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Volume 695: debated on Wednesday 17 October 2007

My Lords, with permission, I should like to repeat a Statement on obesity made in the other place by my right honourable friend the Secretary of State for Health. The Statement is as follows:

“The Chief Scientific Adviser and his Foresight team have today published the report, Tackling Obesities: Future Choices, which pulls together the latest evidence and expertise on this vital issue and seeks to answer the question: how can we deliver a sustainable response to obesity over the next 40 years? Foresight exists to challenge existing policy and this report is nothing if not challenging. The report predicts that, on current trends, by 2050, 60 per cent of men, 50 per cent of women and 26 per cent of children and young people will be obese. Incidents of type 2 diabetes are set to rise by 70 per cent; attacks of stroke by 30 per cent; and cases of coronary heart disease by 20 per cent. Obesity-related diseases will cost the nation an extra £45.5 billion a year.

“The implications for those individuals who are directly affected are profound. An obese young man who remains obese, as most are likely to do, will, on average, die 13 years younger than his peer group. However, this report is based on current trends. Our destiny need not be pre-ordained, and we can buck these trends provided that we are all prepared to take the necessary steps. Indeed, the work assembled for this project gives the UK a platform to become a global leader in tackling a problem that is challenging policy-makers across the world.

“In recent years, we have focused on child obesity. Sure Start children’s centres provide parents with high quality health advice in the crucial pre-school years. We now intend to start earlier still with the proposed nutritional grants for pregnant mothers. Over the past three years, the share of children on the school fruit and vegetable scheme who are eating five a day has increased from just over a quarter to just under a half. We have introduced tough new nutritional standards, are investing almost £100 million a year to improve school food and have added an entitlement to cooking lessons on the national curriculum. We have established the National Child Measurement Programme, which will provide the largest database of its kind in the world on children’s weight.

“In 2004, only half of all pupils did two hours of high-quality PE and sport every week; today it is 86 per cent. We are now raising our sights so that every child has the chance of five hours of sport every week, backed by a further £100 million of additional investment. Working with the Food Standards Agency and the food industry, we have introduced front of pack labelling. We have worked with Ofcom to prohibit during children’s programmes television advertising of foods which are high in fat, salt and sugar. This was a bold measure, but we are determined to go further if the evidence supports the need to do so. We will therefore be reviewing the impact of the restrictions on the nature and balance of food promotion to all children, across all media.

“The Foresight report endorses interventions such as these, but argues for an even bolder approach. The report says that although personal responsibility is a crucial determinant of our body weight, our environment also plays a vital role. The chilling reality is that modern life makes us overweight. As Sir David King said:

“We evolved in a world of relative food scarcity and hard physical work—now energy dense food is abundant and labour saving technologies abound”.

Modern transport systems, sedentary jobs and convenience food make life more comfortable, but also lie at the heart of this dilemma. In a sense, we are victims of our economic success. The pace of technological revolution outstrips human evolution. Tackling this problem calls for a fundamental shift in approach. Although the report projects us forward 50 years, it does of course require action today. And many of the areas identified in the report cannot be tackled successfully by the Government alone. I hope this report will trigger the national debate that is essential if we are to rise to the challenge.

“The report highlights the responsibilities of employers to look after their employees’ health, which is not just in the interests of their staff, but is also in the interests of the business: enhancing performance and improving productivity. The report also shows how small changes to everyday routines can make a real difference. Employers might look at providing loans for bikes, not just season tickets; subsidising gym membership, not just canteens—even putting out fruit at meetings, rather than biscuits. But the report also points to more substantial measures; for instance, with the built environment. Local authorities must ensure that healthy living is built into the infrastructure of our towns and cities so that planning systems improve our health and well-being.

“The report examines the availability of and exposure to obesogenic food and drinks. Front of pack labelling is now increasingly prevalent, but industry has yet fully to embrace the colour coding system. There is emerging evidence that the FSA’s labelling system is more effective at informing consumers and I want to work with the industry to see this adopted, but this report underlines the expectation for change. I have also asked the Food Standards Agency to conduct an immediate investigation into the use of trans-fats to examine whether there is more we should ask the food industry to do in this area.

