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Health: Obesity

Volume 726: debated on Monday 4 April 2011

Question for Short Debate

Asked By

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

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?

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.

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?

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.

My Lords, you cannot really find fault with the logic of the noble Lord, Lord McColl—do not eat and you will not put on weight. The problem is that for most of us, if you mention food we want to eat. I am going to focus on strategy, but I cannot find fault in his logic.

The noble Lord has already referred to the fact that obesity is recognised as a major public health problem and that it may well be getting worse. A policy review of several countries, including the United Kingdom, finds common themes. All express concern at the prevalence of obesity, thought to be the result of over-consumption of energy-dense foods and inadequate levels of physical activity. Few countries have specific strategies; instead, obesity is tackled through separate policies of nutrition and physical activity. Policies often in general terms identify sets of actions without any firm commitments—often interventions that focus on schools, workplace and active transport. What is noticeable is the absence, almost, of fiscal and legislative interventions from policies; neither are the policies funded. The interventions are poorly supported by research or evidence. The proposed measurement of the effectiveness of policies is weak and not clearly formulated. The strategy to tackle the so-called “tsunami of obesity”, which threatens several countries in the world, is largely concerned with options for ways to develop policies rather than a set of interventions to reduce obesity.

We have known about the associations of obesity and disease, and the noble Lord, Lord McColl, mentioned some of them. There are some 17 different diseases that we know of that have associations with obesity, costing the health service in England in the region of £4 billion—costs that will exceed health costs due to tobacco and alcohol use. The joint report in January 2011 of the Academy of Medical Sciences and the Royal Society of Edinburgh—and I declare an interest as a fellow of both—made some key recommendations on diabetes and obesity that have implications for policy research and management of patients with obesity and diabetes at individual and population level.

Obesity, as everybody understands, is a condition characterised by an individual having excess body fat caused by higher energy intake than expenditure. Excess energy is stored in the form of adipose tissue. Statistics have already been mentioned and are clear: 25 per cent of the adult population is obese and 65 per cent may well be overweight, while 23 per cent of children at reception in school are obese or overweight and 33 per cent of 10 to 11 year-olds are obese or overweight. Those are important findings from the child measurement studies. The pester power of children and the pushing of calorific foods to children by shops contributes to this. A well-known politician reportedly asked:

“As Britain faces an obesity crisis, why does WH Smith's promote half-price Chocolate Oranges at its checkouts instead of real oranges?”

When he said that, he was much applauded by the population and by the citizens. The politician was David Cameron.

I turn to the current Government’s strategy, or what it might be. We await the publication. The public health White Paper suggests that the Government will take a holistic approach with emphasis on personal responsibility and choice, but they will be reluctant to use regulation or legislation. The focus will be on voluntary agreements with industry through public health responsibility deals. Interventions are likely to be based on strong evidence, but there is not enough strong evidence, especially as NICE is asked to put the obesity interventions review on hold. There are suggestions that the Government will use the famous “ladder of interventions”, beginning with the least intrusive—information, education and so on—but regulation of industry or individuals will be used only if the initial steps of the ladder do not work. That is the well known nudge theory which involves no regulation, prompted choice and co-operation with the private sector, and it will be subject to strict post hoc evaluation.

I ask the Minister: what is the evidence that the nudge theory will work? What is the roadmap to evaluation? What measurements will be used and who will carry them out? A major plank of the policy is the responsibility deal. Who will lead that responsibility deal? Who will be responsible for it? Could the noble Earl comment on the reports that several charities and consumer organisations have withdrawn, seeing it as industry influencing consumers rather than reforming their business practices?

I hope that the Government will take on board in their strategy several issues that have some evidence as to their effectiveness. They are such simple things as a front-of-pack colour-coded labelling scheme for foodstuffs; a ban on advertising on television before 9 pm of food that is high in fat, sugar or salt; a continuation of the national child measurement programme; information on calorie content on all products; a commitment from local authorities to provide, to protect and to maintain the environment that will enhance physical activity; promotion of research into psychology and anthropology of behavioural change; cost effectiveness of interventions; and, lastly, a ban on trans-fats in all foods, as I have said before. Strategies that demonstrate reduction in childhood obesity are key indicators of success and, therefore, the childhood measurement programme should be continued.

My Lords, I would like to intervene briefly to express some marginally politically incorrect sentiments, because I share concerns expressed by Members of the Committee about the scale of the problem of obesity nationally, which I think is huge.

