Is nutrition a public policy issue?


On 19 January, the New Statesman, with the support of Compass Group plc, hosted a round-table discussion on whether nutrition is a public policy issue. Surveys show that people are more concerned with diet than ever before. But the increase in chronic diseases associated with poor nutrition, from mental illness to heart disease and diabetes, shows that the healthy eating messages are not getting through to people. Poor diet now costs the NHS billions of pounds, so what can be done to reverse these worrying trends? The representatives from education, research, prisons, media, government and the food and drinks industry who took part in this discussion agreed that a more focused and targeted approach is needed to ensure that people are empowered to make informed choices. Some participants felt that the emphasis should be placed on educating children's palates, teaching hands-on cookery skills. Others felt that reaching parents is crucial, and that training home helps and carers would make a huge difference. What was clear from the discussion was that an NHS that focuses on prevention is key to change. With a combined approach, future generations will hopefully not only only live longer, but remain healthy for longer, too.

Michael Crawford - Director, Institute of Brain Chemistry and Human Nutrition

Helen Crawley - Science director, Caroline Walker Trust

Caroline Flint - Minister for public health, Department of Health

Catherine Geissler - Professor, Department of Nutrition and Dietetics, King's College London

Bernard Gesch - Senior research scientist, Physiology Department, University of Oxford

Deirdre Hutton - Chairman, Food Standards Agency

Prue Leith - Cookery writer and presenter

Melanie Leech - Director, Food and Drink Association

Paul Lincoln - Chief executive, National Heart Forum

Andrew McCulloch - Chief executive, Mental Health Foundation

Sarah Mukherjee (chair) - BBC environment correspondent

David Ramsbotham - Chief inspector of prisons for England and Wales, 1995-2001

Sian Robinson - Medical Research Council Environmental Epidemiology Unit, Southampton University

Gordon Walker - Headmaster, Tywardreath School, Cornwall

Roundtable discussion

Spencer Neal Welcome to this discussion which is part of a six-month-long programme with the New Statesman and Compass looking into nutrition, policy and eating habits.

Sarah Mukherjee (chair) I am impressed by the fantastic quality of people we have around this table, many of whom I have wanted to interview for a long time. The health minister, Caroline Flint, will start the discussion.

Caroline Flint Thank you. The short answer to the question "Is nutrition a public policy issue?" is "yes". I have to deal with the whole range of issues in relation to public health: what people eat; the amount of exercise they do; smoking; alcohol and other lifestyle issues. Part of the challenge for us is to think more clearly about a health service that is about prevention rather than just treating sickness. The debate we are having at the moment will lead to our white paper about services outside hospitals. We are inundated with information. Many people are acting on it and are pretty self-sufficient, but many are not and they are often those who are in our poorer neighbourhoods. Addressing that by concentrating on prevention is very important. It is easy just to pick out nutrition and say: "Let's have a plan about that". But the key to this debate is the sort of health service we want.

I see what will happen in my own constituency, Doncaster, in terms of the poor health outcomes if we do not address some of these issues. We all know that poor nutrition is a recognised cause of ill health. It costs the NHS an estimated £4bn a year.

Yet, we also know that there is a high level of awareness around healthy eating. A huge amount of information is out there. The issue is whether people feel confident enough to use it and whether they feel the targets being set for them are too high or not sustainable. Some people feel like a failure before they've even started, just from reading the information. That is part of what the government has to address. We need a more focused and targeted approach to the work we are doing at the Department of Health. We want to enhance and support activities in other fields. Obesity is a priority, but it is also important to realise that some people are underweight. Many others, who may not fall into either category, may still be lacking in essential nutrients which could affect their health, energy levels and concentration.

A survey last year indicated that a third of parents take little interest in their children's eating habits and that many parents also indulge their children. In the area of public health, we can see quite clear socio-economic differences in terms of health inequalities, and there are still issues about our more deprived communities regarding diet. But we are also seeing the indulgence factor among more affluent families. It is often linked to lack of activity caused by computer games and TV, but the busy lifestyles of families with two working parents also has an impact. We have to be mindful of all these issues.

The survey also indicated that around 72 per cent of 11- to 16-year-olds understand the importance of a balanced diet. The problem is putting a healthy diet into practice. Children often find it difficult to stick to. We need to look at whether they can easily act on the information they have. On smoking, for example, some of the health messages hit home, but being attractive to a future boyfriend or girlfriend, by not smoking, seemed to be more important to young people. A more targeted approach could make a difference.

That is why the Department of Health is working with the National Consumer Council, and also with industry, because one of the things about industry is that it does an awful lot of social marketing. Deirdre and I have had meetings with retailers and food producers about how they can help us reach people more effectively.