“The report talks about the importance of targeted public health interventions. There are regional disparities in the prevalence of obesity and I hope that primary care trusts will look at what more can be done to help obese people to achieve sustainable reductions in their weight through advice and training in health consumption and activity. Underpinning all of this is an acknowledgment that the Government must do more. We will develop a comprehensive cross-government strategy on obesity to respond to the evidence in this report. Because of the need for concerted action on a number of fronts, I will convene a cross-government ministerial group to guide our approach. We will continue to focus particularly on children. Over 80 per cent of obese 10 to 14 year-olds remain obese into adulthood. As part of the spending review, we have already set our ambition to reverse the growth in obesity so that by 2020 we reduce the proportion of overweight and obese children to the levels of 2000.

“Ensuring that our health service is as focused on prevention as it is on treatment is already a priority, and obesity epitomises the need for that change. In the past, tackling obesity has always been regarded as a matter of personal willpower but, as this report starkly demonstrates, people in the UK are not more gluttonous than previous generations and individual action alone will not be sufficient.

“Obesity is a consequence of abundance, convenience and underlying biology. Solutions will not be found in exhortations for greater individual responsibility or in what the report calls the futility of isolated initiatives. Let us begin the national debate here in Parliament today and let us use this report to forge the consensus that will allow the UK to pioneer the new long-term integrated approach that this issue requires. I commend this Statement to the House”.

My Lords, that concludes the Statement.

My Lords, the House will be grateful to the Minister for repeating the Statement. My first reaction is that it is a Statement that contains more hope value than realism. We all appreciate that obesity is a societal problem, but government have a major role to play and the Government’s record on obesity is, frankly, not inspiring.

In 1999, they abandoned the targets set by the previous Conservative Government. Nothing then happened until 2004, when the PSA target was set following two scathing reports from the CMO and the Health Committee on the costs of obesity. Even then, it was a further two years before a letter went out in September 2006 admitting that the local delivery plans by strategic health authorities to tackle obesity had still not been finalised.

The target set in 2004 was to halt the year-on-year rise in obesity among children under 11 by 2010, yet the Government have repeatedly failed to provide figures to show whether or not progress has been made. The evidence we have suggests that we are moving in the wrong direction, and this latest Foresight report bears this out. The Government’s new target is therefore incredibly ambitious given that, up to now, they have not yet managed to stall obesity levels, let alone reverse them.

Their failure on that front is perhaps less surprising when looked at alongside the numbers of staff working in NHS public health. Those numbers, if we exclude consultants, have more than halved in the 10 years the Government have been in power. What plans are there to reverse that position, given that none of these initiatives can be rolled out without people to do the work on the ground?

On school sport, an enormous amount of hot air is being blasted out. In July the Prime Minister announced £100 million to give every child the chance of five hours sport every week. Yet it turns out that only two hours out of the five are going to be built into the school curriculum; the other three hours will have to be funded by community sports clubs. The amount of lottery money going into sport has fallen by 50 per cent since 1998, and we now know that the Olympics overspend will remove another £70 million. The pledges made in 2000 by Tony Blair to give £750 million to school sport and to create 30 sport action zones are so far just words; six years on, only half the money had been spent and only 12 action zones set up. So we have been here before. I ask the Minister: what is different now?

The Minister mentioned trans-fats. Does this announcement represent a change of policy from that set out by Caroline Flint in a Written Answer in January? After explaining that there was limited information on the amount of trans-fats in fast foods, she stated that the FSA had,

“no plans to carry out further analyses. Results from the National Diet and Nutrition Survey (2000-01) which looks at dietary intakes shows that intakes of trans fats are within maximum recommended intakes, whereas saturated fat intakes currently exceed public health recommendations. Consequently saturated fat intakes represent the greater…health risk and remain the priority for the Government”.—[Official Report, Commons, 23/1/07; col. 1762W.]

Is that statement still accurate?

On school food, the Government spent £66 million in two years on the school fruit and vegetable scheme, yet found that this had done nothing to encourage consumption of fruit and vegetables outside the scope of the scheme. In fact, consumption at home was reported as having gone down.

On food labelling, the FSA finally published proposals for a traffic light system in 2006. With all due respect to the noble Lord, Lord Krebs, who is in his place, that was 20 months after it was first asked to do so and the proposals were immediately rejected outright by six of the leading food manufacturers and retailers. When the White Paper was launched in 2004, we argued that it would be better to have a system linked to guideline daily amounts. The Government have now accepted that proposition, abandoning what they said in 2004, but so much time has gone by that we now have a situation in which competing systems of labelling, introduced by retailers and manufacturers, are well entrenched. It is therefore likely to be a considerable time before there is any resolution of the two differing approaches. Can the Minister give the House any idea of the timescale for that?