Perhaps the noble Lord will forgive me, but we were not notified that he had his name on the speaking list.

I am afraid that there is; this is a timed debate. However, as one of the speakers has scratched, the noble Lord can speak for four minutes in the gap.

I intend to intervene only briefly. I support the noble Lord, Lord McColl, and congratulate him on introducing this debate. His speech is worthy of passing around our friends and colleagues because it would have made a very good after-dinner speech. Although it was amusing, it dealt with an extremely serious subject.

My noble friend Lord Patel raised the issue of calorific information on food products sold in stores and particularly in restaurants. The other week I went into a Harvester restaurant which I had never been into before. I noticed that every item on the menu had its calorific content in bold lettering, so much so that I cannot believe that people who eat in those restaurants are not aware of and do not take into account the calorific content when they order their food. I am told that in parts of the world, particularly in America, the authorities in some cities insist on calorific information being provided on all menus in restaurants.

I wonder why we cannot do something similar here in the United Kingdom. I know that the Government are not over-wedded to the principle of too much regulation, but when so much is at stake arising out of problems of obesity and their consequences for health service expenditure, why can we not grasp the nettle in this area and introduce a regulatory framework for food manufacturers whereby the general public really do have to sit down and consider what they eat daily? If we were to do that, I believe that it would certainly have some consequence for obesity.

I return to being slightly politically incorrect. There is another problem as well. Families are often simply not prepared to raise the issue internally. There is an embarrassment about fatness. People just do not want to talk about it. Even among one’s colleagues, here or anywhere, we do not talk about whether people are fat or thin. We have to get over that because a huge problem is developing, in part due to an element of political incorrectness which is reflected in how the media and the industry treat the subject.

I am sorry if I did not comply completely with the rules. Having come from the Commons, and as I normally speak only at Report, in Committee and on Third Reading, I am not used to listings during debates.

My Lords, I congratulate the noble Lord, Lord McColl, on his persistence in calling this debate; he is well known for his concern about this issue. I also offer congratulations to my noble friend Lord Brooke on having lost a lot of weight by reducing his intake of food by 10 per cent since June last year. I am not going to tell the Committee what he has gone to or from, but it is very impressive. In a way, that proves a point made in the remarks of the noble Lord, Lord McColl.

I address my remarks to the growing crisis that is childhood obesity. There are high levels of concern about obesity in westernised society, and about obesity in children in particular. The National Child Measurement Programme was implemented in the UK to monitor changes in average body size among children who are starting or about to leave primary education. It showed that, in 2008-09, almost one in 10 children—9.6 per cent—aged four to five was obese, while for 10 to 11 year-olds the figure was almost one in five, or 18.3 per cent. Over the past 10 years obesity among six year-olds has doubled, and it has trebled among 15 year-olds. With such levels of obesity, diseases such as type 2 diabetes are now being seen for the first time in children.

I draw on a recently published report entitled The views of young children in the UK about obesity, body size, shape and weight: a systematic review. It was undertaken for BMC Public Health and published on 25 March, and I commend it to all noble Lords. Among other things, it states that recent research shows that,

“Children are likely to experience immediate physical and psychosocial problems as a result of being obese and are at a higher risk of obesity as they grow older”.


“Children’s attitudes to and beliefs about their bodies”,

including high levels of body dissatisfaction, raise enormous concerns.

I have to confess that so far, taking their rhetoric with all possible seriousness, I am underwhelmed by the Government’s strategy for tackling childhood obesity. It seems that they are intent on removing all the levers that might make a difference nationally. For example, today the school dinner grant loses its ring-fencing and can be used to cover other budgets in schools which, it is safe to say, will lead to a rise in prices of possibly up to 17 per cent and a fall in take-up of school meals. The official national statistics on school lunch prices show that the average price for a two-course meal across primary and secondary schools with catering provided by the local authority was £1.88 in 2009-10. The Observer reported yesterday that more than 30 local authorities plan to increase the cost to children in the coming months, with some schools seeing an increase of as much as 17 per cent to £2.60.

Research by the School Food Trust reveals, not surprisingly, that the uptake of school meals correlates with price changes. According to its studies, a typical lunch brought in from home is not as nutritious as the average school lunch, which must meet national food standards. Packed lunches can also be repetitive. Therefore, despite reports of increased lunch fees in some areas, the School Food Trust says that it is “really encouraged” that many schools have continued to put the same level of investment into their school meals and has welcomed proposals to make it easier for schools to offer price deals such as ‘buy one get one free’ for larger families. Indeed, writing in yesterday’s Observer, Jamie Oliver said that he hopes the Government will continue to invest in,

“quality school food and the integral support and training of kitchen staff”.