The Choosing Health white paper had some core principles, one of which was about informed choice. People want credible and trustworthy information and different levels of support to make decisions about their lives, and the health service has to be able to respond to that. I cannot tell people what to do, which is why the work with industry in terms of labelling is so important. We have to recognise that making choices is not always easy. Especially in relation to the promotion of food to children, it is important that we create a culture where people can say, "Yes, I can discern between that product and this product and make a better choice for myself".

We have to move away from the fashion for big public health campaigns which are all-embracing but unclear about whom they are targeting. Primary care trusts really have to know where the most severe problems are, and how they can make sure that their services are tailored to deal with them. Effective partnerships, aside from those with retailers and food producers, are also crucial to our success. By working with pharmacies, for example, we are trying to make it easier for people to take initiative in their daily lives.

The voluntary sector can also play a big part in health issues, as can the the leisure and sport industry. I am particularly keen on using the interest we have in sport in this country to get to difficult-to-reach parts of the population, for example, men of a certain age who go to football matches every week but do not look after their own health very well. Why can't there be mobile units available at matches, or health information in the programmes? We are working with the Football Association on these issues.

Two GPs e-mailed me during the summer to say that they had organised a mobile surgery at a cricket match. That afternoon, they saw 500 men. That is a great example. Often, it is a matter of setting goals for people and not just blaming them and making them feel bad about themselves.

In Cornwall and Devon, we have rolled out the Healthy Start programme which will transform the Welfare Food Scheme from one that is just milk-based to one which provides opportunities for low-income families to buy fruit and vegetables. We are providing 400 million pieces of fruit per year to schools in England. But families are also a big influence on public policy, so we are working with parents through initiatives such as Sure Start.

Evidence is emerging that consumers are changing. The Food Standards Agency's 2004 consumer survey showed that people were increasingly concerned with diet and health, especially the amounts of salt, fat and sugar in foods. Recent National Consumer Council research found that two thirds of adults in Great Britain have changed their families' eating habits or activity levels. I know we see "Obesity timebomb" headlines, which are rather daunting, but there are some underlying trends which suggest that people are up for change.

Sarah Mukherjee I would like to pick up on the issue of information. You cannot read a paper or switch on the television without being told that something is good or bad for you, so why is this message about healthy eating and nutrition not getting through to a vast proportion of the population?

Deirdre Hutton Some messages are. Take salt, for example. The research done on the back of last year's "Syd the Slug" campaign showed that the awareness of salt as an issue has risen by about 20 per cent. Couple that with the fact that sales of table salt have gone down by 13 per cent, and we have to conclude that some messages are getting through. The "Five bits of fruit and veg a day" message is also well established.

Sian Robinson We studied 12,500 random women in Southampton. You couldn't have made up the poor diets of substantial numbers of the women. They do understand, but it's like smoking. Smokers understand that it is not good for you. But it is hard to make changing your diet relevant to how you live your everyday life. These people are overloaded with information. The women we studied have difficult lives. They need to be empowered and supported so that they can make a healthy diet an easy, simple, everyday thing. It has to be relevant to them and to their families.

The picture in Southampton, which is fairly representative of the UK, is quite depressing. We need to talk to these women and ask, "What are your difficulties?" and "What are the influences on your everyday food choices?" It is not just about money, though money is important and clearly a healthy diet is more expensive. If everyone could get to a supermarket it wouldn't be such a problem, but they can't. People are just surviving day-to-day and we need to start to understand how to support them in their day-to-day choices.

Prue Leith I have discovered in almost all the work that I have done in this area that people who eat badly do not like the healthy food that they are asked to eat. Their children have never eaten fruit and vegetables so they have no desire to. You are not going to risk your benefit money on giving children a meal which you suspect will end up in the bin. So, naturally, you do the safe and easy thing, which is to buy pot noodles because you know they will get eaten. The fundamental thing is for them to like it. Consumer demand is what we need to change.

I wish I could say that I had the scientific evidence to prove this point, but in all the work we have done we have never been able to monitor results in a scientific way. What we definitely know, from schools and parents, is that if the children are taught to cook, taught about food, taken on farm visits and made to understand and develop a love of food and an interest in cooking, they start to change what they want. We need to teach food and cooking in a hands-on way.

Sarah Mukherjee A few years ago, I went to Poland to look at some work that the WHO was doing with people who had very poor diets - mostly butter and pork - and low incomes. They started in schools, and all the children were doing was cutting up cucumbers and tomatoes. The parents were saying, "Oh, we have had enough of cucumbers. The children are always wanting to go to the markets to buy them." But the difference in the behaviour of those children was dramatic, according to the headteacher.

Gordon Walker One of the biggest questions is: how you get this message across to the greatest number of people? Jamie's School Dinners did a lot for school dinners, but what about packed lunches, snacks and healthy eating in general? My idea - and probably everybody will laugh about this because it is so simplistic - is that you could get the soaps on TV to feature some of these issues. If that happened, we would hit some of those people who are not listening.

