EHJ April 2004, pages 106-108
The rising level of obesity among children is a 'ticking timebomb'. Each year sees numerous initiatives aimed at tackling the growing problem of food-related disease, but as Nick Warburton explains, little of this work is joined up or co-ordinated

Judging by the seemingly daily headlines, the government appears hellbent on tackling the UK's appalling legacy of poor dietary health, which, left unchecked, threatens to undermine the National Health Service. Every month or so, it seems there are a flurry of government and governmental agency consultations, initiatives and reports aimed at reducing food-related disease and encouraging healthy eating.

The urgent need for action to tackle food-related conditions like obesity is a key message in former Natwest chief executive Derek Wanless' report, Securing good health for the whole population, published in February. In it, he called on the government to develop a more coherent strategy to reduce preventable illness caused by unhealthy behaviour. While welcoming the report, environmental and public health commentators claimed that too much emphasis is being placed on the role of the Department of Health and not enough is being made of the role of other organisations, which carry out valuable work in preventing ill health.

Within a month of its publication, health secretary Dr John Reid unveiled details of a national consultation on ways to improve the nation's health and wellbeing. The feedback will feed into a public health white paper later this summer. The debate, due to run over the next two months, will seek a wide range of views on key food- and health-based topics such as food labelling, advertising and access to fruit and vegetables. To complement the white paper, the DoH has also been consulting on its food and health action plan, which aims to establish a coherent and effective programme of activities on nutrition.

While these moves are undoubtedly well intentioned, many critics believe that the government, fearful of accusations of nanny state intrusion, will ultimately steer clear of controversial, albeit arguably more effective, measures such as stricter regulation. Furthermore, political pledges made in the past have failed to resolve the rising levels of obesity.

As Mr Wanless points out in his report, targets set in 1992 by the previous administration, to reduce obesity levels in men and women by 2010, failed to produce results. Rather than curbing the trend, obesity levels have in fact soared. According to the Food Standards Agency, obesity levels in England have tripled since 1980, with little sign of this upward trend stopping. The most worrying trend is the rising level of obesity among children. The FSA points to shocking statistics which show that, in the past 10 years, the level of obesity among six-year-olds has doubled, while among 15-year-olds there has been a trebling in the number of obese children.

On top of this, the FSA estimates that, currently, over half of women, and around two-thirds of men are either overweight or obese, with significant long-term impacts on the nation's health and economy. Being overweight or obese, for instance, increases the risk of heart disease, type 2 diabetes and high blood pressure, and the cost to the country is already huge and is likely to get worse. The National Audit Office estimates that obesity results in 18 million sick days and 30,000 deaths a year, as well as 40,000 lost years of working life in England alone.

Tackling food-related diseases and promoting healthy lifestyles will require a multi-partnership approach from national to local levels but, for this to happen, there will need to be a more coordinated, joined-up approach, which is exactly what many fear is currently lacking.

"Lots of work is done on many different fronts to develop and implement strategies to promote healthy eating and reduce food-related disease," says Dr Geof Rayner, chair of the UK Public Health Association. "But that's also the point. Matters aren't joined up enough and there seems to be competition between parts of government over the policies, with Defra interested in environmental sustainability, the FSA in food standards and some aspects of nutrition, the DoH interested in fruit and vegetable consumption, and the Department for Culture, Media and Sport interested in protecting the advertising and media industries. An impartial observer could be forgiven for thinking that it's a mess."

Jeanette Longfield of Sustain agrees. "An integrated approach has been the usual casualty of interdepartmental rivalry," she argues. "There is a lot of disjointed national policy and a lot of muddling along at local level, and what we have at the moment is a whole that is less than the sum of the parts."

This lack of effective coordination on food policy is counterproductive. For instance, where multiple initiatives are being targeted at a particular area, there is a risk that resources could be used poorly and that effort may be duplicated.

The UKPHA and Sustain are among a number of non-governmental organisations and pressure groups calling for a mechanism to ensure better coordination on food policy initiatives. "My personal view is that there should be a national council of food, nutrition and physical activity - the aim being to bring together all the key areas where action is needed and to develop an overall view which is currently lacking," says Dr Rayner.

