Cynulliad Cenedlaethol Cymru

Welcome to the Health and Social Care Committee this morning. I move to item 1, and we have apologies from John Griffiths this morning. If there are any declarations of interest, please do indicate now. No, there are not. As always, we operate bilingually as well.

This morning, we are continuing our evidence gathering as part of our inquiry into the prevention of ill health—obesity. We have three witnesses this morning on our panel, one virtually and two here on the Senedd estate in the committee room. So, I would ask the witnesses just to introduce themselves for the record. Kevin, I'll come to you first.

Thank you, Russell. My name is Kevin Miller; I'm a paediatric dietician working in a children and young persons' weight management service in Swansea bay, called Lighthouse. 

Thank you, Kevin.

Professor Nadim Haboubi, professor of clinical nutrition and obesity, and consultant physician in Aneurin Bevan University Health Board, and running weight management service level 3.

Thank you.

Bore da, bawb. Good morning, everyone. My name is Enzo Battista-Dowds; I'm a highly specialist weight management dietician in one of the tier 3 adult weight management services in Wales. Today, I'm here on behalf of the British Dietetic Association, their obesity specialist group, as their Welsh representative.

Diolch yn fawr iawn. Thank you for coming to committee this morning. Just before we started, you all indicated that you're happy for us to refer to you by your first names, so we appreciate that. Right, so, if we can dive into the first set of questions—each Member will have questions, but some general questions to start with—I just wonder whether weight-related stigma and discrimination is an issue. I almost certainly know your answer to that, but just to capture your views on that. And what impact does it have and how can that impact be reduced? So, a very wide opening question, and I expect that you'd all want to, perhaps, comment on that first question. Who would like to dive in on that first? Nadim.

I think it's well known that stigmatisation does exist among the obese, particularly the morbidly obese, and I think there are several issues in this, for example, employment. Obviously, they feel that there is a stigma, these patients, these subjects—I call them patients, because I, personally, believe that obesity is a disease. The other thing is that there are lots of publications on this in the past about these people even being stigmatised by health professionals in the way that we treat them. When they come to hospital, the patients who have, for example, pneumonia and who are slim have far more attention than those who are obese or morbidly obese. So, this is a general, incredibly sad issue that needs to be addressed among the public, health professionals, politicians and everybody else. And there are other issues, obviously, in the way they are treated socially and so on.

Thank you. Dr Enzo, the same question to you, but also, to what extent is the use of language important, how you use language in this regard as well?

Yes, of course. I'll take a slight privilege, if I may. I would like to introduce the concept of weight bias, which isn't necessarily mentioned here. The reason why I mention weight bias is to add a bit of extra context. So, if you think of weight bias as the actual thinking about weight—what our thoughts, feelings and perceptions are about weight in society—that is the concept of weight bias, so the thoughts behind it and what our feelings are around weight. Weight stigma is the consequence of those thoughts in society; it's the behaviours, the things we do and the things we don't do as a result of our weight biases.

If you step back and have a bit of a think about it, in society we've got people who have certain numerous biases for very many reasons—social pressures, cultural norms, everything else, which we haven't got time to discuss today. That stigma then influences people in two ways. It's explicit and it's implicit. What I mean by that is explicit is, very specifically, direct stigma and prejudice towards people. This is how we might speak abusively or aggressively towards people—that's the more far-end example of explicit weight stigma. Implicit weight stigma is more structural within society, where our thoughts about weight, our weight biases, influence what we do and what we don't do within society.

The simplest example, and a bit more practical, is thinking about how we accommodate people living with obesity when they need to sit down. Every time somebody with a particular higher weight—. Not every time, but many people are very conscious about where they can sit, and whether that seat is able to accommodate them, so they don't have an accident. That could happen anywhere in society. Where do you sit? You sit in a cafe, you sit in a doctor's appointment, you sit on a plane. If there isn't appropriate seating, you fall. It's one of the most humiliating experiences of your life. That non-accommodating of people in that situation is implicit weight stigma. There are lots of others. Nadim mentioned a very specific one as well within healthcare—how people are given less time because they're perceived to be not worthy of their time because of this health professional's weight bias. And why does somebody feel that? Because they are then thinking, most likely, that weight is somebody's fault, it's a blaming situation.

If you want to think about language, Russell and the committee, you also have to reflect on how we perceive obesity. If we perceive obesity as a behaviour versus a condition, then it's much more likely people are going to lean into a weight bias of blaming and fault. If you come to realise, as Nadim has put it—and I support the notion that obesity is a disease—that obesity is a condition, it makes you think a little bit more differently and a bit more openly in the way you speak. The first part of that is addressing what we think, understanding our weight biases and how it's influencing our behaviour—individually, structurally, societally. When we're talking more directly about how we speak to people living with obesity, there's some excellent guidance from Obesity UK about language matters, how we approach them. They suggest 10 principles—following those principles as a way of being kind and considerate and opening up to people. I'm mindful that I've talked a lot.

Mabon, you come in, yes.

Thank you for the question. More often than not, it's how it's perceived within the whole context of the conversation. There's a societal level and limited amounts of control that people have that contribute towards their obesity, because of biological, psychological and social reasons. That's not to say that people, when they're openly conversed with in a respectful and caring way, don't want to take responsibility for the things that they're doing that might help with their obesity. Most people do want to do that. Most people want to make changes, especially the people that I meet in my clinics. But when we talk about it in a way where it's the sole responsibility of people, I think that is a huge mistake and a huge misconception. Many people have very limited amounts of control, especially when we're talking about social inequalities. Their capability to do very small things might be within their gift, they might want to do that, but we have to acknowledge that there's very limited opportunity, especially for people with lower socioeconomic status. 

Thank you, Enzo. There's quite a lot you've said that could do with unpacking, but I'm not going to ask questions now because Members are going to dive into some of what you said, I know. Kevin, if I come to you, obviously there was my opening question, but I'll also ask you if there's sufficient training and knowledge of weight-related stigma and discrimination. I don’t know if you can comment on that, as well as any other comments you want to make on my initial questions. 

I think Enzo's done a really good job of describing my own thoughts and feelings on the issue. I think what I can potentially add to that is some of the experiences that have been shared with me by patients and families that come into our service. We know that the stigmatising language and the implicit bias that they've experienced can impact their willingness to engage with healthcare services, that there is evidence to show that people are less likely to engage with services such as ours. They've experienced that kind of stigmatisation, and certainly there are examples of families that have come into our service and shared some really negative experiences of being blamed and shamed and not really supported. I think when the perception is leaning too heavily on personal responsibility, then you're setting people up to fail. The experience that is shared with us from families that come into our service is that they've been told they need to lose weight, they've been told their weight is causing this issue with their bowel or this issue with their lungs or this issue with their pain, but not really supported in terms of how to address that, how to achieve that, other than exercise more and eat less. So I think it can be quite disempowering when the blame stops at obesity. 

Thank you, Kevin. I'm going to come on to Lesley Griffiths in a moment to ask some questions on her subject area, but just to say I don't think we'll have time for every witness to answer every question, but if you think you want to come in on something then please indicate, and I'll keep my eye on the screen as well for you, Kevin. Lesley Griffiths. 

Thank you very much, Chair. Good morning. I think it's generally recognised that there is a link between an individual's mental health and obesity, whether that's perception or whether that is actually the case. I was wondering if you could say a bit more about the impact of the state of a person's mental health as they went into weight-related interventions and weight management interventions. I wonder if you could say a bit more about what you think about the link. 

I'm happy to comment. 

I'm happy as well. I think we'll just have to share this, so if you can cover anything I don't, please. I think this works both ways, actually. Probably a third of my patients, and I call them patients, have a psychological problem and I am, in these circumstances, very dependent as a clinician on my psychologists. That's one issue. So these people probably have a psychological trauma, emotional trauma, back when they were children and so on, which could be physical assault, which could be bullying, which could be sexual assault, et cetera. That is very likely to make them obese. But there is also another part of this, in that people who are obese, particularly morbidly obese, would give an arm, would give an eye in order to lose weight. So they become depressed, frustrated, they are trying to lose weight, they go to Slimming World, WeightWatchers, they run, et cetera, but they still can't lose weight. And this group of patients are so frustrated, so upset, so depressed. I think that mental health is very much dependent. And we as clinicians running weight management services rely very much on cognitive and behavioural therapists as well as psychologists, and these are specialist psychologists—weight management psychologists. Do you want to add anything else on this? 

Absolutely. I think it's commendable how you've structured today, because we've talked about stigma already, which links into the mental health aspects of living with obesity. Nadim has mentioned trauma. A surprising number of people who come into our service have had problems with sexual or domestic abuse, and more often than not in those cases it has led to severe mental health troubles. And ways of coping have led more into eating behaviours that are obesity promoting. 

You can see that eating is one of the easiest things to lean into as a way of coping with distress. Eating particular foods is dopamine promoting, and some serotonin promoting, so it can feel stimulating and relaxing and it's temporary relief from mental and emotional difficulties. That can become a habitual cycle that then leads to weight gain and quite excessive weight gain for people over years who don't come to terms with a lot of these problems. 

When we talk about mental health, I mentioned the trauma, but we talk about people living with learning difficulties as well. You have to consider the capabilities to maintain personal environments to try and keep things as healthy as possible, and the people caring for them. That means they lean into cheaper, easier foods to prepare, typically more energy dense, and they don't create such feelings of fullness, so people tend to consume more calories, and find themselves in a situation of weight gain. The more severe the mental health condition—and the medications for many of these conditions are obesity promoting—the more severe the obesity. It's very common. 

The problem I would highlight as well is that the obesity stigma that people are experiencing through society also pushes them to drive for thinness, which then leads to people trying to lose weight and maybe getting certain success with weight, but then maybe they've lost a couple of stone and their eating habits and their health has changed, but they're completely dissatisfied because they've internalised weight bias and they have a drive for thinness, so their dissatisfaction causes them to relapse and give up on things that they may have done and return to these negative eating behaviours and other things that lead to an obesity-promoting condition. They are very much intertwined, and the far end of that is eating disorders.

Just picking up on that last point about them being intertwined, Nadim, you mentioned that you have specialist psychologists who you work very closely with. Within mental health services in general, would you say that health professionals would look at obesity and think that there is a link between the two, or do you think that that's not happening in a way that you would wish it to do so? 

I'm glad that I have been trained in motivational interviewing, how to approach these patients, because these people do definitely have a mental health problem, and I think that's what actually makes them go into comfort eating and having an eating disorder. So, I think there is a link certainly in it, but the problem, obviously, right now is resources, whether we have enough resources to address this. Have I answered your question?  

Yes, you have. I'm just picking up on eating disorders. Again, I think what you were saying is that there is a link between how a patient manages their weight and whether they have an eating disorder.

Yes. When I—. I think I would probably say that there are certain obstacles in the way of managing these patients. If the patients have an eating disorder, what's the point of telling them about what they eat or what they shouldn't eat? The problem is much bigger than that. And unless you address that itself, then it would be fruitless talking for an hour or two. They know exactly what is good food, what is bad food, when they should eat, when they shouldn't eat, but that's not the issue. It's actually the link between their emotions—. They have just a certain pathological or abnormal link or relationship with food, which is very much related to their emotional and their psychological problems. And they don't often tell you straight away about it, but you have to dig in, and we have to—. And that's why I strongly believe that, in this group of patients, management has to be tailored, has to be personalised, has to be one to one, because food is a very—. How much you eat, when do you eat and what do you eat is very much a personal thing. So, you need to build a rapport with this group of very difficult patients in order to alleviate or sort out or understand the original problem, which can be very much complex and can be related to way beyond and when they were very, very young. For example, if I may, a lot of these patients—not a lot, I mean a group of them—who are very difficult to manage are those who were assaulted in childhood, sexually assaulted, particularly by somebody who they know, related; it could be a father, could be a brother. It's quite a difficult task to address.