Caroline Flint Again, the issue is what people listen to and what will have some effect on them? It is one of the reasons that the regional press and magazines that people read are important. We do a lot of work with youth magazines and radio stations for that reason.

Catherine Geissler I wanted to follow up on what Prue said about people not taking healthy food advice because they don't like it. This is largely because, to a great extent, people do not know how to prepare food. So I agree that a focus on food preparation with children is an important approach to changing attitudes to food and exposing children to different tastes.

Caroline Flint The point you make is important, but it seems to me that we are surrounded by cookery programmes, from the sophisticated to the basic, and I just wonder what the outcome of all of this is?

Prue Leith I believe that 90 per cent of television programmes are counter-productive. You sit on the sofa stuffing your face with crisps while you watch. A taxi driver once said to me, "You're that food lady, aren't you, oh, I love cooking". I said, "Oh, that's interesting. What do you cook?" He said, "I don't do it, but I like it. I like to watch Nigella Lawson."

Michael Crawford The incidents of chronic ill health and the cost to the Department of Health, which is by far and away the greatest in the lower socio-economic areas, such as Hackney, show clearly that the messages are not getting across to the right people. We ought to be reinstating domestic science colleges. I do not know why they were closed down. It has left us with people who cannot make an informed choice. I would suggest that it really needs to start from the pre-school period. Sesame Street has some wonderfully educational programmes for pre-school children, but those children are bombarded and manipulated by more negative television images too. Once children are empowered to make decisions about their own lives and their own health you will change the nation for the better.

Caroline Flint Cooking does happen in schools. Whether or not we need to look at what the curriculum is in terms of that experience is something which is worthy of discussion. But what happens in the home is also important. We can, for example, give out free fruit in schools, we can have better school dinners and cooking lessons, but it has to be reinforced at home to make a real difference. It is important to have an emphasis on families, such as we do with the Healthy Start and Sure Start programmes. One of the key things about the Healthy Start programme is that, for the first time, midwives and health visitors will be engaging pregnant women and new parents about the importance of nutrition. Again, it is about focusing on what people can do for themselves.

Michael Crawford I agree with that. It is absolutely vital that we have a well informed nation and that will only come by starting with school children. It is not just about cooking. It is about understanding what food is and a little about the nutritional reasons for eating certain things. The sooner children understand what food is about and how important it is for their own reproduction, health and future, the better.

Caroline Flint To get the Healthy Schools kitemark, schools have to show evidence that they are being innovative in addressing the issues of food and exercise. It could be done through school meals or vending machines, for example, or their approach to the subject and how that is linked to exercise. You cannot get away from this issue. It is a foundation.

Bernard Gesch I wondered if I could just visit the notion of what we describe as "choice". I noticed that this week's New Statesman asks: "Why are British men rapists?" I do not know the answer to that question, but 68 per cent of the population I was working with in HMP Aylesbury were in for grave offences against the person, a number of which were rapes. When we investigated with them the effects of their behaviour, it transpired that many of them had never heard of a vitamin. So what do we mean by informed public choice if people have not even reached that stage of awareness?

The discussion so far has completely failed to grasp that what we eat may be driving our choices. What we demonstrated at Aylesbury was clear. Serious offences by the group which received the active vitamin supplement fell by 37 per cent compared to no change in the placebo group. That is a powerful effect at the first attempt. If you talk to physiologists, they will tell you how nutrients are assimilated into the organs which form our senses. In other words, the nutrients support the ability of our senses to operate. Therefore, you could expect that the nutrients would impact on our choices by driving the physical senses that inform our choices in the first place. There is a major physiological component to what is going on.

I have been arguing for years that dietary standards have never considered these effects because, to a large extent, nutritional scientists do not do behaviour. We already know that aspects of western diets are strongly associated with heart disease, cancers, etc, but the area which is most likely to be sensitive to diet is brain chemistry and, hence, behaviour because the brain is the most sophisticated organ in the body. We simply have not begun to address the behavioural implications. It is a little like people becoming drunk or intoxicated but not even being aware of the source of the intoxication. Would you expect that, in altering your brain chemistry, what you eat alters how your brain works? Clearly, the evidence that is mounting now appears to suggest that, yes, it does. These are major effects which we could be looking at. Please, do not forget that what you eat will affect your choices.

We have had examples where offenders would never eat salads, greens, cheese and so on. Sense of taste is dependent on zinc status. Simply by replacing zinc in the diet of one offender, for example, we found he suddenly started liking salad.

David Ramsbotham The aim of a prison sentence is to try to persuade people to change their lifestyles and to live a law abiding and useful life when they come out. One of the most interesting courses I ever found was in Belfast in a young offenders institute called Hydebank Wood. It had a course called Learning to Live Alone, which included domestic science, plumbing, electrics and home economics. The fascinating thing about the food bit was that, instead of focusing on some of the television programmes, they based it on where they came from - some of the chaotic and dysfunctional parts of west Belfast - and related it to their lifestyle and what it was possible to do there. That course would be ideal for all schools.

