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Joint Committee on Children and Youth Affairs debate -
Wednesday, 18 Apr 2018

Tackling Childhood Obesity: Discussion

I thank the members for their attendance and I welcome Senator Warfield to the committee this morning. I note the apologies received from the Vice Chairman, Senator Joan Freeman. I welcome our guests from the Irish Heart Foundation - Mr. Chris Macey, head of advocacy and Ms Janis Morrissey, manager of health promotion. I also welcome Dr. John Sharry, the founding director of Parents Plus, and Dr. Adele Keating.

I thank all the witnesses for coming. I wish to advise the witnesses that by virtue of section 17(2)(l ) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if a witness is directed by the committee to cease giving evidence in regard to a particular matter and continues to do so, the witness is entitled thereafter only to a qualified privilege in respect of his or her evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I remind members and witnesses to ensure their mobile phones are switched off or left in flight mode as they interfere with the sound system and this can make it difficult for the parliamentary reporters to report the meeting, and it can adversely affect the broadcasting.

Any submission or opening statement made to the committee will be published on the Oireachtas website after this meeting. I understand that witnesses will make short presentations this morning followed by questions from the committee members. I now invite Mr. Macey to make his opening statement.

Mr. Chris Macey

I thank the Chairman for the opportunity to speak today on what we regard as the greatest single threat to the health of this generation of children and young people. State-funded research estimates that 85,000 of today's children on the island of Ireland will die prematurely due to overweight and obesity. Sadly, we are seeing evidence that something catastrophic is already happening; children as young as eight years old are presenting with high blood pressure and young people are presenting with heart disease, which used to only be seen in middle age. In disadvantaged areas we are also witnessing a new phenomenon of children who are simultaneously obese and malnourished. Consequently, our timeframe for action is rapidly receding.

There have been welcome recent developments such as the impending sugary drinks tax but we must do much more to turn the tide. This is a hugely complex area and we cannot hope to raise all of our issues and proposed actions in the time allotted today. This statement will address the marketing of unhealthy food and drinks to children, which the evidence shows is a key driver of our obesity crisis.

The Irish Heart Foundation is an international leader in this area. In 2016 we published Europe's first ever research on the tactics used by junk food marketers to target children online. This research was endorsed by the World Health Organization, whose follow-up study has been influential at European Union Commission level. Along with our Stop Targeting Kids campaign our research has impacted as far away as Canada where a Bill to ban unhealthy food marketing to children is now before its Parliament.

If a small consultancy company that virtually nobody has heard of potentially influenced the course of a US presidential election using data harvested via Facebook, imagine the extent to which junk food marketers can use digital platforms to manipulate children. Cambridge Analytica attempted to persuade adult voters to exercise their franchise in a particular way over a short timeframe. Junk food marketing involves the world's best marketing brains in the biggest agencies relentlessly targeting children, who we know are way more susceptible to advertising, every single day.

When we published our groundbreaking research we had not heard of Cambridge Analytica or pyschographic micro-targeting. Junk food marketers have been doing this for years to bombard children with clever marketing messages that distort their food choices. It is important to state that the causal link between unhealthy food marketing and childhood obesity has been proved conclusively. This is why restrictions on broadcast advertising were introduced in Ireland five years ago. This did not, however, prompt a more responsible approach from marketers, just an explosion in unregulated digital marketing that is more personalised and effective, and therefore potentially more damaging. As a result, junk food brands have achieved a wholly inappropriate proximity to children, pestering them relentlessly in school, at home and even in their bedrooms through their smart phones. It is called "brand in the hand" and it gives marketers constant access to children.

Marketers have huge amounts of individuals' information, extracted from children through digital platforms such as Facebook: who they are, where they live, where they go, who their friends are, their hobbies, their heroes, favourite foods etc. The marketers use this information to connect with children on a one-to-one basis, employing to so-called three "Es", which are powerful engagement, emotional and entertainment-based tactics. There is strong emphasis on fun and humour and on using sports stars, celebrities, festivals, special days and competitions. The effect is that children associate positive emotions and excitement with junk brands and they often do not realise they are being advertised at. Brands get on to the young people's newsfeeds and interact like real friends, effectively becoming part of children's social lives. The brands even get children to become marketers for them by tagging friends in to advertisements and by posting messages. All of this happens behind parents' backs on social media and much of the pester power they are subjected to is generated by junk brands pestering children.

The argument is often put that people can ignore advertising, but from tobacco marketing in the past to junk marketing and the targeting of voters, which is now under the spotlight, there is a longstanding pattern of people being persuaded to act against their own interests. This is not the exercise of free choice; it is manipulation that usurps free choice. I reiterate that children are far more susceptible.

The foods most commonly marketed to children are sugary breakfast cereals, soft drinks, sweet or savoury snacks and fast foods that are advertised as everyday products when in a healthy diet they should be consumed rarely and in small quantities. This has turned the food pyramid on its head and has distorted the public perception of what a normal diet is.

Sadly, the State's response has been feeble, putting its faith in a voluntary code in an industry whose major players have consistently shown they will do as little as they can get away with. In fairness, their remit is not the protection of public health; it is to maximise shareholder wealth and in the hard-bitten boardrooms of the multinational processed food industry this is what executives are judged on. These companies, therefore, have no role in the solution. The damaging impact of overselling their products has created a market failure that the State must resolve.

From banking to gambling and from tobacco to environmental protection, across the planet voluntary codes do not work. A voluntary industry advertising industry code was in place throughout the online explosion of unhealthy food marketing to children here. Companies adopting the code are not obliged to abide by their commitments while firms acting responsibly are put at a competitive disadvantage that can only be remedied by the level legal playing field of regulation.

Junk food marketing is fuelling obesity, obesity is damaging children and the State is failing to protect children's health. The only remedy is an outright ban on unhealthy food marketing to under-16s.

In this country, we are used to looking back at failures of previous generations in meeting their duty of care to children. In 30 years' time we will all be in the dock, health charities as well as policy makers. How we act now to minimise the toll of preventable chronic disease and premature death facing so many of our children will determine the judgment passed upon us.

I thank Mr. Macey. I note and thank Dr. Adele Keating for her attendance this morning. My apologies to her for not reading her name out earlier, as it was not in front of me.

I invite Dr. Sharry to make his opening statement.

Dr. John Sharry

I thank the Chairman and we are very grateful to be here to have an opportunity to present from Parents Plus.

Parents Plus is a national charity that develops evidence-based parenting programmes to support families to overcome emotional behavioural problems.

We have noticed in the past 20 years a big increase in the difficulties for families regarding unhealthy eating and relating to all of the health and emotional problems that brings into families. We are all aware of the health difficulties that obesity can bring but equally, there are all the emotional and behavioural problems in families, as well as the relationship difficulties that are caused.

Presenting with me here today I am delighted to be joined by my colleague, Dr. Adele Keating, who is a psychologist in Our Lady's Children's Hospital, Crumlin and who works with Parents Plus. One of the strengths of the Parents Plus approach is that we have tried to collaborate with other agencies, such as the HSE, the hospitals and Tusla, to deliver parenting programmes to families.

As the committee has just heard an eloquent submission from the Irish Heart Foundation about the challenges of marketing to families, I will not spend too much time providing details on those issues. Certainly, the families Parents Plus is working with are bombarded with an obesogenic environment, in which it is very much harder to bring up children and to maintain a healthy lifestyle than ever before, to the extent that the editor of the The Lancet journal has stated that being obese is a normal response to an abnormal environment.

We want to focus on the whole issue about the potential solutions and on the aspect of supporting families. Families are the basic unit that are being bombarded and are under terrible pressure in a very unhealthy environment. The key to the main solution is to try to support them to manage that. The previous speaker spoke about the pester power families face. Families and parents know a lot about what the children should be eating and about healthy lifestyles but find it very hard to put that into practice. If parents try to buy petrol, they are immediately bombarded with chocolates, drinks and three-for-one offers and they come back out with a whole host of unhealthy foods they are pestered to take with them.

The approach in which we are interested is the basic and most promising approach to our families, which is to support families in accessible small groups in communities to take action against this themselves. It is to empower them with the knowledge that they are not at fault, that they must make choices and must really push back against the environment they are in to change the direction for their families.

The way Parents Plus do this is that we have worked with safefood, as well as with the charity Supporting Parents and Early Childhood Supports, SPECS, in Bray, to deliver good educational information to families in workshops and in small groups. They are delivered through services like family resource services and primary care where one supports parents by setting up good routines around eating and good rules regarding food and sleep in order that they can build a healthy family unit. These are the key aspects of the programme.

In the future, the key message - referred to in our detailed submission that I hope all members have had the opportunity to see - is that an important part of a solution to the obesity crisis, in line with health-based and school-based programmes and environmental changes as to how food is marketed and retailed, is the development of small-group healthy family programmes that are educationally delivered in schools, primary care services and family resource services in which parents are brought together and families are supported to develop healthy eating routines, to make good rules in respect of food, exercise etc. but also are given key lead strategies for dealing with the associated behavioural issues. All the evidence shows that parents know what they should eat and the exercise they should take but the challenge is how to devise an approach. What does one do with a child throwing a tantrum when all of his or her friends are being bombarded to go to McDonalds? How can the parent help him or her to make a better choice in such instances?