Lesley, Kevin wanted to come in.

Yes, thank you. Sorry, I'll be as quick as I can. I just wanted to add, from a children and young people's perspective, to what my colleagues have been saying already, that, within our service, we're trying to support children and young people and their families to manage in environments that they don't have control over from a psychological perspective. And, certainly, what I'm referring to there is there's a history of adverse childhood events—trauma, children in the care system. Weight-related bullying is massive for children and young people in school and something that really impacts their emotional wellbeing, and, of course, impacts their relationship with food and with their bodies. Coming back to the question around eating disorders, mental health services and obesity, I think—certainly, I can share from experience—that some children and young people who have a very likely eating disorder who come in to our service feel that they are seen as not as important to eating disorder services as someone who presents as underweight. So, when they present with something like bulimia, but have a high BMI, they feel like they're dismissed from eating disorder services because their BMI isn't low enough, their weight isn't low enough.

Thank you. So, just going back to eating disorders, I appreciate what you're saying—if somebody has an eating disorder, then you don't talk about it, in the way that you've just explained. But is screening done? So, when a patient presents with obesity, is screening done in relation to eating disorders, or would that be as you unpack, as you referred to it—

I'm happy to talk on this one.

—when you get to build up that rapport with somebody?

Yes. So, especially in tier 3 adult weight management services, which I think we'll come on to, there's a comprehensive assessment for people who come into the service on their particular eating behaviours and relationship with food—so, the things we've already talked about in relation to trauma, mental health that we would keep in mind. There are particular questionnaires. So, the most common one that comes into a service such as ours, most likely, is binge eating disorder. And there are questionnaires that we use to understand the severity of their binge eating, to see if it's most likely a binge eating disorder. The thing is, in those instances, that is then an eating disorder, and we work in weight management services. An eating disorder requires an eating disorder team. So, you can imagine a patient's experience, okay—I'll talk you through it. They've waited for an adult weight management service, they may have been on the waiting list for a year to two years, they come in and they have an hour assessment, their BMI's over 70, 80, they're more on the severe end of obesity—much more severe end—and they spill their heart out to you in an assessment, and they explain their very difficult relationship with food and their frequent binge eating behaviour, and then I have to tell them, 'I'm sorry; you have an eating disorder, you're not in the right place. I have to refer you to the eating disorders service', where they might wait a year, two. The point I'm getting at is that this screening and training and education could be happening a lot earlier, and that's a training need in primary care, essentially, and secondary care.

Can I just ask Kevin very quickly: is that the same in children and young people's services?

Yes. Yes, I can definitely relate to a lot of what Enzo is expressing there. We do, similarly, a comprehensive initial assessment, the information will be brought out of that assessment and may lead to a specific screening tool that we would use to identify the presence of an eating disorder. I think, within the all-Wales weight management pathway, certainly for children and young people, it does recommend fostering those links between services, so links between weight management services and mental health services. So, I feel that there is probably work that can be done there to make those links more efficient and effective.

Thank you.

Thank you, Lesley. We've got three main subject areas to cover, and I'm just conscious that we're not going to cover all. We've got about 10 minutes for each of the subject blocks, and if I can ask your permission as well if you're happy for Members to interrupt if they want to get to a particular point. Yes. Thank you; I appreciate that. Joyce Watson.

We've talked about treatment, but I'm trying to move us to prevention. So, what is the right balance between prevention and treatment?

That's a grand question. Thank you, Joyce. So, if you think of the obesity Foresight publication that came out in 2007, that was a fantastic document that mapped out all the areas that contribute towards obesity, and you're looking at like 100 different factors across society, and including the psychological and biological aspects around that. We are intertwined in a health disruptive environment that is obesity promoting. If we don't do anything to the health disruptive environment, we're going to fight a losing battle. So, we do need to start thinking about how we do counter that from a Government and regulatory perspective, not that this is much of the conversation for today. That can help in a more indirect way of supporting prevention, generate Government funding, retarget that funding in ways where you might then create treatment services in prevention.

I'm very mindful of the balance between focusing on one area at the exclusion of another, and getting that balance is very challenging. I appreciate and in many ways support the notion of looking into early years and targeting things there. You can get double wins. You know, we have got maternity and child services in here, where we are trying to help mothers during conception. There's work to be done there in Wales in creating a weight management pathway for maternity services. So, the balance between them, I think, is, essentially, putting a lot of focus on early years while maintaining or ensuring that there's adequate funding to maintain the services that we've got, and, essentially, try and enhance the services that we've got, in terms of weight management services. The treatment side of it, if left at the expense of the prevention and early years side of things, or if neglected, let's say, will cause more severe and extreme obesity for many people who are the most vulnerable in areas of social deprivation, and we will find quite severe increased costs to the NHS and Government as a whole as a result of that. So, the balance is tricky, but I do think you have to ensure that there are very effective treatments in place and work in collaboration with Government and health services, and a huge, broad public sector—

Enzo, I'm just conscious, as I've got Kevin and Nadim—

Yes, sorry. It's just such a big issue—

I apologise. We're short on time.

It just takes you from one thing to the next. I'll stop.

Kevin, I'll come to you, and then I'll come to Nadim. No problem at all. Thank you, Enzo. Kevin.

Yes. I guess I just wanted to add in to Enzo's point there that obesity management itself is prevention. By supporting someone to manage healthy weight, through whether it's lifestyle change, diet change or managing the complications associated with excess weight, we're attempting to prevent future complications or those complications becoming more significant—hospitalisations and chronic diseases. I don't have the answer in terms of what the right balance is, but I think we have to acknowledge obesity management as a preventative measure as well.

Thank you, Kevin. Nadim.

Thank you very much. I just want to give you a very small example, actually. Back in 2008, the Foster medical report—and this is a Dr Foster from somewhere in London, actually—looked at every single county in the UK and looked at where were the worst obesity areas and the best slimming parts, which county, and, interestingly, the top five in slimming, with the best BMI, were in counties where, all of them—the best five—were in London. I recommend that you read that report. When you look at the worst five, the worst, hottest, spots in the UK, they were all from south Wales, and the worst part was Blaenau Gwent. We call it the capital of obesity, where I work. I think the reason why is because they walk, and when you walk and you—. You know, they take the underground, they don't drive as much, and I think that's probably one of the main—. So, prevention, it has to be started early: avoid a sedentary life, not only just know what you eat and so on. And I think this is important, that you know that there are so many things that you could do in order to prevent obesity.

Now, when you talk about management, management is a very different thing, because we know that the cause of obesity is multifactorial: it could be genetic, it could be environmental, mental health, eating disorder, a hormonal problem et cetera. Then the treatment is very complex and difficult, and it has to be addressed in that way. And then, obviously, apart from modifying your lifestyle and so on, which has to start very early—. I mean, what's the point of asking people to—? If they walk with crutches because of their severe osteoarthritis, how can you exercise them? And that's why there is just modifying according to their problem, and then, obviously, now we have other avenues to address, for example pharmacotherapy, which is drugs, and bariatric surgery, which, surprisingly, is not an item in this particular meeting today.

Thank you. Joyce, I just think—. We're short on time. Any last question at all from yourself?

Yes. You've mentioned lots of the things—minority ethnic groups, deprived areas—but I'm going to ask you about ultra-processed foods, and the link between poverty and eating ultra-processed foods, because I watched a documentary a few nights ago where they were talking about ultra-processed foods being a real problem when it came to obesity.

I'm happy to go first. Excuse me if this is not exactly direct, but it helps to illustrate the point. If you look at the Eatwell Guide and you see the differences there—maybe you're familiar with it—in terms of the concept of healthy eating, you've got your variety of food groups, fruit and vegetables, your carbohydrates, your proteins, and everything else that's in there. I won't go into the depth of it. But one small slither of it is the acceptance that these foods are within our society and, eaten in balance, they are not likely to cause any harm—in balance. And that is quite a small slither of the balance, because of their high energy. You take that guidance, and then you look at how that is done in a practical way for people on the breadline, with financial difficulties, getting through day by day, and to follow a healthy eating diet, it's going cost them 50 per cent of their income to be able to do that. Compared to the other end of the scale, the top end of the Welsh index of multiple deprivation—it's 10 per cent. So, the ease of healthy eating is dramatically easier based on your financial position.

We know that those foods, through their energy and the way they are created—they're made to be consumed and to be consumed more of. So, they're highly palatable, less satiating—'We don't want you to be full on them, because we want you to eat more of them so we can sell you more.' And they're cheap to produce so they can be sold cheaply. So, it's a very rational decision to buy them, because they're affordable, if you haven't got much money to buy other things.

So, the reason why I went down that line of thinking on this subject is that we have to recognise that this is a problem, it's an affordability problem, and we've got very cheap foods that are exacerbating the health disruptive environment and being more obesity promoting, and we've got more expensive foods that could be helping us to alleviate that problem. And there are ways of making healthier eating more affordable, of course, to do that work with people, but we do have to think about the fact that we have a societal duty to try and make healthy eating more affordable, and we could do that through the taxation of things, including ultra-processed foods, to try and make fruit and vegetables more affordable, and other health-promoting foods.

Enzo, Lesley just wants to come in with a quick question.

Do you think ultra-processed foods are addictive?

What did you say, sorry?

Do you think they're addictive?

Kevin wanted to come in. Kevin's got the answer. Kevin—. I'm joking.

Yes, go on.

I don't know if I have the answer, but what I would say is that the process of ultra-processing foods really involves food production, which is extracting components of foods and then repackaging them. Of course, what food producers are looking to do is create a formulation that's going to really stimulate our appetite and really stimulate those—. I can't remember if it was Enzo earlier who said about the different hormonal responses that we have in relation to foods. That's what they're trying to stimulate. Whether I would describe it as an addiction, I'm not entirely sure, but there are certainly similarities between the neurological responses, then, within the brain. So, we're having food produced at a mass and being marketed towards particularly children and young people, but also adults, that are ultra-processed, that are stimulating appetite and drive for more and more consumption of those foods.

Okay, thank you. I'm hoping Joyce has asked all the questions she wants, because we're short for time. I'm just thinking, in the last 20 minutes of this session, ultimately, of course, what we want is to have your advice on what you think are reasonable recommendations that we can make positively to have influence, because I think, in many senses, we’re talking about some of the problems, which we all agree on, but it’s just finding some solution, and we want your advice in that regard. Sam Rowlands.

Thanks, Chair, and thank you for joining us this morning; it’s appreciated. I just thought, and then I’ll perhaps come to questions—. I was reflecting on how, I guess, over the last 60, 70 years, the relationship between socioeconomic standing and obesity has probably flipped, in that I expect, 70-odd years ago, those who were poorest in our communities had probably, in terms of BMI, the lowest levels of BMI, where that has flipped over this sort of 70-year period, whereas those in the poorest communities perhaps suffer the most with obesity. It was just a reflection; I could well be very wrong on that. I wonder how much—it’s just an interesting thought—our socioeconomic circumstances seem to have done a complete reverse when it comes to obesity.