Andrew McCulloch We have to look at the relationship between food and society and how the family as a whole relates to food. We need to have a sophisticated, multi-disciplinary understanding of what is going on here, which we can all contribute to, to empower people to be more healthy.

Protecting the health of the people who are most vulnerable will involve universal interventions. It is going to have to involve personal support and services down the line. There are some good examples in mental health about how it might work. There has been funding for a programme of nurses in the west Midlands, and to supplement all pharmacological intervention with dietary and exercise for schizophrenia patients. That is working well. There are services local to you, Minister, in Doncaster and Rotherham, which are dealing with intractable depression and the early onset of schizophrenia in late adolescence, using dietary and exercise regimes, apparently to good effect. I appreciate it costs a lot of money because some of those people are going to need a lot of ongoing support, from dieticians and primary and secondary carers, to enable them to move their lifestyles in a more mentally and physically healthy direction. So we are going to invest in that. We can use existing staff and retrain them. I do not think that it is about money for a lot of new services.

Melanie Leech Some people are overloaded with information and others are not getting enough. Information needs to be streamlined and made more accessible. The delivery channels for that information, such as TV soaps, as Gordon suggested, are important because neither the food industry as a whole nor the government get particularly high ratings for being trusted to give information. Interestingly, while that is true of the food industry as a whole, individual brands do score highly in terms of consumer confidence and trust.

The ultimate partnership is the one with each and every consumer. The goal is to change demand because individuals make choices and those choices have consequences. Food and drink manufacturers respond to consumer demand. They respond to the challenges of the marketplace. If people do not buy things, those products will not be produced. If people want different things, those products will be produced.

I am an advocate of the balanced diet and balanced lifestyle, but I agree that that starts by equipping children to make those healthy choices. If you focus on individual foods and individual choices, you run the risk of creating a situation where people become deficient in essential nutrients. You need to help people to construct balanced diets. We need to help people reconnect the leafy countryside with the food on their plates.

Helen Crawley We also have to be aware that a lot of people make informed choices for others or have a big impact in influencing others. At the moment, everybody is concentrating on early years and teaching children in schools, but we have no training programmes for home helps, staff in residential care, and young offenders' institutes and people who look after children and the learning disabled.

Foster carers, for example, have an enormous impact on the lives of many people but we have missed them out. One of my students is doing a project at the moment to find out what nutrition training is given to home helps in London boroughs. The answer is absolutely none, yet they make decisions for vulnerable people. It is no surprise that we then end up with these vulnerable older people arriving malnourished at our hospitals. We have a lot of gaps.

Caroline Flint In public health, the links with local government and the different provider services are key to that. I am always pleased to see where there are, for example, jointly appointed public health directors between local authorities and primary care trusts. Some of the families we are talking about often call on different public services in all sorts of different ways and, to be honest, cost a lot of money. People are working in isolation rather than working together.

Sarah Mukherjee We have heard a lot of compelling evidence that nutrition and changing nutrition works. Yet there is still a feeling that this is not a terribly serious subject. Nutrition is not sexy. It's associated with "those birds with Thatcherite hair dos, the domestic science teachers". Why is it that politicians do not take nutrition seriously?

Caroline Flint We are getting better. In the same way that I am advocating better partnerships at the local level, we need a better connection at the national level. We have established, for the first time, an inter-ministerial committee on public health which will bring all the departments together to look at a whole range of issues. As part of the Respect Action Plan, one of the things that the Department of Health, along with others, has signed up for is to identify the families whose children are getting involved in anti-social behaviour, and try to find a better way for different agencies to work together to help those families tackle their problems.

For example, it is quite hard to go in to a family and start dealing with, say, a mental illness, if the whole house is in complete disarray. What is the point of that person going along to their local trust provider only to go home to complete chaos. The onus is on us in government, as well as at the local and regional levels, to find ways of dealing with this. That is something we are all learning more about. There has certainly been more acceptance in the educational establishment about the link between what happens in the home, and how a child behaves at school. It is challenging, but there is more of an understanding, if you like, on the economic case, because that is what it comes back to.

We cannot have a fluffy attitude to public health. We have to impose on public health the same rigour that we impose on other areas of delivering our health services. We have to be able to say that the models and the ideas we are advocating can create outcomes and can save money in the long term.

Catherine Geissler One of the issues which has been brought up is the amount of training that is needed in the different sectors for the good nutrition message to permeate society. This brings out the issue of the workforce in public health nutrition, which is minuscule at the moment. There are very few public health nutritionists. Somebody said that people are getting such varied advice from so many people, that they don't listen any more. I think that is largely because those people are inadequately trained. The only way that people can know whether a person has adequate training or an adequate background is if there is some kind of registration of particular disciplines. The Society for Nutritionists is working on this at the moment. Otherwise, we have this plethora of people - who might have specific ideas about things, writing books on diet, health and so on - who begin to cause nutrition to lose credibility. Something has to be done to increase the numbers working in public health nutrition.