A key thing in delivering these programmes is they have to accessible and in the communities. As specialist services do not reach half of the families that are struggling with this, it is about getting them out to local communities, helping parents to make the programmes themselves and to be involved in their delivery. This is something that Parents Plus, through the network of the services we work with, are very interested in developing and partnering with agencies like Tusla and the HSE to do.

I thank Dr. Sharry. Before I open the discussion up to members, even though it is touched upon in the Parents Plus submission, could Dr. Sharry talk us through the parenting programme and what it entails?

Dr. John Sharry

Parents Plus has developed a number of parenting programmes but the programme we are talking about is the healthy families programme. The research has shown that the most promising approach if one really wants to intervene, and this is shown internationally, is to deliver an educational, supported programme to parents that is delivered in the community. This would bring together eight to ten families who all attend a school and would be advertised very positively about being a healthy positive family. The families and parents would come together over six to eight weeks. They would be given ideas on nutrition, healthy lifestyles, but also the important things regarding how to implement these things, how to handle behaviour, how to set up good routines and things like that, as well as how they can motivate themselves and their children to change positively. A key part of that is to break the whole blame and stigma in this because, usually when people are overweight, they are blamed for that, that somehow they have made poor choices. One cannot even raise the issue with a child or a parent in that situation because the stigma is so strong when actually they should be told, it is not their fault, it is the environment in which the person has been brought up. Effectively the person has been abused by their environment, literally. We want to empower people not to feel bad but to make positive empowering choices by bringing them together in groups and helping them do that.

For example, parents could campaign to not have junk food advertised to their children. They could campaign not to have the tuck shop selling unhealthy foods or for parties not to offer fizzy drinks. One of the most successful initiatives was the healthy lunches projects in schools. Its success is evidenced by the fact we are not doing it anymore. We bring parents and groups together to make those very empowering choices.

Does either organisation, in terms of trying to inform people to make healthier choices, give them examples of a better shop? Invariably, one of the issues that arises, in terms of poor choices being made in supermarkets, is that people are going for processed foods, the simple and easy choices which often are cheaper than the raw materials, and are obviously far worse? Is this part of any programme or does the Irish Heart Foundation have any particular input on that, or any particular programmes that it might be bringing into the public domain? Would Ms Morrissey like to comment on that?

Ms Janis Morrissey

A resource that we developed a number of years ago is a very simple food shopping card that is like a banking card size and used as a traffic light system to empower citizens to read food labels and to decide what is a healthier choice. It simply uses red to indicate a high-level, amber as a medium-level and green as a lower level of fat-saturated, fat, sugar and salt.

We have disseminated tens of thousands, if not more, across the country. They are phenomenally popular in schools, communities and workplaces. It is a very simple and accessible way to support people in making more informed choices when the food labelling available to us is not consumer friendly.

Dr. John Sharry

A key component is the aim to help families. There are a number of myths, for example, that healthy foods are dearer than processed foods. Processed foods are marketed better and made more attractive. It costs 20 cent or less to have a bowl of porridge which, in many ways, is the most nutritious breakfast one can have. Vegetables are the cheapest they have ever been. It is about trying to educate and empower parents to make good choices in a sea of marketing where foods that are unhealthy are made to appear far more attractive and come with toys and so forth. Nobody is promoting the giving of free toys to people who eat broccoli.

Dr. Adele Keating

We give nutritional advice when we run workshops. safefood has fantastic resources which we always use. As Dr. Sharry has engaged in a lot of collaborations with safefood, we use a lot of its nutritional information for parents.

I will now open the floor for questions.

I might hand over to one of my colleagues because I have to attend the Chamber to take a Commencement matter at 10.30 a.m. and would be too rushed.

As the clock had been taken off the screen, I could not see it. Deputy Tom Neville was the next speaker to indicate.

I have a number of questions about the presentation. I thank the delegates for coming. They mentioned marketing. I have been in supermarkets in the past few days to look at their marketing. There is a conflict in that there are rows and rows of sweets, although it is said supermarkets use fruit and vegetables at the front to draw people in. What are the delegates' thoughts on shelf planning?

The delegates mentioned the stigma associated with being overweight, Will they share some of their experiences in that regard and eating disorders? Is there a difference in psychology or the approach to a situation where there is obesity and an eating disorder? Are there parallels from which we can learn because from my experience eating disorders need to be discussed more. Perhaps they have been discussed more than obesity which we are now starting to try to address.

On the initiatives to discourage fizzy drinks being provided at parties, prohibition does not work. It is the 80:20 rule. It is fine to do it for school lunches and in normal day-to-day activity, but there has to be a balance at parties or on special occasions because prohibition does not work, particularly with children. I hate to hark back to my childhood, but having a fizzy drink was a treat and was treated as such. I do not think prohibition would work.

Will the delegates address some of these issues?

Dr. Adele Keating

The Deputy asked a number of questions. There is huge stigma attached to obesity and professionals find it very difficult to address it with families. I work in an endocrinology department where we see patients with clinical obesity. We have children who are at the very extreme end of things and what we find is that there are very few community services that intervene with such families because of the stigma attached to addressing obesity with families at a primary care level. There is a real difficulty when it comes to where we refer on in the provision of of community resources and services. The problem is probably twofold wherein professionals do not believe they have the skills to address it and it is also stigmatising to address it with families. One of the big issues is accessibility in order that families can receive support.

On eating disorders and obesity, there is a qualitative difference in the psychological underpinnings and the treatments used for both groups. Sometimes eating disorders can be taken more seriously by services because the risk is seen as more immediate, whereas with obesity the risks are longer term and perhaps not as immediately evident. They are not offered the level of support somebody who presents with anorexia nervosa or bulimia.

On prohibition, I completely agree. We always advocate, when working with this population, that everything be in moderation. It is about looking at treats as treats and how we support families to do this when they are under severe pressure to provide treats constantly.

Dr. John Sharry

Eating disorders are a serious problem but so also is obesity, although it is not approached with the same seriousness. It is a much more prevalent problem. More than one in four children is in danger of being obese. I will refer to Dr. Keating for the exact statistics. Perhaps 1% or 2% are at risk of having an eating disorder. We need to get the scale right.

Prohibition does not work. I think Deputy Tom Neville had a very good childhood if he saw fizzy drinks just as a treat.

I wished I could have had more of them.

Dr. John Sharry

Now families have them every day. Most of their calories are coming from junk food, not healthy food. We need to row back. They are now the dynamics in families. People have moved away from thinking about what is healthy. They think some foods are healthy that are not healthy. They are marketed successfully-----

Is it just marketing?

Dr. John Sharry

People perceive yoghurt as a very healthy food. Would the Deputy perceive it as such?

I do not see-----

Dr. John Sharry

It is full of sugar.

I do not see sugar, or anything with sugar in it, as healthy.

If it is not full of sugar, rather it is full of chemicals.

Dr. John Sharry

The food industry avoids labelling sugar as a toxin which is causing great harm. It markets yoghurts which are full of sugar directly at children. They are probably as bad as chocolate bars.

Mr. Chris Macey

If one thinks of what is on top of the food pyramid, it allows for just a small amount of foods that are high in fat, sugar and salt. The advertised diet has distorted it and really turned it on its head. There was a study carried out in Australia some years ago that showed that for every healthy food advertisement a child saw, he or she saw 100 unhealthy food advertisements. That is what has distorted the picture. The picture of what a normal diet is has changed as a result.

I thank the delegates for their presentations. It is not just digital marketing that targets children. Last week I was very critical of the "Big Big Movie" because of how it was marketed on RTÉ One. To move on from it, I have read the delegates' submissions in depth and prepared a number of questions.

My first question is for Mr. Macey who mentioned that a healthy diet could be hindered by the four As - accessibility, awareness, availability and affordability. Will he give us some real life examples from case studies of these four barriers and what they mean for people in their everyday lives.

Will I ask all of my questions before the delegates respond?

My next question is about the no-fry zones around schools and other jurisdictions. Are there studies which show the outcomes of having no-fry zones?

A study on a ban on vending machines in French schools showed a reduction of between 20 and 120 calories in daily calorific intake. Is that meaningful? It is a very small number of calories. It may be a step in the right direction but I wish to hear the witnesses' views in that regard.

That several studies have shown the low rate of PE in schools was mentioned. Did any of the studies discuss the reasons for that?

Professor Sharry outlined the elements of the Parents Plus healthy family programmes. What are the main outcomes he is measuring and the results he is observing from the programme?