The words “hope” and “expect” rather jump from the page when one reads the Statement. If I can follow suit, I hope the Minister will use his personal influence to ensure that the messages from this significant report are translated into sustainable public health initiatives across the country.

My Lords, I too thank the noble Lord, Lord Darzi, for repeating the Statement. The Government are launching a new cross-departmental strategy for obesity—again. They did exactly that in 2004 as part of the public health White Paper. As the noble Earl, Lord Howe, intimated in his response, while the report is interesting and contains much that the House will wish to see followed up, it is an indictment of the Government’s lack of action on the recommendations made in 2004. Yet again we have an announcement of a strategy but no action plan.

Sir Derek Wanless, in his recent review of the 2004 report, has made clear that the Department of Health promised that when that report came out the CSR would address issues of lifestyle, and yet we see nothing specifically about that in the recent CSR. As a newspaper points out today, the Government have in fact changed the targets they agreed in 2004; as the noble Earl said, they have changed their targets on child obesity from 2010 to 2020.

The noble Earl is also right that since 1997 public health budgets have been raided to tackle deficits. Non-public health consultants and registrars have increased in the NHS by 60 per cent since 1997, but the number of public health consultants and registrars has gone down. I too wish to know what the department intends to do to reverse that trend so that there are enough informed officials working in public health to ensure that whatever strategy the Government finally decide to fund is implemented.

The Obesity Awareness and Solutions Trust has conducted some interesting research that reveals that 80 per cent of general practitioners believe that obesity is a patient’s own fault. That was echoed in August 2007 when Dr Hamish Meldrum from the BMA made his announcement that obese people were greedy. Those are strange statements when there is an increasing amount of research to show that obesity is caused by a combination of lack of knowledge about diet, mental health issues such as depression, and not just a lack of access to sports facilities but a lack of confidence to use those that are available. We know, for example, that many older people would like to take part in healthy activities but are frightened to go to sporting activities when there are going to be younger people around. They lack confidence.

Where are people who want to tackle these issues going to get their support from? Key to that are families and parents. In Scotland in 2007 some interesting research was produced that showed that children and toddlers who had poor diets did so not because of lack of knowledge—their mothers knew what constituted healthy food and a good diet—but because the mothers were concerned about their own cooking skills and did not know which healthy foods could be given to children to fill them up. They therefore tended to resort to foods that were not healthy.

Some of the issues that are identified in the Foresight report show that there are initiatives that are worth following up in a slightly different way from the department’s over the past few years. It signals that there is perhaps a different track from the one which the department has gone down in encouraging weight programmes for children in schools and programmes of “naming and shaming” obese children, programmes that have faltered in their efficacy because of resistance and resentment on the part of the very people who would benefit from them.

The noble Earl, Lord Howe, mentioned the role of employers. We all agree that employers have a role to play. British industry is becoming aware of the costs to it of obesity. Schemes such as BT’s Work Fit scheme are good. How are we going to encourage employers to introduce them? Bariatric, or gastric by-pass, surgery is known to be effective in addressing diabetes. It is a NICE-approved clinical intervention; PCTs are legally obliged to fund it. However, there is a backlog of 60,000 people who are waiting for the procedure. What is the department’s attitude to that issue? Like the noble Earl, Lord Howe, I am pleased to see that another strategy exists. I hope that the noble Lord, Lord Darzi, will tell us when it will be backed up by resources and action.

My Lords, I thank the noble Earl, Lord Howe, and the noble Baroness, Lady Barker, for their responses to the Statement. The points and issues that they raised highlight the challenge posed by the problem of obesity. As the noble Baroness pointed out, it is a challenge not just to an individual but to their family, their community and society.

I want to cover some of the points raised first by addressing the issue of staffing in public health, and then I shall certainly come back to the issue of public health budgets. It is important to appreciate that the enlarged number of staff performing public health duties in the NHS and social care are, rightly or wrongly, not formally coded in our workforce; that includes health visitors, school nurses, general practitioners and other professionals who make a vital contribution to public health. The number of nurses in primary care in community settings has increased by about 40 per cent since 1997, with a 10 per cent increase in public health consultants between 1997 and 2006. Whether that is adequate to meet some of the challenges referred to in the Foresight report remains to be addressed.