Paul Lincoln Food is a public good therefore it is a public policy issue. Policymakers are beginning to see the macro implications. Coming back to young people, the origins of chronic disease are at the beginning of life and that is the time to intervene. We know what the causes are and we know what to do. We just have to put it into practice.

In all fairness, the government has set a framework for this, looking for systemic change to alter the food culture around the agenda of informed choice and producing an economy promoting more healthy foods. The foundations are in place.

I recently read the Wanless Review, which looks at the future demands on the Health Service. That demand is unsustainable in terms of chronic diseases. We are predicting that about 50 per cent of young people under ten will be obese by 2020. That is the precursor to a diabetes epidemic and all those other chronic diseases, such as mental health. There are huge macro-economic implications in terms of productivity. It really becomes a public policy issue in every area.

Let us take the Turner Commission. It has looked at life expectancy increasing, but the technical annexes show that it has not looked at healthy life expectancy, and it has not really modelled what may happen with future generations of young people. People may live longer but they will not be fit enough to work. A lot of this comes down to diet-related chronic disease. Let us have a 20 year plan and look at this in the way that other countries are not looking at it.

In schools, they teach food technology. Young people learn how to design pizza packets. We do not teach them life skills or health skills. Those behaviours are set as absolute rules for future generations. Errant behaviours are much more difficult to reverse later on. We know that if people smoke by the age of 20 they are going to continue into adulthood. We know that a lot of food choices are determined from the ages of two to seven, so you have to persist with trying to encourage children to eat food that they do not like. We know that after many attempts they eventually will. It is those sorts of skills that are important. We have to get food-preparation life skills into the curriculum. That will be investment in the future.

Deirdre Hutton One of my abiding memories is seeing a baby of about six months in a pushchair with a bottle full of Coke. While I agree with everything that people say about schools and the need to educate children, the problems start before then. Unless you engage parents, it will not work. A recent survey showed, counter-intuitively, that the biggest influence on teenagers was their parents. Being informed at school is not enough if the parents are not informed as well.

You can do all the education in the world but at the moment, you are asking those people whom you are educating to exercise constant willpower as to what is on offer and what is advertised to them. One of the things we really have to get at is what I would describe as our "push-pull" role, and the sort of Faustian bargain we are trying to develop with the food industry: if it will change we will try to deliver the demand. The industry has a terribly important role in leading and we have a terribly important role in trying to create the demand but frankly, we are not going to get change unless what is on offer changes as well. That is partly about the industry changing and partly about giving simple and clear information to people so that they can make choices quickly when going up and down the supermarket aisles, hence, sign posting. It is also about what is advertised, especially the predominance of advertising aimed at children which, at the moment, directs them to food which is inherently unhealthy.

Access is also an issue. In Tower Hamlets, for example, there are no decent shops selling fruit and veg. Actually, there is an extremely poorly resourced project there, a fruit and veg van, which is mobbed. So it's not even that the people living in those areas don't like healthy food. It's just that it's not available.

So much of this discussion has focused on educating children. I cannot possibly be against that, but there are multiple strands here and unless we attend to all of them we are not going to make a change.

Melanie Leech Industry is doing a lot already and we can demonstrate that. To give you a couple of examples, by the end of last year, £2.2bn worth of products had a lower level of fat in them, and £1.4bn worth of products had a lower level of sugar, compared with 2004. So the industry is responding. It is doing a lot and it is leading.

Going back to my virtuous circle of demand and response, you have to go at a pace that takes consumers with you. If you go too fast, they turn off. They stop buying and that is not what we want. We want informed choice moving over time to a more healthy place and that has to be at a pace at which people are prepared to go with you on that journey.

Deirdre Hutton I accept that, Melanie, and I also accept that the industry is working, and we are working with you, but there is a kind of ever faster approach.

Caroline Flint There are issues here which have changed in the past 30 years in terms of women working. People will, whatever changes they make to their diets, continue to take advantage of convenience foods. The question we are trying to work with industry on is, can we encourage better production of convenience foods, with less salt and fat to give consumers a better, healthier choice. Consumers are keen on loyalty points, so why not give more loyalty points for healthy foods? That way, consumers will have more to spend on food as a result of purchasing healthier items.

Andrew McCulloch We are working with Imperial College on influences on mental health, which is something we have not discussed much. Yes, universal intervention in schools is important, but the mother's health and behaviour are important too. We have to be careful here about victim blaming and not creating guilt, but we also have to be telling the truth on what our best view on the data is.