I want to touch on the adult weight management services that exist in Wales at the moment. I know, Enzo, you’ve already described some of those services, and perhaps some of the frustrations with the waiting times with those services. But, perhaps, between the three of you, you could outline the current support and treatment that is offered to adults, or adult patients, through the all-Wales weight management pathway. And perhaps if you could outline whether you believe there is sufficient provision and capacity to meet the current need and demand within our systems, to keep those waiting times to what might be an acceptable level. So, I’d welcome your thoughts on that.

Kevin's indicating. Keep in mind that we need to be shorter with the answers. I'm so sorry to say this, but it's just to get through all we need to get through. Kevin. 

Yes, just really briefly, then. Of course, I work in children's and young people's weight management, but, from my awareness of the wider service within Swansea bay, there isn’t a level 3 weight management service for adults that exists within Swansea bay. So, I guess it’s bringing attention to the inequity across Wales. What they do have in Swansea bay is a level 2 offering, which is very limited and delivered by the department of nutrition and dietetics. So, there’s no multidisciplinary team around it. And what they’re seeing are lots and lots of referrals—probably more, or certainly more than half of the referrals that go into that service will be for people, for adults, who would be eligible for a level 3 service if it did exist.

And Nadim.

One of my positions is that I’m privileged to be chairman of the specialist obesity service. Now, 10 years ago, there was only one health board running a weight management service. Luckily, and fortunately now, because we worked hard to establish that, every single health board has a weight management service, which is fantastic.

I think one pride of the Welsh Government is the all-Wales guidelines on weight management, which divided the prevention and treatment into four levels. I think the—. We are very short on resources. The waiting list for my patients now is three and a half years, which is a joke. And patients come and complain, obviously. And I think we need to start to ensure that—. More resources are needed for every single health board, actually, in relation to ensuring that there is enough staffing levels, that there is enough—. And we are just not managing, actually. And now patients, because they are more aware than us about what treatment is available, for example drugs that have become recently approved by the National Institute for Health and Care Excellence and so on—and these are very effective medications; I’m one of the prescribers—these patients want these drugs, but they can’t have them unless they see the specialist, and unless they see the person who prescribes them. And to see them, you need years. I think this is sad. I think that makes them depressed, frustrated, and I think something has to be done about it.

Similarly, in the past, for example, we had, and still have, a problem of ensuring that certain patients who must have surgery in order to lose weight—they must. There is no other way about it. But they are denied that, simply because the way we commissioned—or the Welsh Government commissioned—Swansea as a bariatric centre. They only commissioned for a very small number, when the requirement for managing morbid obesity is far more than what has already been available. I don't know whether I've answered the question or not.

Can I come in very quickly? I'll be as quick as I possibly can. I want to draw your attention to what was called the all-Wales obesity pathway, published back in 2010. It was the first of its kind in the UK. It was before the UK obesity guidance was published, about a year or so later. We lost a decade. We lost a decade—we had an opportunity back then to start to implement these services from 2010. We lost a decade. We had 'Healthy Weight: Healthy Wales'—great. That came in. What came with it? Commitment and funding. We had actual money going into places, places that are now starting to actually implement services. It's not equitable. It needs equity across Wales. That means tier 3 services in all health boards, tier 2 services in the appropriate conditions. I commend the diabetes prevention programme that we now have, but there is room for improvement. So, my point is that we need commitment and leadership from Government to make sure that this is happening for everyone in Wales. When it is equitable, let's provide equitable treatment. It's only 250 or so a year in my health board. Let's provide them with the treatment that they should be eligible for, and I mean that in terms of the glucagon-like peptide-1 receptor agonists. That's not a lot of people.

Are you saying we need leadership? Are you suggesting that we haven't had leadership?

I think there's been a lack of leadership in that decade, a decade, not lost—. I say the leadership is good, because what you get is you've had mostly nutrition and dietetic managers scrambling to try and do what they can, with pockets of money from here, there and everywhere else, doing different things for different patient groups. But since the 'Healthy Weight: Healthy Wales' publication and the new weight management pathways that have been published, we've had funding attached to that in many health boards, so that is a massive step.

Sam.

Okay, thank you for that. I just want to move briefly to touch on Professor Nadim's point around some of the new drugs that are approved by NICE and are starting to be accessed by patients, whether through the NHS or through private provision. I just wanted your comment, perhaps, on the long-term impacts or the long-term benefits of these drugs, and also to understand, perhaps, between the three of you, the current success of the interventions that are available to you as clinicians and whether, just going back to the previous points that Lesley raised, there should be more focus on the mental health side of interventions to support the patients you're working with, if that's the root cause of many of the issues that you're dealing with, or are the interventions that you have in your toolkit, as it were, appropriate and successful in terms of better outcomes for those patients? There are a few bits there. Thanks.

In terms of the long term, in relation to pharmacotherapy or drug use, we know for a fact now—and I think it's been even in the national papers—that since the drugs have been available, these people, who were unemployed before, are getting more employment and start working. So, there's an issue about when they are treated and they become slimmer. But that doesn't mean every obese patient has to have a drug. No, on the contrary, there are certain people who are morbidly obese and are definitely far better having surgery, because there's a limit for how long the drugs can be used. I mean, right now, we are told, not for medical reasons but financial reasons, that we cannot use whatever drug it is that's available for more than two years. But we also know, from research, that when you stop the drug, yes, two years later there is a weight regain. They do rebound. So, it's quite a challenging problem. And I honestly personally believe that there is treatment and there is how to maintain that weight loss, which is not going to be easy, and maybe with a drug, but using it over a longer period of time, probably with a much smaller dose. Money. That's what you need.

You asked whether services were appropriate, and you highlighted the root cause being psychological. There are many root causes, but in the individual, it's psychological. So, with extra commitment in more recent years, we have been able to fund and have psychologists within the service, who are paramount to these services. There are some excellent ones in Wales. And they have helped to enhance the psychological and behavioural aspects of programmes that have been lacking in the past. There has been quite an advice-giving approach, which has a very limited impact on many people. But these things have improved as behavioural science has improved in the last decade, and as we've had psychologists within our service. There's definitely a need for improved provision of psychologists within weight-management services. There's definitely an argument for that. 

In terms of the GLP-1 receptor agonists, this new wave of medications, if we were in a position to at least offer them to the majority of people within services—and I mean tier 3 services, as it's described now—that could transform what we're doing at the specialist level. If there was any action to take outside of that, we could have a very complicated situation in terms of people losing weight in the community. And this is happening in the private sector. People's drive for thinness and taking these medications means that they're taking them without help and support and they're losing 20 per cent or maybe more of their body weight in quite a short period of time. When that happens, they lost quite a significant amount of their muscle mass as well as fat mass, which is mass that you don't want to lose from a metabolic perspective. You want that for your health and well-being and your physical fitness. So, people are becoming more frail. They're still living with obesity, but it's not as extreme, and they are at a higher risk of falls and co-morbidities. What are falls as a cost to the NHS? One of the most severe costs to the NHS. So, we really need to keep those things in mind.

Thank you. I'm really sorry that we're so short of time. Kevin, I know you wanted to come in, but if I can ask you to hold fire, perhaps you could answer some questions and make some points after the next set of questions, if that's all right. Mabon ap Gwynfor.

I'll bring in Kevin first, and Kevin if you want to make any other points in relation to the last set of questions as well. 

Yes, just firstly to answer that question, I could very quickly say that services are not equitable across Wales in terms of maternal weight management. There isn't a specific service or pathway within Swansea bay. That's not to say that expectant mothers don't receive any guidance or advice from the services that they are engaged with, but there aren't any specialist pathways to support them in that. Of course, we know that there are links between maternal obesity and childhood obesity, and of course the concern around gestational diabetes, which also will have an impact on childhood obesity, potentially, as well. 

Coming back to the GLP-1s, just really briefly, the GLP-1 agonists, they're not something that we prescribe within children and young people's services across Wales, to the best of my knowledge, and certainly not in Swansea bay. I wanted to address something about how the impact or success is measured in terms of services. Something that we feel is really important, certainly within Swansea bay, for measuring success, is: are we measuring it in a really weight-centric way? Is success only judged by weight reduction or are we moving beyond those measures and looking at the impacts that we've touched upon today, including psychosocial complications, metabolic health and physical health and well-being?

Yes. Mabon, do want to ask any further questions?

Yes, I think that's a very valid point. When children and young people come in—. So, we've got the levels, the four levels, across the pathway, with level 2 being those children and young people who—. Specifically, it's measured with BMI as a metric. So, those between the ninety-first centile for BMI and the ninety-eighth centile for BMI would be appropriate for a referral into a level 2 intervention to support healthy weight and well-being. The uptake of those services across Wales is minimal. There may be lots of different reasons for it. One thing that I see as a challenge is that, if these services sit within health, but people don't see the health consequences of carrying excess weight in themselves or their children, they're less likely to go seeking healthcare. And I query, I guess, whether these kinds of interventions would sit better elsewhere within early years settings, within a combination of public, private and voluntary sectors.

A really good example, actually, of something that has taken off and become quite popular in Swansea is the Fit Jacks programme, and they're expanding that, as far as I understand it, to a new programme, called Fit Families. So, whereas Fit Jacks has been primarily aimed at adults, Fit Families, I think, really appropriately as well, addresses the whole family—supports the whole family as opposed to singling out any individual. And, yes, I think maybe looking at ways to engage and better connect with communities rather than expecting people to come in to healthcare settings, when, actually, at a level 2, if they're not seeing complications from that level of excess weight, then they are not going to come seeking healthcare.

Yes, I'm more than happy to. So, we were set up as a children and young people's weight management service to follow the all-Wales pathway for weight management. We include myself as a paediatric dietician; we also have—. So, we're a multidisciplinary team now, so we also have a physiotherapist, a clinical psychologist, an occupational therapist, a consultant paediatrician, and administrative and support staff as well. So, we are a small team, but we've got a good mix of skillset within that team.

I've thought about how I'd describe the service, and I thought a really good way to do that is to think about what our key principles are that we work towards, because I think, probably more than just describing job titles, this is a really nice way to describe us. Our principles are that weight management is about improving health and well-being, not simply the numbers on the scale; that weight stigma and weight bias can be barriers to weight management; that interventions should address the root causes, so that's about identifying what are the complications that people are experiencing and supporting them to manage those; and that the best BMI or weight that a child can achieve is not necessarily the ideal weight, but that success actually looks different for everyone. For some people, yes, they may be looking for weight reduction; others may be looking to improve their quality of life, their self-esteem, their physical function, their mental and social health. So, yes, that's a really sort of brief run-through of who we are.

Thank you. We're just out of time, but I did want to just come to each of you, and for time, I'll ask you two questions in one, which demand really short answers. If you were to make one recommendation that you think would bring about positive change, what would it be? I'm going to come to each of you in turn, so a specific recommendation to bring about the change in regard to what we've talked about this morning.

And the second part of my question is different. Are there any international examples anywhere in Europe or around the world that you can point to where there's been good success in tackling issues around obesity that you think we should look at or explore? So, two different questions, but who would like to go first on that? Nadim, yes.

Can I take the first one? You take the second one.

We're over time, but you can answer both each, because they're both very specific questions.

To be honest, didn't get exactly what the second question was. That's why I pushed it to him.