The report is a challenge to all of us. I am grateful to the noble Earl, Lord Howe, for his ideas and suggestions, which have been very much at the forefront of the recommendations. We have made great progress in breaking down some of the targets in school sports and setting out the standards for school food. I know from my experience of schools in my own environment that changing the content of school meals has been received unfavourably because most kids do not like what we put in front of them. That is a cultural challenge that we need to deal with.

Primary care trusts were certainly notified of their revenue allocations for 2006-07 and 2007-08 in February 2005. The allocations separately identified funding to support the initiative set out in the White Paper, Choosing Health: Making Healthy Choices Easier. The PCTs need to determine how to use the funds allocated to them in commissioning services and meeting the healthcare needs of their local population. The balance between so-called national targets and locally decided priorities should be in favour of the latter. Although we have received a number of representations about ring-fenced funding, our position remains that the National Health Service must be free to make its own local spending decisions while we monitor their outcomes.

That does not represent a less ambitious commitment—far from it. Our new ambition is bolder and recognises the need to go further and faster. It focuses on healthy weight, which allows us to tackle overweight as well as obesity. It also has more emphasis on overweight and obesity in the broader population while maintaining our priority focus on children. It also reflects the recognition of the need for long-term commitments, with joined-up action across Whitehall and society more widely.

The noble Baroness, Lady Barker, raised the issue of bariatric surgery, an area in which I have practised and been involved in introducing keyhole surgery. The threshold in the acceptance of patients has significantly reduced. When I sit with my patients to counsel them about surgery, I always tell them that it is the last resort. Prevention is better than cure and we need to concentrate on efforts in targeting the populations at the highest risk. I wish to see that, rather than more patients referred to bariatric surgery. The market-driven forces across the pond in the United States has driven up bariatric surgery significantly, with growth rates of about 400 per cent, but I would not consider that an example of good practice.

My Lords, does my noble friend accept that there is a very real and wider problem which we all have to address in society and which he has put in very good context? As he has touched on, it goes right through society and includes all parties. One of the most important aspects in my judgment has been that in the past 50 years there has been a dramatic increase in home entertainment, with television and computers. Prior to that, children played outside, normally. It is activity, not just food intake, that we should think about in this context—but it is not easy for parents to pull the plug on home entertainment. That is why there needs to be a much wider debate. The business of children being inside much more has implications both for obesity and for the way in which communities develop and maintain community links.

My Lords, I agree with the noble Lord in some of his suggestions on sports activities and the entertainment provided by the media, which preoccupies the whole household and not just children. It is an issue that I have no doubt we need to address in partnership with the media and other TV providers. There is some early evidence to suggest that some of them could, if they were structured in the right way, enhance playing and exercise activities. In other words, the media could spread good practice rather than just providing something to watch, which most of us have been concerned about as parents.

My Lords, the playing fields to which the noble Baroness refers have been a priority for this Government; we now enjoy better than ever protection through government planning in regulations and in arrangements established by the DfES. Fifteen new playing fields were created last year, and £387 million was invested in 636 new and improved indoor and outdoor facilities in 2004-05. This is an extremely important issue and the Government are committed to increasing swimming and playing-field activities related to this challenging problem.

My Lords, I very much welcome the Foresight report and the Minister’s response to it. However, as the noble Earl, Lord Howe, has already said, this is not a new issue. Indeed, as the British Heart Foundation said in its press release, each time the matter of obesity is raised, the Government have pressed the snooze button, turned over and gone back to sleep.

I have two questions. First, does the Minister accept that many of the actions taken so far are either tinkering at the edges or not based on sound evidence? For instance, the changes introduced to school meals have resulted in a reduction in the uptake of school meals of about 17 per cent. The front-of-pack labelling, to which noble Lords have referred, is a voluntary action and will not be accepted by the industry as a whole. As the noble Earl, Lord Howe, said, different parts of the food industry are adopting different labelling schemes, confusing the consuming public.

Secondly, does the Minister accept that unless the Government are prepared to take firmer action, which will involve regulation, the issue of obesity will not be effectively tackled?