Sian Robinson My concern about informed choice is that it really leaves the responsibility with the individual. It is not good enough to wait for consumers to change their demands. It has got to be a combined process. I have a confidence which enables me to accept and reject information, but the more vulnerable parts of our community perhaps do not have that confidence. We cannot wait for them to change their habits because, as you say, the food is not available to them and they cannot just suddenly decide that they are going to change their diets in a context which does not support them.

Michael Crawford In 1972, based on the evidence of cardio-vascular disease, we predicted that a healthy vascular system was the necessary condition for brain development, and we said that brain disorders would follow in the wake of the rise of mortality from heart disease. Heart disease now accounts for 17 per cent of the burden of ill health in the European Union and brain disorders now account for 25 per cent. The whole June 2005 issue of the Journal for Neurology is taken up with an audit of the cost of poor mental health throughout the European Union. The total cost is e386bn. That is a massive amount of money. As to the cost in the UK, the mental health people tried to work out a cost, which was about £100bn. It is very scary, because there is a major nutritional component. The question is whether this is going to continue in the way that coronary heart disease continued to rise in the last century. That is a scary scenario.

Prue Leith I have one cheery note. If the Education Bill goes through as we hope, if the food clauses survive, and I look to Caroline to make sure that they survive, then food and hands-on cooking will become compulsory in schools, which is something we have been wanting for years.

But what about training? Primary school teachers don't get any food teaching or cooking training, yet in the primary school curriculum, teachers are expected to work with food. That tends to mean that they cut up an apple and give a biology lesson, rather than actually cook.

The next thing is training dinner ladies. One of the few bad results of Jamie Oliver's school dinners programme is that dinner ladies are now getting abused by parents for poisoning their children. It is not fair to suddenly say, "You now have to buy everything locally and cook it fresh", when these people have been hired to open packets and heat up ready meals.

Fergus Lowe from the psychology department in Bangor has done some really impressive work. As a counter blast to the advertising and promotion of junk food on television, he went into schools and advertised fruit and veg, using little characters and cartoon scripts and offering prizes for healthy eating. The results were amazing. When he went away the the children still ate all the fruit and veg because they liked it by then. It does take some training to re-educate your desires. Another danger is the way in which food has changed because of our sweet tooth. Dentists are now saying that some grapes are too sweet.

Bernard Gesch If you look at some of the studies where they give rodents diets which contain 25 per cent of calories as sugar and then withdraw them from the sugar, the animals go nuts. They become aggressive and cannot concentrate on their tasks. You cannot project simple animal studies on to the human population, but you have to ask the question: when, at any stage, was it concluded that giving children breakfast cereals, which contain upwards of 40 per cent sugar, on an empty stomach, had no implications for their behaviour? It has not. So you really have to begin to look at some of the modern dietary practices and say that, from the point of view of the brain, is this safe? Are many of the aspects of modern diet experimental? I am inevitably drawn to the conclusion that they possibly are, with unknown impacts on our behaviour.

The brain has really not been considered in dietary standards. This has allowed, for example, hydrogenated fats to creep into human diets. A couple of years ago, the US Food and Nutrition Board suggested that, in view of the fact that there were absolutely no health benefits to this stuff but a growing list of deleterious effects, the recommended intake be set at zero. Curiously, the evidence which shows that these materials damage the brain goes back many years to before they ever discovered problems with the heart. One has to ask why the brain is less important to dietary standards than the heart? Do we need to start labelling these products as being potentially dangerous for the child's brain?

Deirdre Hutton I would like to make a technical point. We do not in the UK have competence over labelling. It is a European matter and we cannot take unilateral action.

Bernard Gesch I am not accusing anyone.

Deirdre Hutton I am just pointing it out. It's just that it's a serious problem.

Gordon Walker Going back to what was said about food technology and domestic science, you are dead right. In secondary schools, in terms of design and technology, now you have things made out of plastic. When I was at school we had woodwork and metal work. I finished up with a stool that lasted a long time. I think my mother, on the day she died, was still using the tray that I made. Those are long-term skills. We have come away from that.

Sarah Mukherjee If any of us went to our offices and smoked, we could be reprimanded or suspended. If we were drunk on duty or got in a car having drunk, we could be criminalised. Yet if you started saying that people should have certain nutrition choices and not be allowed others, there would be complaints about a nanny state. But the damage they are doing, as we have heard, both to the economy, to themselves and possibly to their families could be just as great. Most people do not drink and drive now. Cigarette packets warn that "Smoking Kills". Yet there is nothing that tough to go with nutrition messages.

Caroline Flint There is, obviously, a correlation between the amount of alcohol you consume and the likelihood of you having an accident if you drive. Similarly, we have done a lot of work on the issues around the dangers of secondhand smoke. There are issues around people making choices which they impose on themselves and which affect others. That can also be applied to nutrition and behaviour.