So, the first question, give us your top recommendation that you think will be positive for change. The second is an example, an international example of where you think there has been success in terms of tackling obesity and some of the issues that we've talked about.

I think we have an excellent guideline by the all-Wales obesity management, but we just need more resources, and probably in every single level. And I think they would have to differentiate between prevention and management treatment. And I think, yes, there should be a link, but I think we need more resources, because you see, the average BMI in an adult in the UK is more than 25, it's 27.6, okay? So, really, we need to start early, very early, and we need to address this by ensuring that not only having resources, but also—. I mean, I remember a long time ago, and I very, very worked through that idea that we should have a body, or a Minister, or a department that actually looked at this weight management, where to get all the sources from the local health board, societies, supermarkets, getting all these collective efforts in order to manage it, rather than just Public Health Wales or just one health board and so on. And I think that—

So, I'm condensing. It's very difficult for us to make recommendations saying, 'Can you give us more money?' So, it's specifics that we're looking for, but I think one thing I'm picking up from you, Nadim, is that you think that there should be a greater focus within Government in terms of leadership in the areas that you're talking about.

That's right. Absolutely. That's what I think.

Okay, and any international examples that you think we can look at?

International examples?

Yes.

I think it's somewhere like in Sweden, there is certainly a group of, like a department, which is supervised by the health department, like the ministry of health, which actually looks at obesity itself from childhood to adult, and I think it's no wonder they don't have obese people there.

So, this is one way, probably of—. Because it's a very complex problem, and we don't think that it is simply a behaviour problem, because there are so many reasons why people are obese, and that's why it needs to be addressed by the whole of society, rather than just by a single group—Nadim Haboubi, the doctor, well, yes, but it doesn't mean that or dietician, dietetics, and so on, so effort has to be made globally.

Yes. Thank you, Professor Nadim. I think Kevin indicated next, and I'll come to Dr Enzo last. Kevin.

Sorry to push in. I'm a bit time-restricted. I have a patient who is expecting to see me, so I just wanted to jump in quickly and just say, yes, there's no easy answer, is there? In terms of specifics, it's really difficult, but I think if the focus can be, from a policy perspective, making the healthy choice the easy choice, because if we're not doing that then the focus is always going to be on the individual, and it's always going to be on personal responsibility and it's always going to be contributing towards that weight stigma, that implicit weight bias that we've touched upon a couple of times. So, it's about how do we make the healthy choice the easy choice so that, the people who have fewer privileges and more barriers to making the healthy choice, it's more accessible to them.

In terms of the second part of the question, there are a couple of examples, one that I'm aware of from the city of Leeds. There's a study that came out of Oxford University in 2019 that summarises their weight management strategy, which they developed in 2009 and was really a whole-system approach to supporting weight management across the city of Leeds. They used a programme of education that was delivered within communities, and what they saw as a result of that was a reduction of obesity levels within I think it was six-year-olds. The child measuring programme that we have in Wales is measuring six-year-olds, and similar in England. They saw a reduction in that, whereas, across England, the rate stayed the same.

I have a patient who is expecting to see me, so I just wanted to jump in quickly and just say, yes, there's no easy answer, is there? In terms of specifics, it's really difficult, but I think if the focus can be, from a policy perspective, making the healthy choice the easy choice, because if we're not doing that then the focus is always going to be on the individual, and it's always going to be on personal responsibility and it's always going to be contributing towards that weight stigma, that implicit weight bias that we've touched upon a couple of times. So, it's about how do we make the healthy choice the easy choice so that, the people who have fewer privileges and more barriers to making the healthy choice, it's more accessible to them.

In terms of the second part of the question, there are a couple of examples, one that I'm aware of from the city of Leeds. There's a study that came out of Oxford University in 2019 that summarises their weight management strategy, which they developed in 2009 and was really a whole-system approach to supporting weight management across the city of Leeds. They used a programme of education that was delivered within communities, and what they saw as a result of that was a reduction of obesity levels within I think it was six-year-olds. The child measuring programme that we have in Wales is measuring six-year-olds, and similar in England. They saw a reduction in that, whereas, across England, the rate stayed the same.

Thank you, Kevin. Sorry for overrunning, and I appreciate if you have to dip off; we're going to finish in two or three minutes, this session, but we've run over, sorry. So, if you have to dip off to see a patient, we absolutely understand.

Thank you very much.

Enzo, so, the last, the final, word to you in terms of your top, key recommendation that you think we could possibly make as a committee to Government and any international examples you can point to.

I think you will be familiar with the work that's been done in Amsterdam, I think Massachusetts has been mentioned, and the work in Finland. That was submitted with the consultation that I co-ordinated from the British Dietetic Association. What you notice within those international examples is that they are multisectoral, so thinking about a systems-wide approach to alleviating the problem of obesity, particularly looking at those earlier years to try and reduce the rates that we're noticing in the younger years, with the expectation or the hope that that is maintained over the longer term. So, these examples, these international examples, putting rigorous evaluation procedures in place—so, clearly, you've got good leadership and expertise to be able to ensure those things are happening—we need that here in Wales, most definitely, in terms of the research being able to cross over with the public sector, so more collaboration with universities.

We—. This is not an easy answer; one recommendation is really tough, thank you—

You can make two, but they've got to be shorter.

Indeed. I'm here on behalf of the BDA's obesity specialist group, but I'm a clinician foremost, and that's my work: I see patients. And I think the fact that we have a postcode lottery in terms of treatment for weight management at the moment is unfair and unjust. So, I would look to put the leadership from Public Health Wales along with the leadership from the management of the services that are in place to do rigorous evaluation. There are minimal data sets in place; make sure those are adhered to as effectively as possible. Implement appropriate research and evaluation to enhance that process and report to Government about what's going on, what's equitable, how do we benchmark, earn the money that we're given, and try and make it more equitable across Wales by doing that.

Thank you. That's helpful; that's a really helpful, key recommendation. Thank you so much for being with us today, Kevin, Professor Nadim, Dr Enzo. Apologies that I've had to interrupt sometimes to cut off, just to get through all the questions; there's so much to fit in in one hour. But we really value your time this morning, your expertise and your professional advice to us. Diolch yn fawr iawn.

Thank you very much.

Thank you very much.

We'll take a 10-minute break. Back at 10:50.

Welcome back to the Health and Social Care Committee, and I move to item 3 today, which continues our evidence session in regard to prevention of ill health around obesity. We have two witnesses for this next session. So, perhaps I can ask them to introduce themselves for the public record. I'll come to you first, Angela.

Dr Angela Meadows, department of psychology, University of Essex. My research focuses on weight stigma in just about every domain, but my background is also biomedical—my undergraduate degree was in biomedical science before I did my PhD in psychology. I'm also a founder of the annual international weight stigma conference, now in its tenth year, which draws researchers and practitioners and advocates, public policy people, from all over the world, and that happens every year in different countries. Dr Flint hosted it in 2018 in Leeds, but we have been all over.

Thank you, Angela.

Stuart Flint. I'm associate professor at the University of Leeds in the faculty of medicine. My research is focused on subconscious processes that govern behaviour, with a focus on weight stigma, which has been a key thread of my research for coming up to 20 years now. I also hold an honorary academic position with the Department of Health and Social Care for UK Government, and I'm president of Scaled Insights, which is an artificial intelligence company.

Lovely. Thanks, both, for being with us today. So, how does weight stigma and discrimination affect an individual? I know that's a short question, but a massive question, but just to give you a chance, perhaps, to set the scene. Who would like to go first?

I'll let you go, Angela.

Okay, thank you. Weight stigma is often considered as a unique phenomenon, but you can actually look, and everything that applies to weight stigma pretty much applies to any kind of stigma and prejudice. So, we can draw on the wider prejudice literature for conditions and identities that have been studied for decades and decades and decades.

Stigma is not about being mean to fat people, or being mean to black people, or being mean to people with mental health conditions. It's a structural form of inequality within society, where some groups are devalued compared to other groups and then they face inequalities across the lifespan in education, in employment, in interpersonal relationships. Weight stigma has the added benefit of being widely stigmatised in the media. Stuart's done some work on this. But it affects outcomes. So, heavier children do more poorly in school, despite having equal IQs. Even at kindergarten level, you're starting to see differences in the way they're treated. In employment, they are less likely to be hired, they are less likely to get the same wages, they're more likely to be fired or disciplined, despite having equal qualifications. There's a wage penalty to being fatter. And all of these apply more to fat women than to fat men. I use the word 'fat' in a neutral way, rather than the medicalised terms 'overweight' and 'obesity'.

And you can see from all of the prejudice literature that stigma, constantly being told that you are worth less and that there is something wrong with you, is a chronic form of stress in your environment. You never get to turn off from it, whether you get it when you go out of the house, when you turn on the television, when someone gives you a dirty look on the bus, and, of course, because so much of—. People are blamed for their weight, so a lot of them think it's their own fault. They don't know anything about the biology of higher weight. So, they internalise it as well. So, even when all the other messaging stops, it's still inside their heads, telling them they're worthless. And there's a lot of research that shows that just having these thoughts, just devaluing yourself, or even just being unhappy about your weight, regardless of what that weight is, is associated with increased risk of a wide range of physical and mental health conditions, including a much higher risk of developing diabetes—about three times the risk, independent of what you actually weigh—heart disease, metabolic syndrome.

But also, from the wider stigma literature, chronic stressors affect us. Our bodies respond to stress in well recognised ways, with stress hormones and all the resulting biological changes to deal with those. And this results in systemic inflammation, increased risk of heart disease, diabetes, hypertension, some cancers, poorer birth outcomes. So, you might think I'm talking about obesity here—that's also from the racism literature. So, any time you think of a health problem associated with obesity, have a look at what's happening in the BAME populations, the black and ethnic minority populations, and you will see exactly the same things. So, that would be the main point that I would want to make, to make you aware that stigma is a systemic problem, and it’s not just about being mean to fat people.

Thank you, Angela. And, Stuart, the same question to you, but, perhaps, if you’re agreeing with Angela, to extend on that, in terms of what the solutions are to reducing stigma.

The only addition that I would make is that—and Angela has touched on some really important points—it has several impacts. So, impacts in terms of health-related outcomes, for sure. There’s so much literature on the impact of experiencing weight stigma on mental health outcomes—increased risk of depression, reduced self-esteem, risk of disordered eating behaviour and so on. Physical health, we know that—again, empirical literature has shown—any experiences of weight stigma increase cardiometabolic risk factors and more. It’s even, actually, been associated with increased weight gain, experiencing weight stigma itself. And, then, behaviourally, it will impact people in many different spaces. So, people typically respond as what is described as maladaptively: disengagement in education, avoidance of different settings, including healthcare itself. So, weight stigma is having a really detrimental impact right across the board.

And the one study that I’ll quickly mention as well was a National Institutes of Health study that was published by Angelina Sutin in the US, and what they were actually showing there is that experiences of weight stigma, irrespective of people’s weight status—so, whether people were in the healthy weight range or in the underweight range or obesity range—has a detrimental impact on people, on their health outcomes. So, weight stigma itself is a modifiable risk factor, irrespective of people’s weight.