The concept of something like a food council to help coordinate policy is nothing new. According to Tim Lang, professor of food policy at Thames Valley University's centre for food policy, Scandinavian countries have made significant health gains since setting up national nutrition councils in the 1970s. Furthermore, there are several examples of how food councils can bring coherence at a local level too. The Toronto Food Policy Council, which was created in the 1980s, has greatly improved food policy coordination across the Canadian city.

Prof Lang believes that if the government wants to "bring governance and institutions into shape to meet the challenges of food policy for the 21st century, better co-ordination across its institutions is vital". He sees a UK food policy council acting as an advisory body, primarily providing advice to the relevant food- related government departments. It should also, he adds, have a devolved structure, with linked counterpart bodies in the national bodies in Scotland, Wales and Northern Ireland.

Jenny Morris, CIEH policy officer, agrees that having a national organisation to coordinate food policy is essential, but adds that work is being done at grass roots level and how this feeds into national policy is just as important. "You need a top level organisation to coordinate strategy but they must take account of feedback from front line experience or you are likely to get a lot of good ideas that don't work in practice."

Nancy Singleton, health improvement manager at Stratford-on- Avon DC, feels that often the government overlooks the important work being carried out at local level. "I feel that central government is full of 'we should be doing this' and 'we should be doing that', but they are not backing it up by looking at what is happening already. There's a lot of good work going on out there. I think they should have a more joined-up approach but also be targeting more resources into what we know works to make these projects more sustainable. That's the issue for me - it's sustainability."

Local authorities are often the key drivers at this level, helping to promote production and access to safe, sustainable and nutritious food in the local community. Recognition of this contribution was acknowledged earlier this year when the Local Government Association, Lacors and the FSA launched the joint website, Food vision - improving community health and wellbeing, which includes good practice case studies.

Local authorities are making a difference in other ways, for example by promoting healthy eating in the private sector through schemes like the Heartbeat Award. The awards are given to catering establishments, which help people to maintain a healthy diet and lifestyle by providing healthy options on the menu. Caterers must also have designated "no smoking" areas and maintain high standards of food safety.

The award is unique in that it takes a holistic approach to food and health. "It's not just looking at the healthy eating option, it's also looking at being able to eat in an environment which you know is going to be free from pollutants like second-hand smoke," says Ms Singleton. "Secondly, it's prepared in a hygienic manner."

As the CIEH's response to the DoH food and health action plan consultation explains, national award schemes can provide a means of encouraging the provision of healthier eating options. Ms Morris believes the Heartbeat Award offers a model that could be extended.

"We believe that the Heartbeat Award has merit and that it might provide a framework for all types of business, within the catering sector, to join the drive to improve diets," says Ms Morris. "We need to reward people for their efforts, even in narrowly focused areas, and then encourage them to move further forward. We've had some discussions with the British Hospitality Association, which backs it and it also believes it could be a useful model for delivering a joined-up approach."

Ms Singleton feels the Heartbeat Award could also be extended into other establishments that don't prepare food on the premises. As one of its initiatives, the council is planning to pilot a modular approach which recognises establishments that promote healthy eating. "It's getting people to think about the bigger picture and getting the message out to other environments," she says.

Due to the scale of the problem, joining up and coordinating action remains key to the debate. "We are talking about an enormous task," concludes Ms Morris. "It's not something you can change overnight - it's extremely long term. You need a series of joined up strategies to tackle issues, from healthy schools which aim to influence patterns of future food consumption to restaurants and retailers that make following balanced diets an easy option."

Working with schools to push healthier foods higher up the menu is just one of a number of proposals that the FSA has committed itself to in its draft action plan, agreed last month. The plan includes a range of initiatives, such as developing advice and guidelines for the food industry on reducing amounts of fat, salt and sugar in products specifically aimed at children. Not everyone is satisfied, however, that the plan goes far enough.

Though welcoming it as a "step in the right direction", Paul Burstow, Liberal Democrat health spokesperson, echoed many critics' views in his response: "Pursuing the voluntary route first and promoting personal responsibility to tackling obesity is the soft option. The FSA will have to ask itself whether it will really make the sort of difference that is now becoming a matter of life or death."