Mr. Chris Macey

Ms Morrissey may wish to answer some of the questions. There have been many studies on the extent of no-fry zones. Some 70% of our schools have at least one and 30% have at least five fast food outlets within a kilometre of the school gates. A study showed that Ireland was second to the United States out of 26 developed countries in terms of the rate of increase of fast food outlets. We have a big problem. We cannot close down existing fast food outlets so there may be an element of closing the stable door after the horse has bolted but we must start somewhere and deal with this issue. Professor Sharry discussed the obesogenic environment and there is nothing more obesogenic than fast food outlets deliberately siting themselves near schools to maximise or boost sales. In terms of the impact of no-fry zones, studies in London have shown that they work. We can forward them to Deputy Rabbitte.

We have addressed marketing as a key driver of obesity. Children constantly encounter advertising and people trying to get them to buy things that are not good for them. That takes many forms. If one goes back 30 years, shops often did not open on Sundays and closed early. Shops now open all day long and are in communities. Junk food, fast food and unhealthy food is available wherever one turns.

I disagree with Professor Sharry in terms of there being evidence of the growing disparity between the cost of healthy and unhealthy food. The Food Safety Authority of Ireland did a study some years ago which showed that a healthy calorie may be ten times more expensive than an unhealthy one. All the research and development in global food manufacturing is to the end of packing more calories into unhealthy food and making food more sugary and salty. Nobody is looking at how to make broccoli more attractive to schoolchildren or how to make fish or lean meat more accessible. All the effort is being put into packing in calories. That is where the money and marketers are and that is what is happening.

Ms Janis Morrissey

On the banning of vending machines, the reduction in calorie intake may appear insignificant but it is clinically significant if sustained over time. We are discussing vending machines in the broader context of the whole school environment. We deal with schools across the country in terms of their food provision and we know that what children learn on the curriculum is absolutely fine but the issues arise when they walk out of the classroom. There is a disconnect between what children learn and what they experience within the school setting and outside the school gates, as we have discussed in terms of no-fry zones. There is a huge opportunity to improve the school setting. We have carried out research on the nature of food provision in schools. There is currently a lack of guidance and support for schools in terms of what should be provided. We welcome the recent publication by the Department of Employment Affairs and Social Protection of nutrition standards for school meals but we believe that should be extended to all schools and all types of food provision. It addresses one small element of a far broader issue. Our research shows that there is significant production of hot snacks such as panini, sausage rolls, pizza slices, chips and so on in schools. Chicken fillet rolls are very prevalent. Healthy options may be available but the vast majority of food available in schools are items such as chicken fillet rolls, pizza slices, etc. Unfortunately, the funding available to schools does not cover the purchase of equipment that might facilitate the school providing more home cooked and nutritious foods.

Engagement in PE has been dropping for a long time, particularly by teenage girls, for several reasons, one of which is the traditionally competitive nature of PE and that it has focused on team-based sports and competitive activities which are not typically attractive to girls of that age. We have been working with PE trainers in Dublin City University, DCU, the University of Limerick and University College Cork, UCC, to support PE teachers to deliver the curriculum in a broader and more inclusive fashion which also focuses on non-competitive activities such as dance, aerobics, yoga and so on because it is very important to maintain teenagers interest and activity levels in this area.

The small amount of research I have done, which is nothing like that carried out by the witnesses, revealed that some children in secondary school do not have the opportunity to participate in PE. Is that indicated in the research the witnesses have carried out?

Ms Janis Morrissey

It is. A significant portion of schools do not provide the recommended two hours of PE per week, which is a huge barrier. We have found that the focus, in particular at senior cycle, is on academic achievement even though there are profound physical and mental health benefits from maintaining physical activity and the focus should be on a more balanced and holistic approach to the school environment.

I have found that the two hours per week timetabled by the Department on the curriculum is not available to some children in school.

As regards team sport, in which all schools like to participate, is it healthy for children to have to take part in team sports during their lunch hour whereby they have to cram in their food and flip between one session of school and going back in for the next?

Ms Janis Morrissey

It is about looking at our relationship with food and whether there is a disconnect between what children are taught on the curriculum in terms of having a healthy relationship with food and food as fuel, etc., and the reality of their school routine in terms of having to eat on the hoof and try to change out of a uniform into sports gear and maybe change back again, as the Deputy stated. It is about looking at what we tell children in terms of the routine of the school day. Work must be done to match the curriculum and academic side with the practical experience in schools.

If we are to teach children anything about life, we must to teach them that they must make time to eat and that one's body cannot be maintained without fuel. The idea of the curriculum is to teach them a positive message in that regard.

I ask Professor Sharry to explain the outcomes and measuring in terms of the Parents Plus healthy family programme.

Dr. John Sharry

That is a great question because the focus of the Parents Plus healthy family programme which is currently in development is on intermediate behaviours associated with health. Parents rate themselves on behaviours such as whether their children only drink milk and water during the week at home. That would be a healthy behaviour, with fizzy drinks restricted to weekends.

Another healthy behaviour is targeting whether we take time to eat a home-cooked family meal. We start with small portions in our family. Vegetables and fruit are on offer during meals, etc. One makes a list of all these healthy behaviours. The parents rate themselves on ones they do already and ones they would like to increase. They set a target, for example, that they would like to increase the number of home-cooked dinners they have or that there would be a bit more time for dinner. There is research to show that rushed food, rushed eating and eating in front of the television are all poor behaviours associated with health problems. We are looking to increase those behaviours which are associated with healthy families.

What are Dr. Sharry's observations on it? He meets a number of families who come together and they start from whatever point. What are the results like? Can he give us some examples?

Dr. John Sharry

The main issue they would highlight as a difficulty is the battles with their children over dinners to get them to eat vegetables or healthy food. Often they fall into despair that they cannot do it. They also have their own battles with their own health and those routines.

The outcomes would be them feeling a bit more empowered. They can do this in a positive way, involve their children and get their children on board. They can get young children thinking that they will not be marketed at and controlled by the food sector and will make their own choices and be healthy as well. The big benefit is that if one gets the family working as a unit together, it is not parents and children battling but them all in this together. There are many other intermediate benefits. We are talking about people having a nice dinner that they cook together and enjoy. That has enormous relationship benefits in the family. Everybody feels proud and connected. They have a better routine around sleep. There is a time for talking and chatting at night before sleep, and that is healthy. That has huge benefits for family as well. These all are gains that have multiple benefits.

I thank Dr. Sharry.

Deputy Rabbitte covered many matters I wanted to cover. I will address the school environment. In my constituency, we have schools that are surrounded by McDonald's, chippers, pubs and betting shops. As legislators, we need to look at what example we are setting our children in the school environment. On schools and funding in schools, what liaison have they with the Department of Education and Skills because the schools in my area have no canteen facilities? What we see is at a certain time hoards of children traipsing across the road to all these facilities. Should we be looking for the Department to make grants available to schools so that there can be a healthy eating option in the schools?

Do the witnesses have much liaison with school boards of management? Particularly when we talk about the vending machine, Ms Morrissey hit the nail on the head. We are educating these children about nutrition and it is a do-not-say-as-you-do attitude where we allow them out then to fill up on vending machines. Is there any policy of schools providing alternative healthy vending machines? Will we try to make this available to schools to do with a grant option? I have noticed that even water stations are not provided in schools. Why is that so? It is something that would not cost much for a school. I wonder what sort of correspondence the Irish Heart Foundation is having with the Department and boards of management on the matter.

I might ask about food advertisements. Deputy Rabbitte touched on this. I am a parent of three young children. Saturday night is a time where children are sitting down enjoying television and the next thing is they are bombarded with every junk food and sweet advertisement. I note the Irish Heart Foundation criticised the voluntary code from the Department of Health aimed at regulating food advertising to children and I ask Mr. Macey to outline why the foundation feels that the voluntary code was ineffective.

On another point to Parents Plus, in how many areas is its programme rolled out? How do people in particular areas get to hear about Parents Plus?

Mr. Chris Macey

In terms of water, we conducted a study of schools some time ago that showed that a high proportion of them had no free drinking water; we were able to extrapolate from our research that it was easier at the time to get Coca Cola from a vending machine in many of the same schools than it was to get free drinking water. We have done some work around that. We have been assured that there is money available to schools to put free drinking water in place for pupils. We believe that the situation has improved somewhat since then.

In terms of healthy vending-----

Who is responsible for the water? Is it the Department of Education and Skills?

Mr. Chris Macey

I think it is the Department of Communications, Climate Action and Environment. I am not 100% sure but I can provide that information later.

Healthy vending does not work as long as there is unhealthy vending. If a child has a choice between an apple and a Mars bar, the child will always take the Mars bar. There was a proposal at one stage to have a 60:40 ratio of healthy and other vending. That is a recipe for making it look like healthy vending does not work because the Mars bar would be eaten and the apple would be left. When one takes the Mars bar away the apple will be eaten.