Your follow-up question there was: what can we potentially do about it? Well, the answer, ultimately, is that it’s not easy, because, as Angela alluded to, it’s systemic. It is ingrained in our society, and it’s very widespread. So, there is no doubt that most people across the population will have a stigmatising view about overweight and obesity, because, actually, it’s promoted to us in many instances as well. And, in January, I will be asked, because I’m asked every single year, ‘But isn’t weight stigma good, Stuart? Isn’t it going to increase people’s motivation to want to lose weight and so on?’ That’s not the case. The literature consistently shows that, for people living with obesity, experience of weight stigma has a very detrimental impact.

Interventions to date, where we’ve seen some benefits—education has probably been the most beneficial. And I say that—. It’s not much, and that typically dissipates over time, because we can change people’s perceptions, potentially, in a lab or a controlled environment, and then when people return to the environment that says, ‘Actually, people with a higher weight status are worth less’, and so on, of course, our attitude starts to dissipate back to baseline.

So, there’s no long-term evidence of changing views about weight stigma that I could point to in the evidence base. Educating people about obesity, about weight, about the biological, the psychological, the social—. There are so many different factors that we’re not told about. We’re often told it’s just, ‘Eat less and move more’, of course. That certainly is beneficial in terms of improving people’s knowledge and awareness, and, I think, on a conscious level, it can start to change the way that people potentially communicate about obesity and so forth. But when we’re talking about some of the more robust attitudes that people have, that’s very difficult to shift.

Thank you. Angela. 

Thank you. Yes, I’d just like to expand on something that Stuart said about educational interventions. So, the vast majority of these focus on the complexity of obesity, the control ability, as in people don’t have as much control over their weight as we think they do, it’s very complex. If you look at the 2007 Foresight report, they came up with over 100 factors that influence body weight. And these interventions—a lot of them have been done with healthcare professionals, or future healthcare professionals like medical students and so on—are very effective, generally, at educating people about the complexity of obesity, but they tend to have much lower impact on people’s attitudes towards higher weight people. So, it doesn’t change their dislike of fat people. They might say, ‘Okay, it’s not their fault’, but we’re still problematising fatness. So, the complexity argument is: ‘Yes, it’s a problem, but it’s not entirely their fault.' It’s still problematising obesity. And, as Stuart says, as long as we are sending a message that higher weight itself is a problem, it’s going to be very difficult to actually change attitudes towards higher weight people.

I’d also just take this opportunity, about the 'Eat less, move more', which seems so intuitive—

Hold fire. We might ask a question on that.

Sure. Yes, okay. We can come back to that.

Yes, absolutely. Thank you, Angela. Lesley Griffiths.

Thank you. I was going to ask you about the links between mental health—and I suppose I'm referring to poor mental health—and obesity, but I just wanted to pick up on a point that you made, Angela. I thought it was really, really important, that, even if you're not obese, you could still be unhappy about your weight and that could lead to mental health issues. So, if you could just say a bit more about the links between the two.

Yes, absolutely. So, there have been some interesting studies that show telling people—. So, there were some studies done in students, giving people feedback about whether they were so-called 'overweight' or 'not overweight', regardless of if they were, so thin people who were told that they were overweight and fatter people who were told that they're not overweight. Being told they were not overweight actually improved mental health outcomes, whereas, for thin people, being told they were overweight worsened mental health outcomes. Angelina Sutin has done a lot of this work, some of it in collaboration with UK researchers, and has shown the directionality, in that the stigma tends to come first, followed by the mental health problems, not the other way around. Does that answer your question?

Yes, it does, yes. That point about stigma coming first is really interesting.

Yes. The other thing I'd like to point out is that there are some very good cohort studies, which is where they follow a large group of people over time, mostly in the US. There's a very good study, the Aerobics Center Longitudinal Study, that's been going since the 1970s. Every couple of years, they send out questionnaires, and every five years they get people into the lab and do maximal treadmill testing to look at their fitness and so on. And they have some data—and it's not just from this study; there is other data from large cohorts—on weight dissatisfaction, so being unhappy about your weight, and I gave an example before. So, there is some longitudinal data, and they found that, compared with people who are satisfied with their weight at baseline, so when they first started measuring, and were still satisfied on average five years later, compared with those people, being dissatisfied at both time points increased the risk—. This is not mental health, but it increased the risk of developing diabetes by three times, even controlling for their weight, which means that it's not how fat they were, it's being unhappy. But the good news, which speaks to solutions perhaps, is that people who became satisfied about their weight, regardless of whether their weight had changed, their risk for these metabolic conditions actually went back down again. So, simply, basically, hating yourself is not good for you, and other people hating you is not good for you. It's a constant form of stress, which has metabolic and psychological health outcomes.

Thank you. I'd just add that the association between mental health and weight stigma is right through the life course, so from very young individuals. So, from the age of three, children are reporting body image concerns and engaging in disordered eating behaviour. Again from a very early age, before the age of five, there are reports of different types of stigmatising and stereotypical perceptions about people or characters that they might see on tv and others. So, it is impacting people from a very early age, and a lot of literature will also talk to the traumatic experiences relating to weight stigma, particularly when it's experienced within the family, so from significant others, from family members, from mothers, from, of course, friends as well. But that traumatic experience that people have that increases the risk of mental health concerns is also associated—. It's associated with both weight stigma but also weight gain, as young children grow and get older, and, of course, then it impacts their engagement with different types of healthy behaviours, whether it's physical activity, what they eat, how they eat, and all of those types of things. So, I think it's a crucial link that's impacting young people today and is only getting worse as people are becoming more engaged with things like social media and so on, where there is more and more information relevant to weight and body size.

Thank you.

Joyce Watson.

I'm going to talk about—you've touched on it—the complexity of obesity. But what are the most significant factors, beyond the ones, perhaps, that you've mentioned? And I'm going to also ask about socioeconomic status and ethnicity.

Stuart, do you want to take that or shall I?

Sure. I can, yes. The complexity of obesity and weight gain more generally has actually been around for a very long time. Angela alluded to the Foresight report, for instance. I'm sure everybody is well aware of that, so I'm not going to mention too much on that, but, ultimately, evidence has consistently shown that weight status—weight gain, but also weight loss—is driven by many, many different factors from many different determinants, whether it's genetics, whether it's social, psychological, the environment and so forth. There's no one reason why people gain or lose weight; it's multifactorial, and there's no commonality. So, the factors that impact my weight and that of other people around this room will be different. So, to say that there is one silver bullet or one solution that impacts people's weight gain or weight loss or change in weight status would not be true. So, complexity is clearly an issue. It's something that we need to better understand, and evidence is coming out. So, the Foresight report—over 100 different factors. We know a lot more, for instance, now than we did in 2007. It's still, however, probably the most talked to document in terms of showing complexity. 

In terms of socioeconomic status, which you mentioned, consistently the evidence would actually show that it's the most important factor. However, it's probably the factor that we don't do enough about. There's also some nice work from Adam Drewnowski in the US. His work would show that house price is actually the most important factor, which, of course, is linked to socioeconomic status. But there's no surprise there for this higher weight or higher levels of obesity in more deprived communities and population groups, but then, if you looked at other health outcomes, there's higher depression, there's higher diabetes, there's higher everything. So, deprivation is driving many of the different health-related outcomes. So, that needs to be a focus. 

And then, ethnicity, again we typically see that obesity is typically higher amongst people who are in the minority ethnic groups, but we also see that weight stigma specifically is typically higher. So, Angela, for instance, mentioned—. Again, literature has consistently shown that stigma is stronger towards females, for instance, compared to men—so, females living with obesity compared to males living with obesity. We would also see that females from a black background, for instance, are stigmatised to a much greater degree than white females. So, it's layered. Ethnicity clearly impacts not just weight status but also weight stigma, and weight stigma seems to be much stronger for people, based on ethnicity.

And one last thing—. Sorry, one last thing I'll just quickly mention is that there's quick a bit of literature relating to the link between poverty and weight status. And if any of you around the room recall the tv programme Benefits Street, for instance, that was really driven by stigma directed towards people living with obesity in poor communities. And there was almost a doubling of effect. So, people were experiencing many different types of stigma within that programme, which is exactly what we see now. And we, of course, now also have stigma towards people with obesity who are also from sexual minority groups, for instance, and so forth. So, there are a lot of layers to the impact that stigma has. Sorry, I've given you a long answer there. 

I was going to ask—

Can I, Joyce, also speak to those two questions? 

Okay. Well, before you do—

Do you want to follow up? Yes.

—can I just ask this one question?

Sure.

Has anybody done a study in terms of fast food outlet applications according to the economic status of the area?

To my knowledge, no. Do you—?

So, there is work in terms of looking at, for instance, the density of fast food outlets and its potential impacts relating to obesity. Again, I would point to the work that Adam Drewnowski has done in the US, which would show that, in many instances, particularly the buffers we use—. So, we use a buffer of around about 4 km when we say that it is in your proximity. The reality is that people move much further away, so proximity increases your exposure, for sure, but doesn't necessarily increase the likelihood that you will actually go and consume fast food, for instance. If people want to have fast food, they'll go and get it, or they'll get it delivered and so on. So, proximity impacts your exposure, it might impact your liking for it, but, in terms of actually purchasing, the actual behaviour, typically proximity isn't the key factor.

Okay. Thank you.

Okay, may I—? A couple of additional points. So, I will deal with ethnicity and socioeconomic status first. I agree with everything that Stuart said. One point about these multiply stigmatised identities—so, if you're fat and an ethnic minority, if you're fat and poor, if you're an ethnic minority and fat and poor and a sexual minority—these people are experiencing multiple forms of stigma. We say that it's intersectional—all these identities overlap. And the impacts are comparably higher because of all those additional stressors.

So, I’m not sure if you’ve come across the Townsend Centre for International Poverty Research. They’re at the University of Bristol. They have a wonderful page on health inequalities, and they looked at the chief medical officer’s, at the time, top 10 tips for better health outcomes, and there were things like, 'Lose weight', 'Don’t smoke', and what have you. And Townsend actually gave their 10 alternative recommendations. No. 1 was, 'Don’t be poor.' Then there were things like, 'If you live in a deprived area, move.' The whole point is we’re talking about social determinants of health rather than individual behaviours. And it is, from a policy perspective, very, very difficult to address poverty and crime and deprivation; it’s much easier to blame individuals.

When I said there was no research on fast food, I think the question you actually asked was about stigma. I would like to go back to your previous question about the key drivers of the complexity of obesity and weight gain over the last few decades. One of the primary determinants is going to be your genetics. This is about how people utilise the energy that they take in—how they burn calories, whether they store them as fat. And that’s all about metabolism, and the main thing driving metabolism is genetics. And coming back to calories in, calories out, which applies here, it seems intuitive, but humans are not bomb calorimeters—we’re not in a closed system. And while it’s hard to imagine that fat people could be fat while not eating a lot, once you’ve gained that weight, you don’t have to eat a lot to maintain it—you can eat less than you need and still be fat. And while that might seem counterintuitive, we all know people who are very slim and eat like a horse and have terrible diets, which proves that it’s not simply calories in, calories out—they are using their energy differently.

