global medicine.

Healthcare

Lord McColl of Dulwich Excerpts

Thursday 28th October 2010 Lords Chamber

[Lord McColl of Dulwich]

My Lords, I, too, thank the noble Lord for introducing this important debate, especially as it emphasises the importance of the individual taking charge of his or her own health. This is crucial, as the present obesity epidemic will kill millions, and half the population will be obese within 20 years.

There has been a great emphasis on exercise as the answer to obesity and, indeed, exercise is very important in maintaining our health. Muscular activity is good for the muscles themselves, good for our bones and good for the heart. It promotes optimal levels of cholesterol, enhances morale and gives us a sense of proportion. Of the calories we consume, 75 per cent are burnt up by the organs of the body such as heart, liver, kidneys, brain, pancreas and so on, but we have no control over that. We can control muscular activity but, unfortunately, muscular activity consumes only 25 per cent of the calories we eat and drink. If we wish to take off a pound of weight through exercise, we have to run a mile. The problem for obese people is that it is difficult for them to exercise. The answer to the obesity epidemic lies in diet. What and how much we eat have a far greater impact than exercise.

It has been assumed that inactivity leads to obesity but it is quite likely that it is the obesity that results in inactivity. Professor Terence Wilkin has been following the same cohort of children over 11 years. He found that, at least in children, inactivity does not lead to fatness, while fatness does lead to inactivity. It is very unfortunate that politicians have been misled by NICE into believing that our weight is determined by a balance between exercise and what we eat. It is simply not true. It gives the false impression that exercise and what we eat are equal contributors to body weight, whereas the evidence proves that what we eat has a far greater influence on our weight than exercise.

Clearly, there are many contributory factors leading to obesity, such as genetic background, thyroid failure, big bones, fluid retention, psychological factors, sexual abuse and so on. However, at the end of the day we are what we eat. I was brought up in the war when food rationing meant there were no obese people apart from those on the black market. At the beginning of the war, one third of the people were either underfed or fed on the wrong food. Rationing cured that almost overnight. It was the greatest and most successful public health experiment of all time.

What can the Government do to reduce the death rates from obesity and protect the NHS from being overwhelmed by the increasing deluge of patients with diseases resulting from obesity? The first thing that would help would be for the Government to tell their members to start giving a clear signal to the public that the real answer to obesity is to reduce the quantity of food they eat to healthy levels. The second thing is to point out that, although exercise is good for the heart and ideal cholesterol levels, it plays a small part—25 per cent—in dealing with obesity. This would reassure the army of obese people that they can take control of the situation by eating less, and then beginning to take reasonable exercise when their bodies have reached a manageable size. Thirdly, the Government could encourage the food industry to increase traffic light indicators on food it sells in order to reduce the amount of junk food. The fourth thing is a much greater drive in schools, ensuring that children and young people understand that eating sensibly will stop them dying at an early age.

The government action against smoking was very successful, but the death rate from the obesity epidemic will prove much greater than that from smoking. Time is running out. Will the Government act now?