There is a company in Ennis called the School Food Company that is going into schools fired with some great thinking around nutrition for children. It is a private organisation but it is doing great work. First, they state all the junk has to leave the school because they cannot compete with it with healthy food. Second, schools need to have a canteen. It is exactly as Deputy Mitchell stated that there needs to be a place for children to sit down, have a proper meal and eat in some form of comfort. They put in a kitchen and they make sure that there is space for children to sit and eat the food. This company, the last I heard, had moved beyond Ennis and had 20 or 25 schools around the country. It is a tremendous initiative and it appears to be working well.

In terms of the voluntary code, I stated in my statement that voluntary codes have been shown around the world not to work because it is not in the interests of the companies to implement them. By their nature, they have to do as little as they can get away with. The multinational processed food sector is in the business of making money. That is what their executives are paid for. They are not in the business of public health. Therefore, they are not in the business of the responses that we need to put in place to protect public health. That has to be up to the State and it has to be regulation.

Under voluntary codes, companies do not have to do anything. If they sign up and do not do it, there are remedies to that. On the other side of it, companies that are trying to do the right thing - there are such companies out there as the food sector in Ireland is multifaceted and there are some great companies doing great things - are at a competitive disadvantage against companies that are flouting the voluntary code. We would say only the legal level playing field of regulation can work. Then everyone is on the same basis.

Ms Janis Morrissey

If I could address Deputy Mitchell's query regarding engagement with the boards of management, for the past number of years we have been running a healthy catering award in post-primary schools where we take a whole school approach. We look to engage with the principal, the teachers, the students, the parents and the board of management. We take that holistic approach because we know that we need the buy-in of all of those stakeholders for there to be any sustainable change. We have awarded 50 schools across the country with this healthy catering award. It is where we are supporting changes in the catering practices and the food provision. We are bringing our nutrition expertise to bear to support the caterers to make those changes, but working in an incremental fashion to explain to the students why this is happening to make sure that there is buy-in from management at a top level as well.

The challenge we keep bumping into is that we can give information about healthy catering practices, but if they do not have the equipment and there is no funding source naturally available, we are operating within restrictions. Nevertheless there have been some great examples throughout the country of quite radical changes. I have seen the fruits of that labour in respect of engagement with the students, better concentration levels etc. It can be done but the structures need to be right for it to be done in a sustainable way. We are fitting into the vacuum created by the absence of national guidance on what food should be provided in schools.

Dr. Adele Keating

Parents Plus is run nationwide. In the past 20 years approximately 5,000 professionals have been trained in the range of parenting programmes. This is a new venture for Parents Plus. We have just developed material on healthy families. We have trialled it in the Bray area. Within a month we ran workshops for 60 parents. We are doing a study on the outcomes of those workshops. We have not done the research study yet, but the plan would be to make these accessible through the trainers trained in the Parents Plus programme, so the reach would be wide.

I am new to this committee and am coming late to this conversation. I held the communications and arts brief. I studied film and television production in Galway and was always conscious of Bob Quinn who, during his time in RTÉ, called for a complete ban on children's advertising. While I accept that RTÉ and TG4, which are State broadcasters, would be appalled by the loss of revenue, the difference could be made up by the State.

Mr. Macey said that the children's commercial communications code was introduced five years ago. It is up for review in the second half of 2018. I understand the limitations in regulating TV only in the digital age, but that is the gold standard for what we can do under the Broadcasting Act 2009 and the Broadcasting Authority of Ireland, BAI. Does he have anything to say about the communications code and does he have any recommendations for the review? Facebook is rolling out changes today on the back of the general data protection regulation, GDPR. That is where this needs to be dealt with. Will we have no chance of marketing healthy food online if people under the age of 16 are not on Facebook?

Mr. Chris Macey

Will the Senator clarify the question about under 16s?

The digital age of consent. Facebook would respond to anyone with concerns about children's advertising online by saying children should not be using Facebook.

Mr. Chris Macey

Its rule is 13. There is plenty of evidence that children as young as nine sign up to Facebook giving false ages. The effort put into preventing that could be better.

There are several weaknesses in the broadcasting legislation that need to be addressed. Deputy Rabbitte mentioned TV advertising and we know that, despite the regulation, children on average see in excess of 1,000 TV advertisements every year. The limitations are that it works only up to 6 p.m. when 50% of the audience is made up of under 18s. Advertisers can advertise as they wish for big sporting occasions such as the recent rugby matches or Gaelic football matches. Most of the international soccer games are later and the legislation does not apply to them. Children watch many of them.

Children do not watch children's TV. They watch soap operas such as "Fair City" and "Dancing with the Stars", which are completely outside the realms of the legislation. There has been talk about advertising around "The Big Big Movie" that is sponsored by large unhealthy food and drink companies. Brands that sell primarily unhealthy foods can evade the ban by advertising healthier items. For example, if McDonald's has a Happy Meal with carrot sticks, it can advertise the carrot sticks but the message about the Happy Meal might get through. We would like that to be addressed.

There are reams of evidence to show that children are more susceptible to the personalised, targeted digital form of advertising. We know that 15 year olds are online for up to five hours a day on average. Very few parents know what they are doing. I have a 13 year old boy and I have no idea what he is doing online. If I try to find out, and I have tried, it does not work. Parental responsibility is crucial, but it is very difficult for parents to get a sense of what people are doing online. For our research parents were interviewed about unhealthy food marketing on digital media. At the start they were fairly relaxed and did not think it was a big deal, but when the tactics were explained to them, particularly the use of sports stars who are promoting products they would never use themselves because of their fitness requirements, they start to get angry. They were especially angry about the tagging in of friends, getting children to advertise unhealthy food to their friends. It is very clever and well thought through, and we need to address it.

Where I live in Lucan there is a boys' secondary school and at lunchtime the boys go directly to the supermarket to get their lunch. There are so many of them they have to be channelled into queues at the delicatessen to buy gourmet sandwiches which cost €4 and €5 each. Can there not be some sort of deal done with supermarkets that says that while it is great business, why not promote healthy sandwiches? I witness baby-led weaning of my grandchildren. My children give their children lumps of broccoli and carrot and God knows if they are choking on them. Should education and early intervention be directed at pregnant women and young mothers because theirs are the hands that rock the cradle?

Mr. Macey said that the horse has already bolted in many cases. Can the promotion, support and education be directed at that cohort of people?

Ms Janis Morrissey

On lunchtimes in secondary schools, a challenge we have found in engaging with this setting is that schools often do not physically have the space to retain the students in a safe, supervised way. It is often not physically possible to keep the children on site.

I did not mean that. I have no problem with them going to the supermarket. Can there be negotiations with the supermarket to provide good food instead of gourmet?

Ms Janis Morrissey

The challenges there come down to pricing of food. Sausage rolls, chicken fillet rolls, spicy wedges and that type of product tend to be cheaper. They are obviously not what we want our children to eat daily. Any negotiations would be very challenging at a local level, where most of the providers operate at a national level. We have engaged with schools that link in with local businesses and have, with our support, changed their catering practices and what the children are offered. It still comes back to the point we made about the environment. Healthier options could be made available in the delicatessen, but will children buy them? If one walks into any delicatessen or newsagent, what does one see? There are shelves of confectionery, crisps, fizzy drinks etc. that are competitively priced. Any meal deals available at these delicatessens tend to include a sugar-sweetened drink and chicken fillet roll. When a child has a certain amount of lunch money per day, that will rule the choices of the child no matter what options might be made available.

Is anybody able to answer the question about baby-led weaning and the education of young mums?

Dr. Adele Keating

I cannot speak so much about baby-led weaning, but on early intervention, I know that there are international programmes in the UK that have targeted under-fives and educated parents about breastfeeding and nutritional intake of infants. They have some promising results with regard to tackling obesity.

Dr. Adele Keating

Not that I am aware of here.

Dr. John Sharry

Early intervention is definitely the way to go. That is the focus of the Parents Plus early years programme. There are different motivational points for parents to reflect and to make positive changes. One is when the baby is born and the other is at the preschool stage when the baby may start preschool. That would be targeted by the Parents Plus early years programme. That is when they are open to new things and new routines being established. Addressing this problem is all about prevention. One has to get in early. Once poor eating habits and obesity are established, it is very hard to stop that trajectory, but if one can educate, support and empower parents with the behavioural strategies that they need to bring in better eating in their homes, increase the level of activity of their children and protect them from the obesogenic environment that they are in, they are motivated by that. Early intervention is the most promising way to approach it.

Ms Janis Morrissey

On that point, the HSE is running a nurture programme which is focused on the early years. There is a wealth of evidence to demonstrate the massive lifelong impact of what a mother eats on the health of the child for its whole life and into adulthood. There is a huge opportunity to influence that child's health positively before it is even born. That needs to be followed through with support for breastfeeding, supporting mothers to breastfeed and to continue to breastfeed should they wish. There is work to be done on societal norms and the culture around breastfeeding. There is much evidence to show how breastfeeding helps to reduce rates of obesity and chronic disease. On fitting in healthy weaning practices, there was shocking research from the Coombe Women and Infants University Hospital about what was going into children's bottles. Food processors were being used to break down takeaways to put into bottles. A huge amount of work needs to be done on weaning practices and getting those healthy habits in from the outset so that it is embedded across the whole family and the whole family is eating as a unit consistently, with the parents acting as role models and eating what they want their children to eat. Early years are vital.