We started the discussion by saying that people can be overwhelmed with information, but also that if we set the goals too high, people start to diet and probably fail within a couple of weeks. But people can't make an informed choice if, actually, the food they have available locally doesn't enable them to. At the same time, we have to recognise that there are things which we can do to create an environment which does tackle some of the issues around the high levels of salt, fat and sugar in our diet, which is what we are doing in our work with the FSA and industry.

Around the table, there has been a lot of focus on what schools should be doing. I believe that the starting point of influence is what happens in families and with parents, which is why I think that Sure Start is so important.

Schools with creative headteachers have worked with their staff to think imaginatively about the way in which they can incorporate these issues, such as having a school council which incorporates citizenship rather than a sterile, lesson-based approach. I visited a school in the north-east that was doing an allotment project with Age Concern. The children were working with older people, which was good, but they were also growing food. It was a fantastic example not just of putting more responsibility on the school but of working with other partners in the community. In many public health areas, the foundation is how people think about themselves and what they want out of life. If this type of project were common in schools, children would start to make informed choices, because they would have some goals and aspirations. That could reach to nutrition and many health issues would be greatly helped.

If you have a job, live in a decent home and your community environment is not weighed down by anti-social behaviour, all of those things impact on you making better choices, because health then suddenly means something. Do we all want to live longer? I'm not sure that I would if I felt rubbish and knew that I was storing up a huge amount of ill health for myself. I accept that we always have to be conscious in government about how these different public policies relate to each other and how they can work together. It is about putting those who are the poorest in our communities in a better place so that they can say, "Yes, I do want to live longer, I want my kids to live longer and I want to have a good life".

Helen Crawley There are enormous areas in which we can use legislation in public health and nutrition. For example, everyone would agree that breastfeeding is a good idea, but we don't even have a law in this country which says that a baby should be allowed to be breastfed anywhere. We have one in Scotland, but not here. My sister works for Mencap. All her staff have to be fire trained but they do not have to have a day of nutrition training. All these things can be brought in to make a difference.

Caroline Flint Part of the challenge for the health community is to give the priority to prevention that they give to treatment. The reality is that, after the last few years, where we have focused on issues about waiting times and getting people the cancer and heart treatments and drugs they need, we are now at a cross-roads where we can more fruitfully discuss getting ahead of the curve on illness. When you talk about needing more training, we actually have to have the commitment which recognises what we want the training for and that is something that primary care trusts will commission, to provide services at a local level which offer people the sort of support they need in terms of nutrition, exercise and so forth.

On breastfeeding, we have said that we are no longer going to provide discounted infant formula on the NHS. The Healthy Start, which will roll out nationally, now offers vouchers not just for milk but for fruit and vegetables to assist breastfeeding mothers. It is also important to reach people who feel uncomfortable breastfeeding.

There are other issues going on. I read a report that indicated that some young women, particularly those who had left school without any qualifications, actually wanted a low birth weight baby and they were smoking to that effect. Why was that? Because they thought they would have a less painful childbirth experience. So that is a pain issue.

Bernard Gesch A colleague of mine did a study in Levensworth, in the US, which has yet to be published, but caused quite a bit of a stir in the field. They went into a primary school where they had armed guards, such were the behaviour and violence problems, and they instituted a number of changes, then monitored the children's behaviour over 12 months. The school meals were taken out of the cafeteria queuing system where most of the fights were and they ate family-style in the classroom. The food dramatically improved and they also gave the children low dose supplements. The violence incidents fell by 92 per cent. More strikingly, the school had for years been at the bottom of its scholastic assessments in its region of ten schools. That year, they came top in maths and second in English. These kind of gifts are, I believe, within the power of our government. In the 1930s and 1940s, children were given supplements of orange juice and cod liver oil because schools knew it benefited the behaviour of children. Can we revisit that wisdom and reinstate it? Could the government not take a very practical approach and produce an RDA [recommended daily allowance] bar, like an extruded fruit bar, which contained the nutrients that a child needed, with different dosages for different ages.

Caroline Flint One of the things we are looking at at the moment through the Healthy Starts scheme is what sort of vitamin base we could provide.

Deirdre Hutton We are doing some important things at the Agency. For example, we have developed a nutrient profiling model against which Ofcom will be able to decide whether foods should or should not be advertised to children. That is an attempt to change the balance of advertising to children, especially for foods which are high in salt, fat and sugar.

We are also consulting and hope to persuade the industry to adopt the sign posting system for front-of-pack labelling so when you buy processed food it will have a red, green or amber label on it, a tracker guide for fat, salt and sugar, which should help people re-balance their diets easily. The support of everybody sitting round this table in getting that sort of system in place would be valuable. It would get the industry moving. Some of the supermarkets are doing this sort of stuff and they are seeing marked changes. If you have one salmon sandwich labelled "high in fat" and one "low in fat", the shift in customer demand towards the low-in-fat option is phenomenal.