However, we then have to add into the mix on school meals that the Welfare Reform Bill is a leap in the dark on this matter and raises the issue of the future of free school meals. Apart from the fact that it may mean children who need them may not get them, it introduces instability in funding.

Food education in schools is also incredibly important. It was made compulsory for children in secondary schools in 2008 and is due to come into schools this September. However, it is already under threat of being removed from the curriculum completely.

On nursery schools, in responding to the publication of recommendations by a government-commissioned panel on voluntary food and nutrition guidance for early years settings in England, Charlie Powell, director of the Children’s Food Campaign, said:

“While we welcome the substance of the recommendations from the Advisory Panel on Food and Nutrition in Early Years, we already know—from years of experience—that more voluntary guidance is almost certain to be largely ignored”.

That is simply not good enough. We should have legal standards for nursery food.

I agree with what Charlie Powell said when the Health Secretary announced the responsibility deals. He stated:

“They are little more than a continuation of schemes that were being done anyway by the Food Standards Agency—until the Government took away its nutrition remit”.

So instead of introducing effective measures to tackle alarming levels of childhood obesity—such as regulation to protect children from junk food marketing—the Government’s pledges require little or no extra work on the part of food businesses, which are delighted by the support they are receiving from the Government.

I urge the Department of Health to ensure that these voluntary commitments are independently monitored and evaluated and to set a timetable for regulation for when, as we expect, they fail to improve public health. As the noble Lord, Lord Patel, said, it is an embarrassment that Diabetes UK and the British Heart Foundation joined alcohol health charities in not signing up to the deal.

Dr Vivienne Nathanson, the head of science and ethics at the BMA, said:

“Children and parents are surrounded by the marketing of unhealthy cereals, snacks and processed meals. This has to stop”.

Two of the partners in the Government’s responsibility deal had the following to say. The Food and Drink Federation rejected the need for restrictions on advertising and a spokesman said:

“Any simplistic scheme that demonises products does not take into account the complexity of people’s lifestyles and the way they eat”.

The boss of McDonalds, Peter Beresford, has made clear that he rejects TV advertising restrictions. He said that McDonalds is not to blame for rising obesity, adding:

“There is no good food or bad food, only bad diets”.

Statistics show that about 70 per cent of commercials shown during children’s viewing are for food and that, of these, between 80 per cent and 100 per cent are for junk food. We are sending the wrong messages to children at a time when we are seeing this terrible increase in weight problems. As noble Lords will be aware, because I promoted a Private Member’s Bill on this matter some years ago, I am strongly opposed to allowing advertising of foods high in fat, salt and sugar during the pre-watershed hours. National Consumer Council expert Sue Dibb has said:

“Anything less than full restrictions on TV ads and promotions for high fat, salt and sugar foods before the 9 pm watershed would be extremely disappointing”.

I agree with that.

On sport and exercise, the Government’s record is again not good. We saw last year the U-turn that they had to make on school sports and the scrapping by the DCMS of the free swimming programme, designed to be a key part of the London 2012 legacy plans. I agree with the noble Lord, Lord Patel, that nudge and suggestion have yet to prove themselves. I have not limited myself to talking about the Department of Health because this is a cross-government matter. I therefore have two questions for the Minister: is there a cross-government approach, and where are the interventions and levers? Although I shall not repeat the questions of the noble Lord, Lord Patel, I add my name to them.

My Lords, I thank my noble friend for raising this important issue, about which he knows a very great deal. I value the insights that he was able to give us in his most informative introductory speech.

Obesity is one of our biggest public health challenges. In England, three-fifths of all adults and more than a quarter of children aged two to 10 are overweight or obese. The noble Baroness, Lady Thornton, reminded us of some other statistics in that connection.

Already, more teenagers and young adults are being diagnosed with type 2 diabetes. Experts tell us that if obesity stays at anywhere near its current high levels the health of the population will deteriorate dramatically in the years ahead. For instance, the National Heart Forum has predicted that, by 2050, the number of people getting diabetes because of their weight will nearly double and those with heart disease caused by obesity will rise by 44 per cent.