I apologise for having to go. I had to raise a Commencement matter in the Seanad. My question is for the Irish Heart Foundation. I have had much communication with Kathryn Reilly and I think she is an excellent employee. She does much work in this area. We all know marketing is a problem. I understand why we are discussing it as an issue. What will we do? It is like the discussion we had on cyberbullying. We have to come up with a report with recommendations. I feel like we are going in circles with this discussion with all of the groups that are stakeholders. The communications code is voluntary, as Mr. Macey has said, and is not that effective. We all know it is a problem. What practical steps will we take as policymakers to effect some change? I am part of the British-Irish Parliamentary Assembly. We recently did a report on obesity. We travelled to Holland. Normally, we would not, but I suggested that there is no point in Britain and Ireland talking to each other about this because we clearly do not have a clue about what we are doing, with the greatest respect to those making efforts. After that, I know that it will take much patience and hard work because we will not see results from this overnight. I had been working on this for seven or eight years before we even had a discussion like this in the House. I want to hear practical ideas about what policymakers can do.

There is much talk about mobile phones. The witnesses mentioned the brand in hand. Traditionally, I am all for nanny state policies and have a slight reputation for that. Will that have the effect that we hope it might if children do not have the brand in hand all day in school or other places? I do not know if a ban on phones is necessarily a good idea because children and marketing people will find ways around it. We need to focus on what will have an effect.

Ms Morrissey mentioned the traffic light system. Surely that should be put in on a wider scale than the witnesses' initiative, which I commend? I have said for years that there should be some such system - I am not married to any in particular - to make it easy for people to navigate labels and the fact that Actimel, for example, has a lot of sugar in it and parents think it is healthy. Will the witnesses address that traffic light system or a similar system?

If the Senator has any further questions, would she mind front-loading them?

I will be as brief as I can. My question is specifically for Parents Plus but might be addressed by all the witnesses. The witnesses mentioned pester power. I do not know about others but when I go into a garage on an odd occasion, if I get something sugary, staff will ask if another is wanted because it will only be 20 cent dearer. They pester people, which is very frustrating. On the junk food deals in supermarkets, I am of the view, and know there is much resistance to this, that we should not allow those marketing tools to be used. People are walking out of shops with much more junk food than they intended to have because they are on deals and store cupboards are stocked with the stuff. That is something we could do but it would probably be unpopular.

Special occasions are something Deputy Neville touched on when Dr. Keating was answering her questions. Special occasions are not as rare as they used to be when I was young. I have had parents say to me that sugary drinks could be allowed at every party and sometimes the children are at three parties over a weekend. There is a party bonanza going on among younger people. I am all for partying but if it means one must consume one's body weight in junk to get through a weekend, it is clearly a big problem. Should schools have more of a voluntary code suggesting that people born at a certain stage in a month should party together and not have so many parties? I sound like a total killjoy again.

That could happen, in fairness.

The stigma point is very important. I have often raised points in the Seanad and I have heard different Senators, and one in particular, saying "for God's sake, they are just fat". Much of the time parents are trying their best but they are busy, so by the time they realise it is an issue, the people concerned could be moving into the emotional side. If one comes down heavily on a child at that point, there could be other issues that outweigh - pardon the pun - any physical ailment or difficulty. I am on my hobby horse but I must stop. I thank the witnesses for coming in. Practical steps for the report would be very helpful.

Mr. Chris Macey

We would ask why junk food companies should be marketing to children at all and what good is it doing anybody. It is creating pester power for use by kids against parents. We would ban marketing of unhealthy food and drinks to children under 16. It can be done as it has been done with alcohol and tobacco. It can be done in a digital sense too, and the World Health Organization agrees with this. If a child can be micro-targeted by pressing a button, it can certainly be turned off as well. It may take some regulation of social media platforms as well as marketing and advertising, but it can and must be done. It is good that this is a matter of political will. If politicians want to do this, they can do so. Some matters, such as availability of food, are much more difficult to deal with.

To interject, we should have a public health (obesity) Bill. The Public Health (Alcohol) Bill was really unpopular but we need something in this area very similar to it.

Mr. Chris Macey

I agree completely. Traffic light labelling is a European issue, and while there was an effort to introduce it with foods some years ago, it fell to some massive industry lobbying. Children are being made fat by the influence of marketing but 50% of 14 year old girls have been on a diet. In the middle of that people are not entitled to know the impact of what they are eating. A regulated traffic light system would be a good thing for everybody.

Dr. John Sharry

The Senator is right about parties and the regularity of treats. Some of the most important initiatives I have seen taken include the healthy schools lunch policy, which works very well. They could go even further with that. Sometimes they allow a treat on Friday but there is no need for that. Organisations such as sports or scouting bodies could have a code of practice so that at parties there would be healthy options. These are possible actions. People think it would be an outrage to do this but there are plenty of healthy, interesting and attractive foods that can be offered. Voluntary organisations could do much work, along with schools and us as individual parents and communities. We could agree to change the dynamics of these parties and social events. It is all about exposure in the research, and the Senator referred to an apple or Mars bar being available. It is not just children who pick the Mars bar.

That is the crux of it.

Dr. John Sharry

Adam and Eve in the Garden of Eden did not stand a chance. If one is told not to do something, it will be done. We must reduce exposure to the problematic issues. That is where marketing matters. In working with families we are trying to reduce exposure in the home and get the stuff out of the home. Do not buy the items. If people buy multiple packs, the food will be eaten by parents and kids. If it is not there in the first place, it will not be eaten by parents and kids. There should be exposure in the home to healthy lunches, nice meals and so forth.

Dr. Adele Keating

On the stigma question, there should be a universal approach in community settings that is easily accessible. This can be built on to identify target populations from universal interventions to give more intensive interventions. If it is universal, it would be run in communities and be less stigmatising for parents. This means we would be better able to engage them than if it happened outside the community in clinical settings that they must be referred into.

I thank the witnesses for coming before us. As I mentioned earlier, the opening statement will be published. If members have any further questions or queries for either of our groups this morning, feel free to email them. If there are further observations, they can be sent to us via the clerk. That would be beneficial in finalising the process in a month or two. On behalf of the committee I thank the witnesses for the presentation and dealing with the questions in such a comprehensive manner.

Sitting suspended at 11.15 a.m. and resumed at 11.25 a.m.

We will hear a presentation by the National Nutrition Surveillance Centre of the UCD School of Public Health, Physiotherapy and Sports Science. Dr. Sinead Murphy is a consultant paediatrician with a special interest in childhood obesity and a member of the Royal College of Physicians of Ireland policy group on obesity. She is joined by members of the clinical advisory group on obesity. They are all welcome and I thank them for accepting our invitation. We are joined by Professor Cecily Kelleher, Dr. Silvia Bel-Serrat, Professor Donal O'Shea, Dr. Cheryl Flanagan and Dr. Brendan O'Shea. I thank them for their attendance and participation. In accordance with procedure, I am required to draw their attention to the fact that, by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the joint committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.

Any submission or opening statement made will be published on the committee's website after the meeting. I understand the delegates intend to make a short presentation to the committee which will be followed by questions from members. I propose to finish proceedings one hour from now at 12.30 p.m. Will Professor Kelleher, please, make her opening statement?

Professor Cecily Kelleher

I thank the Chairman and the joint committee for giving us the opportunity to present some current research evidence on childhood obesity from the National Nutrition Surveillance Centre. The centre has been in existence since 1991 and is based at University College Dublin. We have a track record of providing surveillance and scientific data for colleagues in the research community and policymakers. I wish to highlight, in particular, the childhood obesity surveillance initiative that has been in place since 2008. It is a World Health Organization international initiative in which Ireland has been participating for the past ten years. In recent years we have collected data in sentinel primary schools for seven year olds in first class. We published data in 2008, 2010, 2012, 2015 and will be undertaking further research in 2018. In the last round the prevalence of overweight and obesity among first class children was 16.9% overall. That represents a stabilisation over time. The prevalence is significantly higher among girls than boys and this has been the case in the rounds of data we have collected. Overweight and obesity are more marked in disadvantaged schools, as designated by the Department of Education and Skills, than in other schools. That is an important inequality we are keen to emphasise. Clear targets have been set by the Government in A Healthy Weight for Ireland - Obesity Policy and Action Plan which was published in 2016. The targets aim at a reduction of 10% in the gap in obesity levels between the highest and lowest socioeconomic groups. That is an important feature of the action. We had the privilege to listen to some of the discussion earlier. Obesity is a multi-sectoral problem. It is a major challenge and something we need to address. However, there is evidence of stabilisation. That is important information on which to capitalise and act.