My Lords, I thank the noble Lord for his comments. I accept that the Government could do more, and that is one of the main drivers of our next-stage review. Certainly, the staying healthy agenda is one major theme in the nine strategic health authorities. I have set them the priority of coming up with the best pathways and models of care to tackle this challenging issue of obesity. That will be evidence based, but I come back to the Foresight report, which is extremely nutritious in its evidence base of the challenges facing us and what to do about them. As I said, the 17 per cent reduction in the uptake of meals and the change in the nutrition and types of food that we are presenting is a cultural issue that we need to work on.

As for changing the voluntary scheme into a mandatory one, the challenge there is that it will probably have to go through the EU. If a case could be made for doing that in the next few years, I have no doubt that it would impact not just on childhood obesity but on adult obesity as well.

My Lords, I should like to press the Minister a little on food labelling. We know that voluntary front-of-pack labelling is not really working. We also know that many people buy pre-prepared food from outlets which do not label at all. I doubt that the noble Lord needs to go up Victoria Street to buy himself a sandwich, but were he to do so he would have no idea of the content and nutritional value or the number of calories in what he bought at many pre-prepared food shops. Will the Government consider extending mandatory food labelling across all food outlets? In reflecting on the lack of take-up of more nutritious school meals, will the noble Lord consider expanding the role of the school nurse to become an individual nutrition counsellor for children who are severely overweight or obese?

My Lords, the noble Baroness brings up one of the priorities in the Foresight report, which is to look at labelling more carefully. I remind the House that we lead on food labelling globally. We should be proud of that, but we could do better. We will work with the Food Standards Agency and the food industry—it needs to be a partnership—to introduce front-of-pack labelling that makes it simpler for families to make healthier food choices. Our preferred model, developed by the Food Standards Agency, is based on the traffic light system, which consumers find easy to understand. This has already been adopted by many major retailers and manufacturers such as Sainsbury’s, Marks and Spencer and Waitrose. A rival scheme, based on the guideline daily amounts, was touched on by the noble Earl, Lord Howe, and is used by a number of other manufacturers and retailers such as Asda and Tesco. We believe that the GDA model is confusing to consumers, particularly those with poor numeracy skills. Last month Defra launched its Year of Food and Farming education programme which aims to give young people direct experience of the food chain to encourage healthy eating. We can do more. I agree that we need more evidence and that we need to monitor the progress of food labelling and its impact on the uptake of children and their families.

My Lords, does my noble friend agree that there is a good deal of conflicting advice on—if I can put it like this—the relationship between calories-in and calories-out, and that people are not certain what sort of exercise, or how much exercise, is appropriate or necessary to maintain a healthy weight and general health? Do the Government intend to look at the issue and provide standardised information to which people can reliably refer for help in determining what kind of exercise is appropriate in order properly to use up the calories that they have ingested?

My Lords, my noble friend raises the very challenging issue of calories-in versus calories-out. The difficulty with that scheme is that it all depends on the size of the engine. The basal metabolic rates of biological beings are very different and this will remain a challenging problem. My advice would be to have a personalised exercise scheme to fit the individual’s age, weight and cardiovascular status.

My Lords, I am too fat—I use that word deliberately, rather than obese, because the word obese is a euphemism—because I eat too much and because I follow the advice of Oscar Wilde on exercise, which is that whenever I feel the need for it I lie down and let it pass. Fatness is an extremely simple problem; if you eat too much and do not take enough exercise you get fat. The more we faff about with enormous reports, the more that message gets lost. That message alone must get across, about people not eating so much and taking more exercise. If I obey my wife and do not eat great chunks of butter on my bread, my waistline will go down by four inches. I should also walk rather than drive to the station.

My Lords, the noble Earl makes an extremely important contribution, and I have no doubt that the Government would be extremely successful if we could disseminate his sage advice.

My Lords, I declare an interest as chairman of the All-Party Group on Lighter Evenings Experiment. I usually do not speak on this subject but we have been lobbied by school heads up and down the country, including the northern part of the country, that an extra hour of daylight would allow children to boot a ball about before going down to the chip shop and slumping in front of the television. It is all very well all three parties saying that we have to take exercise, but are we to take exercise in the dark? Will the Minister do a survey of all school heads on this subject, asking whether they would prefer lighter evenings for exercise, which they all want and advocate?