And I think one of the major drivers—. Two I’ll mention, but one of the major drivers of the weight gain we’ve seen in the last few decades is actually dieting: the rise of the diet industry, intentional weight-loss efforts. And we actually have some very good data from Finland, where they have a twin studies database. So, they've monitored twins since the 1970s. And what they’ve found is that intentional weight-loss attempts—. Every time that they have tried to lose weight, their final weight becomes higher than their monozygotic, their identical twin. So, it’s not just that fatter people diet more, it’s that dieting makes you fatter, and this is because of the restriction that your body experiences. It doesn’t know that you want to be a size 12 or that you want to go back to how you looked when you were 16—it thinks you’re starving. And what it does is—. The common parlance is that it messes up your metabolism, so you store fat more easily and more readily, you are less likely to burn any fat that you eat. It changes the way that your body processes food; it changes your hunger signals—it increases them. It reduces the satiety hormones, so you’re hungry more often. It changes the way your body handles blood sugar. Your sense of smell and food response and food reward become more acute. So, our bodies are actually doing exactly what we have evolved to do, which is, when we are deprived, it encourages us to eat more and store more of that energy. And the initial weight loss that people experience, some of it will be fat, but some of it will be lean muscle tissue, which actually burns far more calories.

When you put the weight back on, which you will—sometimes, you’ll start to put that weight back on even whilst maintaining your restricted diet, because your body is driving you to that—what goes back on will be fat. So, you will have less lean mass, you will be in a worse metabolic state than you were before. And again, speaking to solutions, actually trying to stop people restricting, but to appropriately feed their bodies, so that your body is not constantly getting these hormonal famine signals and is more prepared to actually release any stored energy that you’ve got—. It's sort of the opposite of what you would think.

Okay, thank you.

Yes, I've made a note: dieting makes you fatter.

Yes, dieting makes you fatter.

If I can just come in—. Can I just come in on that one as well?

Yes. Stuart, yes.

One of the issues that we've inevitably had is that it’s been driven by a misconception about weight. And that links very much to Angela’s point there relating to dieters. The way that we’ve ultimately approached weight is that it’s something that’s very short term and something that can be changed very quickly and rapidly, and that’s clearly not the reality. When we’re talking about people gaining weight and people living with obesity, that's not something that happens over a few weeks or a few months, or even maybe a few years; this is something that happens over many, many years.

So, when we have diets that suggest you go on a four-week diet and you can lose a stone, et cetera, even where that could be possible for some people—some people who live the life of somebody like a celebrity or an influencer who has the personal trainer and everything else and they can potentially shift weight—for most people, it's not, and therefore it's unrealistic, and people drop off because they're not seeing the results that Kim Kardashian had, or whatever else. Or you've got your 12-week weight management services; again, people haven't gained weight, people aren't living with obesity over 12 weeks; it doesn't make sense to have a short-term solution for a long-term outcome.

So, diets don't work, but healthy lifestyles do. 

What you need to be able to do, and again it goes back to the point around restriction, is live a life that is something long-term. If it's something where you're changing your life, restricting or so on for a few weeks or a few months, there's a point where you stop doing that, and therefore your body changes again. That's the point around diets. Within reason, if everybody had an energy deficit, most people will lose weight, because that's what will happen, but a lot of people put the weight back on, because you're not continually on the restriction, so it doesn't work.

And usually, around two thirds of people will regain more weight, will see that rebound, because of the metabolic changes. But on the point about whether a healthy lifestyle works—and this is the most important thing I'm going to say today; get your pen out, yes—at this point, we may already be too late, because we're here to talk about obesity, at which point we're already on the wrong framework.

Well, we are, but we also want to make sure people don't get to that position in the first place, so absolutely.

But it doesn't even matter if they're already fat. The important thing that I want to say is that the goal of Government and public health is not to make people thin, it's to make them healthier. And they're not the same thing. First of all, you can improve all the health markers that you are interested in without weight loss. Secondly, any health improvements that come with weight loss—. These programmes, the 12-week weight management, or whatever lifestyle changes that people are doing, generally involve improving nutritional quality of their food, they generally include physical activity, and there will be some weight loss, but there will also be some metabolic benefit of these things.

Generally, we give credit to the weight loss for having caused metabolic benefits, but they kind of go hand in hand. Interventions that just look at physical activity compared to diet generally deliver almost no weight loss, even under controlled physical activity, so it's not just that people are lying about what they're doing. But they do deliver improvements in blood pressure, blood sugar control, glycaemic control, and other cardiovascular markers. We can deliver these improvements without focusing on weight loss. Focusing on the weight loss when people stop losing weight, which they will, because their bodies are resisting it, they tend to give up all of those healthy behaviours that were actually improving things.

There have been some studies that look at weight-loss trials, and those that have looked at cardiometabolic outcomes, and they show that the improvements in these markers of health that we're interested in are not in any way related to the amount of weight lost. The thing that actually is driving most of these is increases in physical activity. So, that's one of the things. Healthy lifestyle works in that it makes people healthier. It doesn't work in that necessarily it makes people thinner, but the good news is, they don't have to be thinner; they're still healthier, and the focus on the weight is actually causing more problems and making them less healthy in the long term than when they started.

Can I understand that bit further? I understand the point you're making, because we were discussing it, actually, before the meeting, about how we don't talk enough about malnutrition and the links between underweight and overweight being perhaps the same around malnutrition. But going back to your point around obesity, I suppose what you're suggesting is that's not always a sign of unhealth, but there is obviously a clear link between levels of obesity and life expectancy, and life expectancy being the ultimate measure of healthiness, I would have thought. So, how would you respond to that? Surely it's very clear that by magnitude of years, the more obese you are, the less your life expectancy—

The poorer your health outcomes are and the higher your mortality.

Yes, life expectancy is going to reduce.

Absolutely. I would not argue with those statistics at all. There is a very robust link between higher body weight and poorer health outcomes. The question is why, and what we do about it. We've already spoken a lot about how the stigma itself is associated with a wide range of metabolic conditions, psychological conditions, and an over 80 per cent increase in mortality—controlling for everything else. So, fat people are experiencing these things that are known to worsen metabolic health and life expectancy, first of all.

Stuart also alluded to avoidance of healthcare, because of fear of being stigmatised. That includes preventative healthcare, so they're less likely to get cancer screening, they're less likely to get flu injections and so on. They're less likely to go to a doctor early on in a condition, and they're more likely to present at a later disease stage with a worse outcome.

Once they are in the healthcare system, they are experiencing more stigma and, quite often, inappropriate treatment. There have been quite a few studies on these. There's a lot of stuff on missed what they call class 1 diagnoses that were fatal. They're more likely to be missed in fat people, including pulmonary embolism, myocardial infarction—heart attack—and a whole range of other things. Cancer is very often missed. People are presenting later with cancer. Fat people are often underdiagnosed—not underdiagnosed, although they are—they're undertreated, undermedicated with chemotherapy drugs.

Doctors are well meaning, and they know that chemotherapy drugs are stored in fat, so to be on the safe side, they're actually underdosing. There was one study, a very large study that showed an estimated—. They worked out just correct chemotherapy drug dosing for breast cancer alone in the US would save 6,000 lives per year. Does that help? People are dying more because of the way they're being treated and the way that stigma is affecting their interaction with the healthcare system, and once they get to the healthcare system.

Here's another example—

If it's a quick one, because we've got to move on. 

Go ahead.

If we can move on. I just know we've got so much to get through.

I forgot at the beginning of the session—can I just check the translation works, if that's all right? Can I just ask the translator to say 'Test'?

[TRANSLATION: 'Hello, this is the translator speaking. If you can hear me, could you give me a thumbs up, please?']

Stuart's just checking.

[TRANSLATION: 'Stuart, can you hear me? One, two.']

Yes, I can now.

There we are, great. Thank you, both. Mabon ap Gwynfor.

I can speak to that, or do you want to speak to that?

You start.

The best thing is—. Can I—? It's very weird hearing myself, but I'll assume I'm still been translated, is that right?

Yes, take them off. You're fine, yes.

The best thing to maintain steady blood sugar and healthy metabolism is regular meals throughout the day, so not eating late in the morning, not necessarily eating a big breakfast, a small lunch and a smaller dinner, but eating small, regular meals throughout the day, and every meal including all your food groups—so, protein, carbs, including slow-release carbs, fats, especially the healthy fats, the omega-3, omega-6s and omega-9s, your monounsaturateds. A balanced diet, regular, possibly smaller meals, rather than three big meals a day. And if you're hungry, eat something. Again, I was speaking to a doctor the other day and I said, 'I'm eating this and snacks' and he went, 'Snacks?' and I went, 'Yes', you know, you need to constantly tell your body that it is okay not to hold on to every single calorie that goes in your mouth, and you do that by feeding it appropriately, by fuelling your exercise, by fuelling your day, by fuelling your cognitive work during the day. That is the most important thing. 

The other one that's very important is physical activity, and we keep coming back to this, because physical activity and physical fitness are, essentially, the great levellers in terms of health outcomes. This information is what rocked my world about 10 plus years ago, because I actually have a Master's in weight management, I've spent my entire life dieting, which is how I got so fat in the first place, because I didn't know any better. And I stumbled across this evidence from a study that showed—this was from 'The Aerobics Center Longitudinal Study' that I mentioned before, and it's how I first stumbled across it—that, compared with people in the so-called normal weight BMI category, who were fit, which they defined as not in the lowest level of fitness, so not marathon fit or professional fit, but just not completely sedentary and unfit, compared with people in the normal weight category who were fit, normal weight and unfit nearly doubled the risk of all-cause mortality, and these numbers are similar for morbidity for diseases, as well.

In people who are overweight and unfit, it was about two and a half times the risk. And in people who were obese and unfit, it was a little over three times the risk. However, in those who were fit, so they weren't sedentary, they engaged in what they called regular fitness, like activity they defined as moderate three times a week, so not even that excessive, the risk went straight back down to the same as normal weight and fit. And that's across the BMI spectrum, so again, fitness and cardiorespiratory fitness and being engaged in physical activity is the great leveller. That study was published in 1999 in the Journal of the American Medical Association and it was conducted in 26,000 men, and when I read it I thought, 'Oh my goodness, I wonder if anyone's replicated this'. So, I went and had a look. It's been shown again and again and again, it's been shown in disease populations, people who had diabetes and hypertension at baseline; fitness is the great leveller—

I'd better just bring Stuart in, as well. Do you agree: eat snacks when you're hungry?

I would certainly agree with eating throughout the day. If it was possible—I don't think it is possible—then I would always suggest that grazing throughout the day is the best thing that we could do. I caveat that with then going back to what I said earlier, it's really complex and we're all very different, so the way that I should eat should be very different from other people's, potentially. If I'm engaged in physical activity, then I'll certainly eat at an appropriate time beforehand to fuel myself. So, I would agree, but also caveat that there's no one way that people should eat. Avoiding overeating, and so on, in singular meals and so on, as a broad-brush—yes, sure.

On your point at the start in terms of Gethin, you're totally right; I've spent my entire life, based on body mass index, being in the obesity or currently in the overweight range—I'm in the overweight range now. I think the key point here, with Gethin, is more likely around body composition and fat percentage and muscle percentage, and so on. He probably will have a BMI well within the obesity range, but of course, he was a supreme athlete at the time. So, there are differences. I know we're going to get to measurements, so I'm not going to talk too much about that.

And then, also linking to the point before that Sam asked about, and again, what Angela mentioned, I would certainly focus on engagement in healthy pursuits and healthy behaviours. If you asked me if there was one metric that I would focus on, it would be VO2 max. Improving your VO2 max is extremely beneficial for your overall health. It will benefit many things, including reducing the risk of all different health-related complications that are associated with obesity. So, I think VO2 max, or physical fitness, is certainly something that we should be focused on. In terms of improving health, this is a key one.