I draw the attention of committee members to a study published in The Lancet medical journal in 2017. The study pooled data over a 40 year period for children and adults. It shows that there has been a global increase in overweight and obesity in all age groups. We are focusing, in particular, on children, but I wish to highlight that the increase has also been happening among adults. There is some evidence of stabilisation in north-western Europe, in particular. That is important to highlight because it means that we need to capitalise and move on the things that are important to make changes.

If the committee wishes to hear about it, we can cover some more of the work we have been doing in the NNSC on the school meals programme and healthy vending machines. I draw the committee's attention to the Health Research Board's centre for diet and health research in which all colleagues present have been participating. As part of that work we have been looking at different age groups and contexts. We have been following cohorts of individuals to see what patterns of growth and development have been occurring. In particular, my work has focused on the lifeways cross-generation cohort study of 1,000 families which covers three generations, including children, parents and grandparents. We see very strong family patterns, clustering, particularly on the maternal line. These are due to factors such as shared environment in the home, of course, but also the intrauterine environment. In school programmes I would focus, in particular, on the children in transition year in order to prepare them for pregnancy and later family development. That will be crucial. Internationally there is an increasing focus on trying to intervene as early as possible in the life course for women in order to prepare them for pregnancy and the best possible outcomes.

I have been deeply fascinated by this topic for a long time. I address my comments specifically to Dr. Sinead Murphy. I had the pleasure of meeting her last year in Temple Street Hospital. I am not sure if it is the same now, but at the time she was leading a clinic for children with obesity problems. She said something to me that has stuck with me ever since. She said children with obesity problems were the saddest children in the world. I have repeated that statement many times. I know that she has her clinic, but what is there for children to cope with them? Is there counselling available? As it obviously has a huge effect on their mental health, what is available for children? I ask her to expand on the statement made.

Dr. Sinead Murphy

I stand over it.

I apologise to Dr. Murphy. I erred. I was supposed to invite her to make an opening statement. I simply did not turn the page. I ask her to make her opening statement and then address Senator Joan Freeman's statement. We will then restart the clock for the Senator. It was my mistake.

Dr. Sinead Murphy

We are very grateful to have the opportunity to present to the joint committee on the issue of childhood obesity. Before reading the points we submitted to the committee, I would like to set the scene a little, as I am sure the previous group did and Professor Kelleher has just done. I am quoting largely from a Government publication, A Healthy Weight for Ireland: Obesity Policy and Action Plan. It states obesity is a largely preventable disorder. It states only 40% of Irish people are a healthy weight. It states 25% of schoolchildren are overweight or obese, albeit there maybe a little stabilisation. That means that between 80,000 and 100,000 children at school are overweight or obese. The risk is 7% higher among socially disadvantaged children. That is really important when it comes to aiming treatment for these children. The problem is that there may be an attitude that many of these children will become obese adults which they will and that then they will run into trouble. It is important to realise we do not need to wait until then. The children are in trouble now. As Senator Joan Freeman said, 40% of children are having huge psychosocial difficulties. They have fatty liver disease. They have an average age of ten years. They have high cholesterol. They have high triglycerides. They have high insulin levels, which means that they will - not may - develop type 2 diabetes. They are hypertensive. These are all issues that we traditionally associate with unhealthy adulthood. These children - 80,000 of them - have them now. They may not make it to adulthood unless we do something about it. It is critical. We are seeing it all the time. Our waiting list is uncontrollable such is the need for some treatment for these children and their families.

We can all quote figures and it all sounds terrible and very dramatic. I will tell the committee about three particular cases - obviously I will not reveal names - of children whom our team and I have come across recently. The first relates to a boy who came into my clinic at the age of four years. When he arrived, I thought he had walked into the wrong clinic because I thought he did not look overweight. By the time children look overweight they are far too overweight and most of the children who come to my clinic are in that category. He had been weighed and measured, as they all always are. We plotted his weight and height on a centile chart to see how he compared with other children of his age. He was not, in fact, overweight; he was in the high centiles but not overweight. I started to explain to his mother that, unfortunately, he was in the wrong clinic and that he was probably meant to attend a general paediatric clinic but that we would try to help her out. At that point she took out her phone and said he was overweight. She showed me photos of him going back for the previous two years since he was just over two years old where he was, undoubtedly, very overweight. I asked her what had happened and what she had done. She told me that she had met the public health nurse who told her what to do and she had done it. I asked her what she had done. She said that when they went to the park, the other kids and moms might have crisps, biscuits or little cartons of Ribena and so on, but he could not do that because he had a predisposition to being overweight. Luckily for her, she had come across a well trained and well motivated public health nurse who had given her advice when she needed it and she had taken it. She just did not know because it was what lots of mothers were doing, but she had changed what she was doing. She brings grapes to the park and only gives him water. He was saved by the public health nurse because he was lucky. It would be great if we could do that a little more.

The next child was aged nine years when I came across her. She had been attending different services in the hospital for a couple of years. She weighed 89.5 kg, which is more than what most men in the room weigh. She was in a terrible situation in that her mother also had psychiatric comorbidity. I became involved because people thought it was a child protection issue. The child was putting on weight because her mother was not doing what she should have been doing. Her mother was feeding her when she should not have been doing so, not allowing her to exercise, etc. As I was not comfortable with the child protection thing, we admitted this little girl to Temple Street Hospital at a huge cost for two weeks. During the two weeks she received 800 calories a day. She was exercised five times a day by physiotherapists and care assistants, taking walks and spending time in the physiotherapy gym. During the two-week period she lost 1.5 kg, which was so little that essentially it was not going to make any difference to her health. That was because we had missed the boat. This type of treatment will not work for a little girl who has reached that stage.

The other case is even worse. It involves a boy from Cavan who comes to see us. He is 13 years old and in first year in secondary school. He weighs 152 kg which is almost 24 stone. He has a really unhealthy lifestyle. He plays the Xbox a lot. He eats takeaways more than one would regard as healthy. He drinks fizzy drinks. His only social interaction is with his friends on the Xbox. I have no idea how it works and how they do it on Xbox. He is socially isolated otherwise because he weighs 152 kg. He says to me - we know that it is true - that all of his friends also do it, but they do not weigh 152 kg. He has hyperinsulinism, a fatty liver and high blood pressure. He will not make it to adulthood unless he has bariatric surgery, which is the only treatment option for a boy such as this. However, he cannot because we do not have bariatric surgery available for him and will not have for another seven years. I do not know if he will make another seven years. That puts it in context and lets members understand the misery these children are suffering.

I will outline what we propose to do about it. We certainly need treatment options for the children concerned. There are two types. There is the behavioural model of treatment for children who suffer with mild or even moderate obesity such as the first little boy who will respond to such treatment.

We need the bariatric service. We need the whole service - the surgery and the psychological support before and afterwards for the other children, the 80,000 children who are in that situation. Nothing else will help. We are very pleased that there has been engagement with the new children's hospital, which understands this issue. The service planners are saying that there will be a bariatric service in the new children's hospital and we are delighted about this and very much welcome it.

They are the two different types of treatments we need. It is not only health. Like the previous speaker said, we need a whole systems approach to this. We need education. I am very involved at an educational level and we would try to educate our undergraduates across the health disciplines but we need education before that. We need it in schools. We need it everywhere. We need environmental planning so that these children can get out and exercise. Possibly, above all, we need regulation of the food industry and advertising around this. This is critical. Unless all of this happens, we will not tackle it successfully.

The other major issue is prevention. All of the speakers alluded to this. We need prevention and we need it early. It has been shown in the US that intervention at preschool level is too late. We need intervention the generation before. Some of that is beginning in terms of health promotion. We need to educate transition year students, not for they themselves, although they will pick up something, but for the next generation. That is where we need to go. It is definitely about pre-pregnancy. There needs to be a lot of investment in the prevention of obesity.

We welcome the initiatives that exist in terms of health promotion. The HSE has a healthy eating and active lifestyle programme. The island demonstration programme links to transition year. These are very welcome initiatives but they are only a start. Some of the previous speakers alluded to a national packed lunch policy for primary schools. That does not cost anything and would be very helpful. We half do it but it would be very easy to do a full-on version for everybody. We certainly welcome the sugar tax legislation and look forward to its implementation. We can see changes so there has been reformulation because, like a previous speaker said, the food industry is about making money. If they reformulate drinks so they can still make money, that is great. The kids are still buying the stuff but at least it has less sugar, so there have been changes. We would love to see the money that is made from the sugar tax legislation being reinvested into the treatment of childhood obesity. It seems obvious to us that this is what needs to happen. There needs to be investment that is significant and sustainable at Government level in the treatment of childhood obesity because the appointment of a national clinical lead on obesity and the setting up of a clinical advisory group - the Royal College of Physicians of Ireland policy group - cannot do anything unless we have investment behind us. The investment needs to be in both prevention and the two different types of treatment for these children.