Our first thought has to be the human cost. Just as obesity cuts years from a person’s life, it also takes life from a person’s years. Statistics do not really convey the long-term effects of diabetes. They include limb amputations, long-term disability, chronic pain and heart disease, robbing people of their energy, their independence and their chances of a decent quality of life.

The other consideration is financial cost. Obesity already costs the NHS £4.2 billion. That figure is set to double by 2050. The prognosis is simple: make rapid progress or face a personal and financial catastrophe within a generation. As a country, we need to change our behaviour. The White Paper on public health sets out a new approach to improving people’s health that is locally centred, outcomes-driven and professionally led.

New local health and well-being boards will help to bring together the NHS and local government under a shared local strategy. The outcomes framework for public health will provide consistent measures to judge progress, and this includes two potential indicators covering obesity. Public Health England, a new, dedicated national public health service, will provide the resources, ideas and evidence to support local strategies. A specific obesity document will follow, setting out how the new system will work to reduce obesity levels.

However, as important as systems and structures may be, this is also about changing cultures. It is about encouraging greater personal responsibility. We have found that the state does not have all the answers, and the more the state intervenes, the more individual responsibility shrinks back. Rather than nannying people, we must nudge them, as the noble Lord, Lord Patel, reminded us, giving them the support and encouragement they need to look after their own health.

Although the noble Lord, Lord Patel, raised this subject, he expressed some doubts about its efficacy. I simply say to him that the Government cannot change people’s behaviour; what they can do is help people to change their behaviour themselves by encouraging them, rewarding them, making it easier and making it the norm. We can provide information to individuals to help them to make informed decisions about their health and we can provide encouragement, which we are already doing.

The noble Lord was doubtful whether the voluntary approach would work. I share his wish for an evidence-based evaluation of whatever we do. That is a core component of the responsibility deal and we are investing in it. However, as part of our new approach, we will consider what can be achieved through voluntary approaches before considering regulation. People’s lifestyle choices are affecting their health. The Government cannot address that challenge on their own. We believe that collective voluntary effort can deliver more progress and do so more quickly than regulation. Through the public health responsibility deal, we can tap into the unrealised potential of a wide range of resources that can promote healthier lifestyles and support people in achieving them. We have examples of working with industry, and this approach works. Change4Life is a recent example of how we have successfully worked with industry. We firmly believe that collective voluntary efforts can deliver real progress. The responsibility deal and deliverables arising from it have to deliver real improvements to public health, and we are looking at what independent monitoring or evaluation will be needed to that end.

While obesity often has complex social, psychological and cultural foundations, its basic cause is simple. My noble friend Lord McColl spoke about energy balance in its broadest sense. He is right: people become overweight because they take in more calories than is necessary and they do not burn off the excess calories that they do not need. I do not think that my noble friend was arguing against that proposition. It is a point clearly made in the NICE guidance on obesity and being overweight, and it is central to the Government’s approach. The NICE guidelines on obesity address the prevention, identification and management of obesity. They stress the importance of addressing both diet and energy out. The guidelines were based on the best available evidence that NICE had at its disposal at the time. However, my noble friend will be reassured to hear that NICE’s clinical guidelines are updated as required so that recommendations take into account important new information, and the obesity guideline is no exception to that.

My noble friend referred to the work of Professor Wilkin. The department is familiar with the EarlyBird diabetes study by Professor Wilkin. The study makes some useful points concerning the importance of early-life experiences for future health. It provides some useful messages on the importance of a child’s early years and the impact that this can have on the child’s future health and behaviour. However, this is one study which needs to be seen alongside other research with different findings on physical activity and weight.

My noble friend Lord McColl made very clear his emphasis on diet as the more important ingredient in weight loss. However, I think he would agree that any planned weight management programme should be tailored to the person’s preferences—their initial fitness, their health status in general and their lifestyle. The NICE guideline recognises that relatively high levels of activity may be required by certain individuals wishing to lose weight or maintain weight following weight loss. However, it also emphasises that, while an individual’s ability to be physically active may be hampered by their initial level of fitness or comorbidities, physical activity recommendations can be built up gradually, be focused on everyday activities, such as walking, and be accompanied by a reduction in sedentary behaviour. The guideline includes a raft of recommendations for clinical practice on dietary management.