There was also one other point that I wanted to mention earlier in terms of what's happening to people living with obesity. I think it was when you were talking about discrimination in the healthcare settings and the link between obesity and other health outcomes. What also gets overlooked for people living with obesity or people with a higher body mass index is that they’re perceived as people who need to have treatment, and, therefore, prevention is not delivered to people living with obesity, and, actually, prevention should be, because you’re also trying to prevent diabetes and coronary heart disease and so on. So, all of the other things that people across the population, who are in a healthy weight or underweight range, receive in terms of prevention, they don’t receive, because they get a higher weight status. So, the benefits of prevention that reduce your risk of diabetes and coronary heart disease and so on, they don’t have, because it’s, 'You just need to have treatment, you need to lose weight', instead of, 'Do these things that actually reduce your risk of coronary heart disease.'

I would say that social prescribing can be very useful, but it's the quality of the evidence ultimately. I think there’s not enough evidence to show that social prescribing will have a beneficial impact in making a difference on obesity at the moment, and it will inevitably differentiate across the population and community groups and so on. So, I think, it could potentially have a beneficial impact in terms of improving the health status of small population groups, and it would need to be tailored to the communities that people reside in, but as a broad brush across a national strategy, I think it’s probably not—. At least, we've not got enough evidence, that I know of.

Yes, I would agree that there is little evidence that social prescribing will impact on obesity, but that gets back to my original point that we don’t necessarily need to do anything about obesity. Consistent evidence from decades of research shows that social support, community—all of these activities—are beneficial to health. And I would agree with Stuart’s point, that people will respond differently, people will have different dietary needs and what have you, but it’s more about doing what’s right for your body, and the more that we try and control weight, the less in tune with people’s natural body signals—. Our bodies have evolved to be very good at telling us what they need, but we’re getting better at ignoring them and overriding them, and the things that are mainly driving this are, again, I would say dieting behaviour, dieting history, but also environmental factors, such as pollution, plastics and the like. These are things that we could maybe address.

I also agree that VO2 max is probably one of the most important factors, in other words, cardiorespiratory fitness, but the greatest health gains that we see with physical activity, actually, come from people who move from being sedentary to not sedentary. The immediate gains are huge and they continue to improve, but the immediate benefits from getting a population to be more active are massive, with the caveat that a lot of higher weight people have a very traumatic history in physical activity environments. And the way they respond to physical activity, the way you respond to exercise, in terms of your weight and your body composition and what have you, is quite genetically driven. And even if you can get past all your prior experiences, you probably won’t lose a lot of weight and you go out in public, running, to the pool, what have you, if you can get past the stigma that you experience—. One of the areas of research that I’m interested in is—. So, you see a thin person exercising, if they’re out running, and they will get sweaty and they will be red faced, covered in sweat, they’ll be jiggling a little bit, they’ll be breathing hard, and you see them and you think, 'Good for them, I should do more exercise', and you see a fat person out running, and they’re jiggling, red faced and covered in sweat, and their hair is plastered to them and they’re breathing heavily, and you think, 'How did they let themselves get like that?' There really is a double standard in the way that fat people are perceived.

We keep coming back to, 'How does this help obesity?' The point is, it doesn’t need to. We are looking to make people healthier. It might not deliver weight loss, but these things will deliver improved health. Stuart alluded to the fact that if fat people are not being treated for diseases they have, they’re being treated for their weight, thin people are being missed, because no-one’s testing them for these diseases because they’re thin, therefore, they must be healthy, so they’re being undertreated for metabolic dysfunction. And the good news is that all of these messages apply to everybody. You don’t have to target obesity. All of these health—. We have not, in 60-plus years, been able to deliver weight loss that is successful and maintained to anybody. But we have a very good knowledge of behaviours that improve health and health metrics and blood pressure and lipids and insulin sensitivity. These messages apply to everybody, so you don't need an anti-obesity campaign, you need a public health campaign that is one message for everybody.

I'm going to ask Mabon, if at any point you want to—as long as the witnesses are happy for Mabon to interrupt, if you're happy to, just to make sure we get through all our questions. Mabon.

Absolutely.

Tell us the solution.

It's a good question. I have too much to say on this topic.

Yes. 

If you have, focus on the solutions then, and tell us the solutions. 

Rather than fails. Well, I'll start with what hasn't gone as well. Most of the policies that I would see relating to obesity are not obesity-related policies anyway. They're actually public health policies. I agree with many of them as a public health policy. So, if you take, for instance, the soft drinks industry levy, I totally agree. Yes, we should tax—I'm in favour of taxing sugary drinks. I'm in favour of reducing the amount of sugary drinks that people consume, and that's people across the population. It will impact people across the population, it will benefit people across the population. Will it make a difference to people's weight status? No. Where there's going to be any potential impact, it's going to be on children with cavities who are less than five and so on, potentially. But it will not impact weight status.

Take the calorie labelling. The calorie labelling is not going to impact obesity. Will it make people potentially change the choices they could make? Potentially, or else there's a study that has just been published that shows that it doesn't have that impact. It was published two weeks ago. So, these are things that are beneficial, but they're actually not relevant to obesity. They're population based. They've been brought in as obesity because obesity, of course, is a big topic and the public are focused and the public are behind it.

And the last thing I'll say on that before I move to what the solutions are, is that I think one of the reasons that we've been held back in that space and the policies that we typically see is because I think governments are well aware that obesity is not something that is going to change overnight or is going to be easy to change, and I think there's a conflict. And the conflict is ultimately that obesity, as I alluded to before, happens over many, many years. That means you need a solution that potentially is many, many years, and that's 'potentially' a solution. And the reality is that governments don't have time to do that because if I implement a change and I spend £20 million of the public's money, then I need to, in a year's time, say, 'Okay, we spent £20 million and this is the effect.' You're not going to see that. You have that with the sugary drinks because 66.5 million people reduce their sugary drinks, well, you've got a significant effect. But obesity hasn't changed, and they don't know who's reduced their sugary drinks intake.

So, what could be beneficial? We've talked about it a lot already, and I think both of you have alluded to it, there is a major issue around physical activity. Physical activity inevitably is a major issue, starting from a very early age. I spent some time with a good friend last night who's a teacher in Cardiff, and what's currently being delivered to children in schools, the lack of provision, and even where the provision is there, the types of physical activity that children are engaging in is very minimal, and they don't understand the benefits of being physically active, they don't enjoy physical activity, and there are many other pursuits that children are now engaged in.

One of the things that's always missed is reducing sedentary behaviour. Actually, in the World Health Organization recommendations—and of course we also have it in the UK—is not just trying to do your 30 minutes of physical activity, but it's breaking up your sedentary behaviour throughout the day. So, for a long time we've had this whole thing around the 23.5-hour day, which is 23.5 hours where I'm actually being physically inactive, and that is extremely detrimental independently of how much physical activity you do in that 30 minutes. I could do 30 minutes of burpees if I really wanted to.

Really?

Maybe—slowly. But if I then spend 23.5 hours of the day being inactive then that increases my risk, irrespective of what I did in that 30 minutes. So, physical activity is clearly a key one.

We can't get away from what's happening in terms of the environment, which ultimately is impacting our dietary behaviour and so forth. But I think probably the biggest issue that we've seen and where I think we can potentially have an impact is around mental health. Mental health has got significantly worse over time and that is related to the different challenges and stresses that young people are experiencing. I alluded to some of those around social media and the increased focus on body image, body size. There was a paper not even recently—. In 2000, there was a paper by Slater that showed that children focus on—. So, they would rather have a size—I think they called it—a size 10 dress size compared to getting straight As in school. So, educational attainment is less of a priority.

So, physical appearance has become more and more important to young people these days, which means that they're increasingly engaging in different types of risky interventions to try and reduce weight and change their appearance, and so on. That's of course why we have so many people who go on social media, post pictures, they don't get likes and it becomes a major issue for people. And then, it goes into disordered eating and everything else that comes with that.

So, I think mental health is a key issue and the focus of the policies needs to shift from, as I say, what is more population health. The population health should still be there, but it shouldn't be described as obesity. Sorry, that was a bit longer than maybe you expected. 

No, that's fine.

I was about to, for the first time, say that I disagree with Stuart, but you saved yourself at the end there. [Laughter.] I would say focus on the population health and stop your obesity programmes, instead of trying to do something about obesity. We've already shown that this backfires and it makes people less healthy, and it's not necessary. A focus on the—

So, you want one of our recommendations to be to stop all obesity programmes. 

Absolutely, stop weight management services—

Go on, Lesley. 

What's Stuart's view on that? 

Yes, that's a good question. 

There are some things that I would certainly change because, as I alluded to, anything that's short term is clearly not relevant at all. And it's no surprise, of course, that the weight management services, they're all now, 'Okay, we've got our weight management plus the medications.' Well, if they were so good before, why have you stopped doing the weight management services that you guys have probably been funding and the regional Governments been funding to the tune of millions of pounds in the past, but now suddenly are not doing anything? 

With very low efficacy and no follow-up on rebound. I would say 'Stop all that', absolutely. I'd say the focus is wrong. Stuart's right in that obesity, weight is a long-term problem, but we both agree there's not a great deal that you can do to shift weight, but there is a lot you can do to improve health and it applies to thin people, medium-sized people, fat people. I would say stick with the population health.

Stuart also talked about the effect on children and young people. I would say scrap the national childhood measurement programme or measure something more useful, like mental health, body image, self-esteem. There is now a lot of surveillance data from around the world that shows these measurement programmes and sending home these report cards, BMI reports, what have you, actually backfire in the majority of cases. Youngsters who are labelled as fat at 14, five years later and 10 years later, they are more likely to be engaged in seriously harmful activities to try and maintain their weight, because they do try dieting. BMI cards don't cause problems because parents don't pay any attention to them; they do pay attention to them, they then restrict their children's food, which then leads to all of these problems. 

So, the other intervention I would suggest—besides dropping your obesity programme, scrapping the national childhood measurement programme—is that the evidence that we have from body acceptance, improving both physical and mental health, is to promote size diversity as natural and to include weight in all diversity education. People come in all shapes and sizes and that's okay. 

Just to finish off because we're a bit short of time, is there anything else you want to finish off with on that point, Angela?

Not on that point. 

That's fine. Just checking, have you asked all the questions you want? 

I'm done. Diolch.

Right. Thank you, Mabon. We're over time by five minutes. If you're happy to stay, we can go on for another 10 minutes. Are you both happy?

I'm happy to stay. 

That's fine, but we've got 10 minutes to cover, I think, three subject areas, which are going to—

Well, I've been studying for two days to be able to talk to you about weight-loss medications. [Laughter.] So, can we do that?

Absolutely. Thank you for staying for another 10 minutes. We'll go on until 12 o'clock. Sam Rowlands.

Thank you, Chair. Thanks again for your time with us today. We've already touched on the sorts of questions that I'm going to ask, but perhaps just to pull some of that together. On the measurement programmes, you mentioned, Angela in particular, that you believe that the current measurement programme is perhaps not fit for purpose, and, Stuart, I think you mentioned about the VO2 max as a potential helpful measure of people’s health, other than existing nationally used measurement programmes. So, yes, perhaps you could talk on those points in particular—how effective current measuring is of adults and children, and what the changes could or should be.