I think Dr. Murphy has answered my question about what happens. She spoke about operating and support. The children who come into her clinic are in very safe hands. I thank her for that.

Who would like to ask a question?

I indicated earlier. I thank the witnesses for coming before us today and telling the stories because that is what makes it feel real. I have lived it myself so I know what this is about. It is not just about having bad parents. I had great parents. Sometimes it gets to a point where it is a case of this being an issue. As I mentioned in the previous session, we do not want to give them a complex. I know the witnesses were probably here for the previous session so I do not want to repeat that. It is devastating to hear those stories but it is very helpful to get the human side of it, which is so real.

The issue of environmental planning is very interesting. I mentioned the report we did on the Netherlands which has taken a very cross-departmental and local approach. I would be very willing to share the report with the witnesses. With many of these reports, I feel that we spend a lot of time producing them and they end up on a shelf and we do not know if anything is ever going to happen. There is some very interesting stuff in that report about how the Netherlands approaches it at local level. Its levels have not been as bad as our levels and are reducing. As I said, it takes a lot of time and that is the frustrating thing about this.

Coming at it from a different angle, we hear a lot of talk about fiscal space. I am not sure I know exactly what economists talk about when they talk about fiscal space but I think there will be an awful lot more fiscal space if we sort this issue out. It is so short-sighted of us as policymakers not to see that obesity will cause so many expensive health problems in the future. If it is not obesity, it is cancer. It is endless. I do not know about the statistics and the witnesses would be much more qualified to say this than me. That said, what percentage of people are presenting in hospitals due to alcohol, which contains a huge amount of sugar, or obesity? The number is huge. It must take up most of our hospitals' time at this stage.

Dr. Sinead Murphy

Certainly in the adult hospitals.

We need to face up to the fact that there is a lifestyle issue here. We are well down a very unhealthy and catastrophic road where young people will die before their parents. I have been talking about this until I am blue in the face and I believe that we, as a Government and society, are not doing enough. Every time I suggest some measure, and I think it is going to have to come from so many different angles, I am hammered by certain people who are libertarians. They are the very people who will criticise us for tax measures that we must put in place because we need money to take care of the health service and everybody will be sicker and sicker because of this. This is a rant but I feel so passionately about this. The pre-pregnancy issue is so crucial because it is a case of monkey see, monkey do. At the end of the day, we cannot expect children not to drink, smoke or eat a lot of sugar if their parents do. We need to educate ourselves first and foremost. I do not know how we as policymakers can do this. I am trying to be constructive in a sense without being too negative. The witnesses have given us a long list of things we need to do. How are we going to get all this done? Is enough of a system in place? The witnesses mentioned funding and, obviously, resources are a huge issue, but how are we going to have the will among policymakers to do this? Is it something we can do because I am withered at this stage talking about it?

Professor Donal O'Shea

If I can start to answer that impossible question, behind anything we do we must accumulate the evidence to say it works. We must look to the strengths of the country, which are our size and our ability to do things. Sitting around the obesity table, as it were, we will often use the smoking ban as a really good example. It was vehemently opposed by the industry just as seat belts in cars were opposed by the motor industry, but when the evidence emerged that seat belts work, it was a good thing. Not smoking in a pub works. It is a good thing. Making our children healthier is much more complex but the forces against which we are working are similar. They are industry forces.

Professor Kelleher and I sat on the obesity task force in 2005. It was dead within a year due to lack of funding. A Healthy Weight for Ireland is the next iteration of that 11 years later. If cycles of policy fail, it takes another ten years to come around before we get another chance. This is our chance for the next ten years to begin to make a difference over a timeframe that in reality, is a 30, 40 or 50 year timeframe. That is difficult for Governments that are elected every four years. In respect of the Healthy Ireland framework, backing this framework and making obesity and childhood obesity a central plank to address childhood obesity, we need to address homelessness, social justice, drugs and alcohol.

All these will have to be sucked into that complex solution. The figure of stabilising childhood obesity disguises continued upwards movement in the less well-off and disadvantaged areas while it slides downwards in the better-off, better educated areas. We are continuing to separate the population.

The obesity policy and action plan has an implementation group which is multisectoral and multidepartmental. The key ones involved are the Department of Transport, Tourism and Sport, the Department of Agriculture, Food and Marine, the Department of Health, along with State agencies.

As professionals in this area, are the witnesses satisfied the Healthy Ireland framework has sufficient measures but they just need to be implemented?

Professor Cecily Kelleher

We certainly need to implement it. We are all players here. We can give the committee the evidence. The policymakers can ensure the legislation follows through as is appropriate. I agree with everything that has been put on the record so far. As Dr. Murphy stated, every health professional should be trained to intervene early and efficiently. That is part of why we are doing this in the UCD college of health and agricultural sciences which I oversee. Every health professional in that is now engaged in a programme where they will be taught to intervene early and compassionately, as is appropriate. All along the spectrum, when a child sees the GP or public health nurse, the message needs to be in there. Some of this does not cost money but is about thinking about things differently.

There is no doubt that there are hard environmental issues which need to be tackled. We are in a sedentary and obesogenic environment. Accordingly, it is difficult to make the healthy choices. The individual can take 10,000 steps a day but it also has to be ensured there is adequate opportunity to take exercise, to walk freely and not get caught up in a congested car-polluted environment. These are all policy matters which support individuals making healthy choices. There are key points of intervention. Years ago, we undertook an evaluation of transition year students and the views of boys and girls around breastfeeding. The boys were enthusiastic about it. The girls not so much, the reason being that the girls recognised this was a practical thing that they needed to know how to do and how to engage with it properly. Every part of the education system, health system and the supporting areas needs to be proofed. That takes political will. We can advocate to the policymakers but we are not people who can do that. Professor O'Shea is correct in that one has to have systematic evidence. The smoking ban is a good example. We are a small country which can punch above its weight. We banned smoking outright in public places. I can give the committee Cochrane Review type international data which support that it has been highly effective across the globe in reducing exposure to passive smoke and hospital admissions, as well as influencing active smoking. We can get these things done, but we are all players in it.

We spoke previously with the Irish Heart Foundation on a public health (obesity) Bill to implement many of these measures. Do the witnesses believe such legislation could work, even if it is potentially unpopular?

Professor Cecily Kelleher

Obviously, the sugar tax is coming in which is an example. There are issues which need to be considered. We spoke about the stigma related to labelling people obese. Whether it is a legislative framework or it is to do with some bottom-up engagement, it takes cross-sectorial engagement to do it.

Should the sugar tax be extended? We are seeing results before it has even been implemented. Should it be extended to confectionery and high-sugar and high-fat foods? At this point, we can see the efficacy of the sugar tax in the fact that reformulation is happening on a grand scale. We heard much about that in the UK recently. Should we be heading down that road or is it too difficult?

Professor Donal O'Shea

Putting aside calorie-posting on menu boards, this is the Government's first use of fiscal measures to make an impact on a massive cost. Obesity is filling our hospital trolleys. If alcohol is added to that, more than 50% of emergency department admissions are between cardiovascular, diabetes, cancer and alcohol related problems. By extending the sugar tax, we run into the issue of the nanny state.

I have run into that a good few times.

Professor Donal O'Shea

The food and the drinks industry went very quiet when we started looking at a top shelf tax several years ago for high-fat, high-salt, high-sugar foods, on which 85% of food advertising is spent and on which 95% of celebrity endorsement occurs. It is one step at a time. We must see what happens with the sugar tax and if the wholesalers begin to change their buy one, get one free promotions towards fresher produce.

Professor Donal O'Shea

I know, but we have to look. Ultimately, we may be looking at extending the sugar tax. It is one step at a time.

Professor Donal O'Shea

It may be too slow.

I thank the witnesses for their presentations. Having this conversation on obesity at this committee is a step in the right direction. Previous speakers set the stage. Those involved have set out what they need and what they want to move it forward. Sometimes at committee meetings I wonder what the witnesses want or need. I thank Dr. Murphy because she told us what she needs and wants to make it work. The evidence base has been done by Professor Kelleher. Anybody looking in this morning will see the facts are in front of us and this is how we can address it. This is so refreshing. We have been asked for treatment options, education, environmental planning, regulations around the environment, prevention and early intervention and ensuring funding around the clinical lead. The human stories have copper-fastened why we need to deal with this issue. The fact that 80,000 are in need of some form of clinical intervention or some kind of support is concerning. If we do not address it now, we will lose this completely. As legislators, we must put pressure on the Government to ensure this matter is dealt with as it has been discussed since 2005.

Sitting down is our new killer. A new road is being developed in Abbeyknockmoy, County Galway, which will have a walking track beside it. Can we not put in lights to allow people to walk this 5 km stretch in the evenings? That is forward thinking but the right way of thinking.

What data are gathered from a first-class child?