Therefore, what is to be done? First, we need to give people the information and the opportunities so that people can choose to change their diet and lifestyle. A powerful way of doing this is through the Change4Life brand, which helps people to cut down on fatty and sugary foods and become more active. Another is working with industry to guide people towards healthier choices. The noble Lord, Lord Campbell-Savours, asked why we cannot ask restaurants and so on to place calorific content on menus. Through the responsibility deal, we now have 29 partners who are committed to posting calorific content on their menus in more than 4,000 restaurants. The noble Lord, Lord Patel, mentioned trans-fats, and my noble friend Lord Addington also referred to the fat content of food. They are both quite right. They will be pleased to hear that businesses have already committed themselves to removing artificial trans-fats from foods so that people can keep the tastes they enjoy without suffering such negative consequences. We shall continue to work with industry on other measures to help people to reduce their calorie intake, including reformulation. We will say more in the obesity document when it is published later this year.

A second issue is improving access to healthier food. In some areas, local shops simply do not stock healthier options. We are working with the Association of Convenience Stores to make fresh fruit and vegetables more available. The scheme has expanded incredibly quickly, with participating stores seeing a marked increase in the sale of fruit and vegetables. Of course, even if people have fresh produce, they still need to know what to do with it, so education is vital. There are many great local initiatives—involving the NHS, local authorities and a range of partners—which provide cookery schools and other local healthier eating initiatives.

The noble Baroness, Lady Thornton, spoke very eloquently about school food, and I agree with a lot of what she said. The Government are committed to ensuring that pupils can eat healthy, nutritious school food. We are supporting the School Food Trust in its work to help caterers to become more efficient while continuing to provide healthy meals. The schools budget will increase by £3.6 billion in cash terms by 2014-15—the end of the spending review period. Although the school lunch grant will not remain as a specific grant, it will be one of the grants that make up schools’ baseline funding from 2011-12. It will, however, no longer be ring-fenced; it will be for schools to decide how to spend the money.

We have not changed the current rules for free school meals. Therefore, some 900,000 pupils in the neediest families—those without work—continue to receive free meals. We took the difficult decision not to extend eligibility to low-income working families because the previous Government had underfunded this plan by £295 million. The money saved by not extending eligibility will be used more directly to improve the educational attainment of disadvantaged pupils, which is key to extending opportunities for poorer children. We are continuing to support three pilot projects of extended free school meals. We will look at the evidence from these of the costs and benefits of extending free school meals before making any future decisions on this front.

The noble Baroness, Lady Thornton, also mentioned advertising. As she knows, the television regulator, Ofcom, has placed scheduling restrictions on the broadcast advertising of food high in fat, salt and sugar during children’s programmes and programmes of particular appeal to children up to the age of 16. Since January 2009, these restrictions have applied to all channels. The Ofcom review in 2010 showed a 37 per cent reduction in the exposure of children to television HFSS advertising, with the highest reduction for children aged four to nine years, and a fall of 22 per cent in children—

Perhaps I may stop the noble Earl for a moment. In the first few moments of his speech he spelt out the scale of the crisis, yet almost all the measures that he has referred to are voluntary. They are based on an agreement with the industry or with this or that body. If that is not working—and it clearly is not, because the noble Earl himself set out the nature of the crisis—why, at an early stage, cannot we go down a more regulatory route?

I hope that the Committee will allow me a little extra time in view of that intervention. The answer to the noble Lord, Lord Campbell-Savours, is that if voluntary measures do not work, we will indeed consider regulation. I need to make that clear. We have a ladder of intervention at our disposal. However, as I also emphasised to him earlier, we think that we can make progress faster by means of voluntary measures. The food labelling regulations, for example, are governed by EU law, and the noble Lord will know how long it takes to change EU law. If we can make progress more rapidly by voluntary measures in this country, I am sure that he would welcome that as everybody else would.

On the other side of the coin, although equally important, is physical activity—the calories we burn rather than consume. My noble friend Lord McColl made some strong statements on that aspect of the issue but, as my noble friend Lord Addington indicated, physical activity is important in the wider context of people’s health. The public messaging on this clearly has to be balanced. We are currently reviewing the Chief Medical Officer guidelines on recommended levels of physical activity and we hope to publish those in the summer. Incidentally, I am delighted that my noble friend Lord Addington has underlined the importance of diet and exercise because I still believe that the two should be emphasised.

Finally, we need to make sure that those who need it can get the specialist help to reduce and manage their weight effectively. Weight management providers will continue to play a key role in this area. I believe that through the new public health system, with the responsibility deal and Change4Life, we can truly make a difference over the next few years.