We will get change when supermarkets and manufacturers see health as a competitive issue and it becomes a thing on which they compete for market share. That, above anything else, will create a change in what is provided to people.

Michael Crawford I want to take up the point of farming. It is no good giving people advice to eat this, that and the next thing if the stuff which is being produced is rotten.

In 1976, the Royal College of Physicians and the Royal Cardiac Society jointly produced an excellent report under the chairmanship of Professor Shaffer on the role of diet and heart disease and what we should be doing about it. The report advised people to eschew fatty red meat and choose lean poultry instead. Channel 4 came to us last year and wanted to set up a programme about our work on the changes that the food industry is inducing in food composition. The data showed that the convenience food made from the chicken, the thigh, will give you 100 calories more fat than a chicken thigh in 1970. If you take a broiler chicken today, it produces between two and three times the number of calories of fat compared to protein, which is absurd. The industry must be making a loss in putting the fat into the birds and the consumer is being conned into buying something which is supposed to be lean but is not.

Channel 4 also wanted to do a programme on salmon. We already had data on wild salmon from Alaska. So we compared 60 samples of salmon from six supermarkets. The amount of fat in the wild salmon was between 6 and 7 per cent, on average. Of the salmons that Channel 4 bought, Morrison's had the lowest amount of fat at 6 per cent. It was farmed, but had a good composition. Conversely, Tesco's salmon had the highest fat score - 22 per cent. The FSA says that women who are pregnant should not eat any more than two oily fish a week, because the oil contains toxins, including mercury. Four to six of Morrison's salmon gave the same amount of fat as one of Tesco's salmon, so what does this advice mean? The industry is not involved at the moment in linking food production and nutrition and that has to change. This is a matter not only for the consumer but for the animals. It is quite clear that chickens with three times the amount of fat are grossly obese and that they would, if they were allowed to live long enough, have suffered from the same kind of diseases as humans.

Gordon Walker Caroline mentioned the fruit and vegetable scheme in schools. I do not know if you all know about that. All five- to seven-year-olds have a piece of fruit and vegetable every day. What I have noticed is that it is a sociable occasion. Then, before they go out to play, they go to their bags and take out a chocolate bar or something like that. Bernard's fruity bar might be a good answer. I think children would eat it. It is really difficult to monitor what people bring to school. There is a difficulty in trying to ban things. I have banned crisps, but I had to do it in a sneaky way. I said it was for health and safety reasons, because seagulls were swooping down to the crisp packs before the children had gone into school. If I hadn't had a health and safety excuse, parents would have come in saying "How dare you tell me what to feed my child"

Deirdre Hutton I had to fight tooth and nail to get nutrition into the Curry Commission four years ago because nobody then believed that nutrition was relevant to farming. It is now the issue that is talked about most. The link between what farmers produce and what we eat is a critical and under researched one. Look at the Karelia Project in Finland, for example, which was tremendously successful at reducing heart disease. I talked to the man who ran that and asked him what the most significant and successful part was. He said it was changing agricultural production to berry production. They are terribly pleased at the extent that nutrition in four years has shot up the agenda.

Sarah Mukherjee Yet berry producers in this country are going out of business.

Deirdre Hutton If you look at the increase of imported vegetables, it is quite worrying because we are good at growing vegetables.

Helen Crawley It would be nice to think that we have got real commitment from the government for a long-term strategy. We see lots of strategies coming along but quite often the funding is short-term. We talk a lot about the success of these projects which are running, an example of which is the fruit and veg scheme in schools. Do we have funding for that for the foreseeable future? If the government is going to make a real commitment, we need to see longer-term planning.

Sarah Mukherjee Does everybody get the feeling, as I sometimes do when I am interviewing politicians, that when you mention 2020, you see the shutters begin to go down.

Deirdre Hutton The 2020 issue where we may be able to get some traction is around pensions. I have been suggesting for the past two years, completely unsuccessfully, that this is the one long-term cross-party issue, but what they have not seized is the issue of poor health among working-age people. When you raise the issue with the pensions industry, they say, "Great. They will die young". But that is not going to happen.

I have three "e's" for today; evidence, education and environment. I think there is still a need to put together some of the evidence. Too much of it is anecdotal. There is not yet a good enough nutritional base. We do not yet have agreement on precisely what we mean by a "properly balanced diet", for whom, in what circumstances, at what age, sex, etc. On education, I absolutely agree with everything that has been said. The third one is the environment - food deserts, for example - in which that education has to take effect.

Melanie Leech I would like to add a fourth "e", which is that it is everyone's issue.

Sarah Mukherjee I cannot top that. Thank you very much. It has been a fascinating morning. I am sure there will be a lot of interesting debate around this subject when the report comes out in the New Statesman.

Spencer Neal Thank you to everyone on behalf of the New Statesman and Compass.

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