And then you’ve also started talking about some of the weight-loss tools, and we’ve seen, recently, weight-loss drugs becoming more mainstream. I suspect you won’t be particularly supportive of the long-term outcomes of those, but perhaps we could have that for the record, and just your thoughts on where weight-loss drugs may be helpful, if at all, and your thoughts on the long-term impacts you think may take place due to the use of weight-loss drugs.

Thank you. Do you want to get a word in edgeways first before I go off on a rant? [Laughter.]

No, I’ll round up and make a couple of other points.

All right. So, let me give you a little bit of background about weight-loss drugs. So, one of the most famous was fen-phen, which was fenfluramine and phentermine, which was an appetite suppressant and an amphetamine-like drug, and that was launched in 1992, off label, for weight loss, based on a four-year study of 121 people. Two years later, the pharmaceutical company involved—American Home Products—was aware of 41 cases of valvular heart disease and pulmonary hypertension, of which they reported four to the Food and Drug Administration. In 1995, it went mainstream, it started getting all the media attention, it was in magazines, these brand new drugs. In 1996, 18 million prescriptions were written in the US alone. In 1997, studies were coming out that about a third of people on them were experiencing serious side effects, including heart disease, valvular heart disease, primary pulmonary hypertension, cardiac fibrosis, and it led to the recall of these drugs, and lawsuits to the tune of billions of pounds—dollars, rather—but with all the long-term effects on cardiac and pulmonary function.

This was followed by Belviq in the 2010s, which originally failed to get FDA approval, because of increased tumour risk in rats. In 2012, the Endocrinology and Metabolic Drugs Advisory Committee basically said that the potential benefits of this drug—lorcaserin—were worth it for the long-term treatment of overweight and obese populations, which is what we’re hearing now: 'There are risks, but the long-term benefits for fat people are great.' And based on this, it was approved for people with a BMI over 30, or 27 with co-morbidities. Their long-term recommendation was based on one to two years of data, which, again, is very similar to what we have at the moment. Side effects included reduced red and white blood cell count, slowed heart rate, decreased cognitive function, heart valve issues and increased risk of cancer. In the studies, around half dropped out without follow-up. The remainder lost 5 per cent to 10 per cent at one year, gained back around a quarter of that at two years, at which point they stopped measuring them. This was described as ‘successful weight-loss maintenance’, which, again, is what we’re seeing now with the new drugs, which basically means they haven’t yet gained it all back at the point we stopped measuring them, but it was on the way up.

In 2020, the FDA required withdrawal due to increased cancer risk. Now, Lilly and Novo Nordisk in the US have made absolute billions of dollars selling insulin—price gouging on insulin—and now there is Government pressure to stop them doing this, and they needed a new cash cow. Now, the new crop of drugs, Wegovy—so, semaglutide—and Mounjaro, Zepbound, which is—

Tirzepatide.

—tirzepatide—thank you—were developed as diabetes drugs to improve glycaemic control, at which they seem to be relatively quite effective. They’re not first-line treatments, because of the very high side effects and poor tolerability, and dosing is started at 0.25 milligram, which is a below therapeutic dose, and increased to 0.5 milligram for diabetes control, at which point, if people have diabetes control, you stop. And for a long time, the upper limit for this was a 1 milligram dosage, and, then, a couple of years ago, they increased it to 2 milligrams.

Now, these drug companies suddenly needed to find some extra money. Weight loss was a side effect of these drugs, along with all the other side effects, and they thought, ‘Okay, if we give people more of these drugs, they’ll have more weight loss.' But the goal is actually to maximise the side effects of these diabetes drugs. That's what we're trying to do at these weight-loss dosages. However, insurers won't cover—. Because of the Belviq and fen-phen debacles, insurers in the US won't cover weight-loss drugs unless they also treat another condition. So, there's a little loophole there.

So, the drug companies then went about p-hacking their way—which is a statistical term for basically throwing the spaghetti at the wall until something sticks—to see if they could find some other conditions that these drugs were good for. And based on the diabetes data, they saw some possible cardiovascular effects. Now, where are my effectiveness notes? Okay. So, based on a four-year study in the cardiovascular trial, the select trial, weight-loss effects taper off at 65 weeks. So, already, at one year, some people are starting to regain the weight, and everybody is stopping losing weight. This four-year trial that was given lots of fanfare started with 8,803 people in the treatment group, and, at the end, there were 157 in the treatment group, which is 90 per cent attrition. Now, these people are being paid and have all these benefits, but they can't stick on the drugs, even with all that support. Only two thirds of those people lost even 5 per cent of their body weight, fewer than half lost 10 per cent, and 89 per cent failed to lose the 20 per cent.

Cardiovascular effects—it was touted in a press release before publication that there was a 20 per cent reduction in major adverse cardiac events, which sent Novo Nordisk's stock prices up 17 per cent in one day. This is a relative risk, which means compared to the control group. So, what we actually saw was that the control group had 8 per cent cardiac adverse events, and the treatment group had 6.5 per cent. So, it's a 1.5 per cent reduction in absolute risk, not 20 per cent.

Sorry, Angela—

They also say—

Angela—

Sorry to—

Please. Let me just finish this.

No, sorry, just—

Angela, we've got two and a half minutes left of the meeting, so I'm just going to bring Sam in and I want time for Stuart to come in as well. 

And I wonder whether you could perhaps send through the information that you have so that we don't lose it. 

Yes, I can do that. 

I really appreciate it. We have to just—. We're tight on time, that's all I'm really concerned about. But to answer the question, I guess, you do not think that the long-term effects of weight-loss medication as you've described are effective. 

Not only are they not effective, but they massively increase risks of acute pancreatitis, acute gall bladder disease, acute kidney injury, complications of diabetic retinopathy, suicidal ideation and attempts, life-threatening ileus. They have a boxed warning for thyroid cancer, they interfere with the absorption of medications, including seizure meds, blood pressure meds, heart meds like Digoxin, ADHD meds, SSRIs for depression, anti-psychotic drugs.

Angela, I'm sorry—

And doctors are not being told this.

It's just that we've got one and a half minutes left, so I'd imagine that Sam's question is: does Stuart agree with what you said?

Yes.

Well the first part, which wasn't addressed, is about measurement. So, just quickly on that, we certainly need to evolve the way that we're measuring obesity and weight status and what we actually mean by obesity. There is a The Lancet commission that will be launched on 26 January. I've had the invite; I'm sure that some people have probably had an invite here. That will talk specifically to describing what obesity is from, I guess, a more medical standpoint and the measurement that is associated with that. So, I would say that that's probably a good place to start in terms of measuring obesity. If we're talking about measuring people across population in terms of national child measurement programmes and so on, well, I think we've known for some time limitations around the use of body mass index, for instance. My perception is that that's only getting worse because, ultimately, that tool was validated in a population group where—. We as individuals are evolving. The body shapes and sizes of people are evolving. 

Yes. Can I just ask on this point—? There's got to be a balance, hasn't there, between the scientific, academic, understanding of this and also the general population's understanding. BMI, I guess, is a simple measure, which whilst not perfect academically or scientifically or medically, is an easy way for people to understand roughly how healthy they may or may not be.

Yes, and, on your point, ultimately, there is an issue there. We want to have something that is relatively easy for people to use, but the more important thing is that it's accurate, because, ultimately, what we want we want is accuracy around health, and that's what we should expect, and we have many of the players that are reducing accuracy about what the public understand. I say this to policy makers all the time: you write your policy, 99 per cent of the population never see your policy, they read the media's interpretation of the policy and so on. So, there are caveats as to why the population don't have a good understanding. It's the same as what we as scientists—. And, of course, stuff I've been a part of the university, at the forefront of, is translating science into something that's digestible by the population, because most academics don't want to read a research article, never mind the population, so it needs to be something that's translated.

Okay. Briefly, perhaps, we're always keen to look at international examples of where we could, rather than reinventing the wheel, learn from perhaps. Stuart first: if you were to point us towards a particular nation that you think is doing better in relation to measures to reduce obesity, are there any particular nations you'd point us towards to have a nosey at, or not?

What I would certainly say is that Japan is very good, not necessarily at obesity intervention, but they’re very good at prevention, and they're very good at addressing the inequalities that are evident within the healthcare system that mean that people who maybe have a higher weight status are not facing some of those inequalities and therefore still benefit from things like prevention, which they're not receiving here. So, Japan, certainly, would be one that I would look to in terms of the way that the healthcare system is driven.

Singapore are doing a lot in this space, particularly with new technologies and digital et cetera, but, again, with the focus on health—so, how do we improve people's health markers, how we do increase people's engagement in health-related behaviours and so forth. And that inevitably will benefit a reduction in health-related conditions. But, probably more importantly for Government, a focus around prevention is preventing many of the different health conditions associated with higher weight status.

Okay. And, Angela, any particular countries you'd point towards.

Well, to paraphrase what Stuart said, nobody has been successful at reducing obesity, despite billions and billions of pounds spent worldwide on trying to do so. But, as we both keep saying in slightly different ways, there are things we know can improve health. BMI is not, and has never been, a measure of health. If we want the population to better understand health metrics, we've spoken to being a little bit fitter—being able to walk up a hill without getting puffed would be a good metric—not smoking, not drinking too much, getting a balanced diet. The answer is to remove the focus on weight completely. Weight-neutral healthcare, as opposed to weight-centric, works for everybody and it delivers the outcomes that you are looking to achieve. Focusing on weight is never going to do that.

Okay. Thank you very much.

[Inaudible.] You can't have a system where you're promoting one thing and then, in the opposite sense, you have everything else that's promoting exactly the opposite. So, you can't have increased fast food and all that type of stuff at the same time as trying to say, 'Well, you need to reduce how much sugar is in your Coke.' That doesn't work.

And all of these health interventions—you have to stop before you say, 'And then you'll lose weight.' These health interventions give health through their own—. Physical activity is health-giving for its own sake. Stopping smoking is health-giving for its own sake. Getting a good nutrient profile in your diet is health-giving for its own sake. The 'and then you'll lose weight' part may or may not happen and has nothing to do with it and shifts the focus, actually, away from health.

Yes. Listen, I'm really grateful to you both being willing to come to us here to give evidence in this session. It's been a really interesting discussion this morning, a fascinating conversation that has bounced around the ideas amongst yourselves as well. I'm grateful for the papers in advance that we've had, and if there's something you think you want to impart—because I appreciate, Angela, there's so much information that you want to impart to us—

There is.

If there's more information that you want to send to us following this meeting, then we'd welcome that.

Thank you. Should I send that to Karen?

Yes, if you send it to the clerking team that corresponded with you, the clerking team will share with us as committee members as well. I'm sorry if I had to cut you off just to get through everything we wanted to get through.

It happens a lot. [Laughter.]

But thank you so much for your professional input to our work on this. So, diolch yn fawr iawn. Thank you very much. And we'll send you a transcript of the proceedings this morning, and if there's something you want to add, then, by all means, do so as well. But thank you and enjoy the rest of your stay in Cardiff this afternoon.

Thank you.

Thank you.

Right, I move to item 4. We have some papers to note. We have correspondence from the Petitions Committee; we also have some correspondence that we've been copied into to other committees as well. So, are Members content to note those papers? Yes, great.

In that case, I move to item 5 and propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public from the remainder of today's meeting. Are Members content? Yes, we are. So, in that case, that does draw this meeting to an end, but, before I do so, I wish all our stakeholders that are interested in our work Nadolig llawen, and the same to Members as well. And that brings our public meeting to an end today.