My Lords, much emphasis has been put on labelling, which is fine, even if it is complicated. But following on from the question asked by the noble Baroness, Lady Falkner, does the Minister have any indication how much food is consumed outside the home where you have no indication of the calories or the fat and salt content? How many noble Lords know that if you go to the local coffee bar and order a large cappuccino and a muffin, you are taking in up to 30 per cent of your recommended daily allowance? Secondly, the noble Lord mentioned that a cross-government strategy on obesity will be introduced. Why not a cross-party strategy on obesity? Not all the knowledge and wisdom on this issue is in the Government. Thirdly, perhaps the Minister should start at home—not in his home, but here—and put labels on the food in the Bishops’ Bar.

My Lords, I am grateful for those questions, particularly as they relate to the educational challenge that we need to pursue. The challenge is not only for children but also for families. Beside the school heads, it is families that we must tackle if we are to achieve change. I strongly welcome cross-party support for such a strategy because this is one of the major challenges facing the NHS, as I said in the Statement. The cost of this is astronomical, somewhere around £45.5 billion a year by 2020. It all starts at home, whether home is the House of Lords, the local school or the family home; we need to start thinking about looking before eating.

My Lords, in view of the serious situation revealed by the Foresight report, will the Government put—among what I hope will be a raft of other measures across government—increased pressure on Ofcom to end broadcast advertising, not only to children but to everyone, of foods that are high in sugar and fat? Following the point made by the noble Lord, Lord Krebs, are the Government ready to introduce early regulations if such advertising continues?

My Lords, I am grateful to my noble friend. One of the Government’s boldest actions with regard to Ofcom, which regulates the broadcast industry, was to restrict food and drink advertising to children. Current legislation provides that the advertising industry is not allowed to target TV ads for foods high in fat, salt and sugar—the so-called HFSS foods—on programmes that appeal to children under 16. I strongly believe that it is a very positive move. However, as my noble friend says, we can certainly do more. As thousands of youngsters watch shows such as “The X Factor” in adult airtime, we need to look at other measures as well.

My Lords, first, I urge the Minister to accept the generous offer of the noble Earl, Lord Onslow, to act as exhibit 1 in school lectures on this topic. On a more serious note, the Minister has given us a frightening figure for the cost of obesity and said that, for example, people who are obese will die 12 years earlier. Does the figure therefore take into account the fact that the Government will save 12 years of state pension and 12 years of care? Does it also take into account the fact that since we all have to die of something, if people do not die of obesity, they may well have another serious illness such as cancer or Alzheimer’s which would cost the state the same amount? Or does it merely measure the cost of obesity without in any way paying attention to the savings?

My Lords, the noble Viscount makes an important point which, as a practising clinician, I find challenging. I have spent all of my career trying to prolong life.

My Lords, when we heard this Statement, for once we had an admission that this matter is not dealt with by one department of state but goes across government. However, a department of state will have to take the lead. Are there any plans to enable, for instance, the Department of Health to tell planners that they must make it possible for people to take recreational activity easily? Will the department at any point be able to say to the education department: “You are getting it wrong. Can we have not only more school sport but a strategy that allows people easily to transfer to adult sport.”? We have not even started to tackle that.

My Lords, the noble Lord has made a statement about the importance of cross-government working, and I strongly suggest that there should be cross-government accountability on this issue. The Department of Health has a serious contribution to make. But if it leads on this without the accountability of other government departments, we will not excel at the speed that the Foresight report suggests.

My Lords, does the Minister agree that as something like 50 to 60 per cent of children are registered with NHS dentists, the dental profession could have an important role to play in offering nutritional advice, not only to avoid dental decay but to help avoid obesity? Will he review the provision of UDAs—units of dental activity—for preventive advice on dental and general health?

My Lords, the noble Lord highlights ways in which we can engage children and adults through advice on how to improve their diets. Dentistry could play a significant role, and I would be more than happy to look at the UDA figures he referred to. In addition to dentistry, pharmacists and all other allied professionals in healthcare provision could play a more significant role.

My Lords, it should have been obvious to the Government that the take-up of healthy school dinners would drop, because children hate anything new and unfamiliar. There is only one way of ensuring that they eat healthy school dinners, and that is to prevent their bringing unhealthy packed lunches to school or going out and buying chips and Mars bars in the lunch hour. When they are really hungry, they will eat the school dinners. We all did when we were children and there was no choice.

My Lords, I am grateful for the noble Lady’s contribution. I feel that a balance has to be struck between what we, sitting here in government, can push kids to do and what families and schools can contribute in taking some of the noble Lady’s advice.