Professor Cecily Kelleher

We have a group of schools with which we have been working from the beginning. We follow the obesity protocols in which we primarily measure height, weight and waist circumference in the privacy of the school classroom with the consent of the parents and the assent of the child. Those are the core data we collect. We also have a questionnaire for the families of the seven year old which gives us more details about the circumstances of the family, including issues around soft drinks and dietary intake.

Is the child's flexibility measured?

Do we measure their flexibility to ensure that they can participate in sport, and that their measurements are good? Does Professor Kelleher know what I am talking about?

Professor Cecily Kelleher

Yes, I do, and I think it is very important. No, it is not in the childhood obesity surveillance initiative, COSI, protocol because that is a core protocol, but there are other researchers who are looking at flexibility, which is a very key piece, and mobility across the life course. I think that is very important.

The issue around sedentary behaviour is increasingly of great interest. I might give the committee an example from the department of preventative medicine in St. Vincent's hospital. We have a number of initiatives there at the moment which have a lot of engagement and which could be replicated elsewhere. For instance, we have regular walks that people take as part of the work programme. We have introduced a step exercise programme whereby staff periodically get up from their desk and hop up and down on the step for a couple of minutes and then sit down again. That is something we hope could become much more widespread for people who are primarily sedentary workers. We have other exercise programmes which have a lot of engagement. Physical activity is a way in for young people-----

Professor Cecily Kelleher

-----and perhaps the dietary question is more complex. These days young men are very interested in physical activity and exercise, including weightlifting and all of those other pieces. Those kinds of things are ways in and the key in schools is to get people involved in things that are not necessarily participative sports, although that is excellent too, so that they are moving and active all the time. There is research on that question but COSI is an international protocol so that we have systematic figures.

I suppose I am no different from Senator Noone in that I have done my own little bit of research. Mine focuses solely on flexibility and mobility and the role the transition year, TY, programme could play with first years such as measuring them when they come in and seeing how they do at the end of the year. That is a way of giving control back and it is peer led. It would be wonderful to have it from first class which would mean there would be a longer span.

Will Professor Kelleher explain the gender difference in the rates of childhood obesity?

Professor Cecily Kelleher

The simple answer to that is "No". It is quite difficult to explain. It is observed internationally and we do not have a clear explanation for why that is.

Professor Cecily Kelleher

Perhaps Dr. Silvia Bel-Serrat could add something. I would like to be able to explain it, but I can simply observe that it is the case.

Will Dr. Murphy explain further the behaviour model for managing and preventing mild or moderate obesity and what type of resources in terms of healthcare staff would be needed to deliver it? She mentioned a public health nurse earlier. Does she want to expand on that because in that case the intervention by the public health nurse was a key factor?

Dr. Sinead Murphy

Yes. If I may, I will respond to a couple of the points that were made earlier about children and exercise. We know that less than half of children get the recommended amount of exercise. From a study that was recently done in our department, we know that less than half of the children who came to our clinic had an outdoor space to play in. If we are dealing with homelessness and tackling the homelessness issue, there is an option to look at this as well because the children have nowhere to go as they cannot go outside and play safely. I am not even talking about a back garden. I am talking about an outside public place to play.

For the second couple of cases that I described, we know that the children have established severe obesity and the behavioural model does not work. What we need is a primary care-led, integrated approach where all healthcare professionals are trained. Regardless of discipline, it is motivated healthcare professionals who are trained in motivating those families to bring about behavioural change and to manage in the obesogenic environment in which they live. That is what we need. We need investment and it must be primary care led and available in communities. Somebody mentioned children coming into hospitals, but that cannot happen. That is not a good way to deliver the solution. It was a public health nurse in the case I outlined but it could just as easily be a dietician. It may be a very interested GP. The healthcare profession does not matter. What is important is that it is a healthcare professional who is properly trained and in the right place so that when the children need the intervention, they can have it.

The other point that is really important is the measuring of children because by the time they look overweight, the horse has bolted and it is too late. Children need to be measured routinely. Perhaps we are a little bit better at commenting on their longitudinal height, but we tend not to measure weight and that should be part of every interaction with a healthcare professional.

Do I have one minute left?

Yes. Deputy Rabbitte can go ahead.

I will try and get three questions into one. I have been very vocal about marketing. It is not just digital marketing. It is all forms and across all platforms. I would be very interested to hear what Professor O'Shea thinks about that. I must also bring in the children's hospital. I am led to believe that a fast food unit is sponsoring a particular unit within it. I have a huge issue with that. I say that openly. I would like to hear the inputs and thoughts of the witnesses in that regard.

Professor Donal O'Shea

We are constructing a magnificent new children's hospital that will be state of the art and one of the most expensive facilities of its kind in the world. A very important part of a children's healthcare facility is being able to look after families and parents of children who are inpatients. The situation here and in other countries is that the Ronald McDonald charity has sponsored, built and run such units, complete with all the explicit twin arches and marketing within that unit. It is not ideal. It is product placement and that is how companies work. In my view it is similar to a drinks company sponsoring a support service for a liver unit.

Professor Donal O'Shea

I think it will be seen as such in 40 years but it is an essential facility and it is just that the people who are delivering it and the way we have set up the children's hospital is with the help of Ronald McDonald because there has been a historical connection. It is a fact that some countries are moving away from that arrangement now.

In terms of marketing, Snapchat was not mentioned in the earlier discussion but it has a massive reach. There is no age limit on Snapchat and children of every age are engaged and they are getting ads. I am on Snapchat and I see them coming through.

In terms of marketing to children, the McDonald's monopoly prize vault runs for six weeks at the moment. A child gets a sticker with a burger and two stickers with a Big Mac. He or she gets a sticker with a small drink and two stickers with a big drink. One gets no sticker with water. The more a child goes, the more chances he or she has to win. How does the child win? He or she pulls a ticket from the bottom of the cup or burger, goes online and enters the ticket number to see if he or she wins a prize.

Is that in Ireland now?

Professor Donal O'Shea

Yes. That is encouraging frequent visits, larger portion size and going online for a flutter. The promotional material says it is not for those aged 16 or under but 13 year olds and 14 year olds are going around to look at trays that they can pick stickers off so that they can go online and they say that it is okay because McDonald's does not care about age. The prize budget is €1.5 million for six weeks. The Healthy Ireland fund last year was €5 million for the year. That is one retailer. It is genius on its part but it goes against all the public health messages we are trying to promote.

McDonald's has been doing that for decades. I remember those campaigns, not just by McDonald's but other retailers also.

Professor Donal O'Shea

Yes, but we are in the middle of a childhood obesity pandemic that is causing enormous problems.

May I make a point?

No. I have not come in yet. Is Deputy Rabbitte finished?

I will finish with a question about funding for the clinical lead and everything else. Do the witnesses have enough funding to do the job they are doing, because they are doing significant work? Would it not be far better if McDonald's were to give the €1.5 million to the work being done by the witnesses instead of targeting children?

Dr. Sinead Murphy

Of course. No, there is not enough funding. While funding has started to be allocated, there needs to be ongoing sustainable funding, not once-off funding, for the management of this health situation, in particular treatment in the community but also the bariatric side of things.

Professor Donal O'Shea

For the record, the clinical lead post and programme manager for the obesity programme through the Royal College of Physicians have been funded by the Health Service Executive. The task is to develop a business case for funding the management of obesity going forward. The HSE is leading on the prevention, intersectoral and cross-departmental piece through the healthy eating and active living programme.

I noted down some broad subject headings during today's discussions. Participation, drop-off, education, control and planning are the themes I am taking from this discussion. Participation refers to physical activity, while drop-off refers to the steep decline in activity in secondary school. Education and awareness refer not only to children but parents in particular. By control, I mean State control. In virtually every contribution she makes, Senator Noone refers to the nanny state. I am all for the nanny state because without it, we would not have rules on seat belts, cycle helmets, smoking, the sale of alcohol sale to certain age groups and so forth. I have no doubt people will continue to rail against these measures. The mere mention of labelling food or alcohol as carcinogenic leads to newspaper articles complaining that such labelling is an example of excessive control, which is nonsense. We all have a job to do, namely, to make life better for all citizens and if that means curtailing an element of freedom, so bloody what. That is what we have been elected to do.

The evidence provided at our two sessions makes clear that the question is not what should be done with the sugar tax but what we should do next. Should we address fatty foods, for example? Professor O'Shea stated we should wait for a certain period to see what has been the effect of the sugar tax. While I fully agree with him, we should also plan our next step, which means discussing issues such as saturated fats, salts, sugars and other products that are added to foods and marketed. These types of goods are the first items we see in the vast majority of retail premises. Only one large retailer places fruit and vegetables at the entrance to its stores. It is a pleasant experience to see the colours of fruit and vegetables. However, this practice has started to ebb since the retailer was acquired by another company. On entering my local store, I used to see the beautiful, bright colours of fresh fruit and vegetables, primarily from North County Dublin, which produces approximately 80% of horticultural produce in the State. This is starting to change, however, with prepacked goods now placed alongside the fruit and vegetables. This is a terrible shame. Perhaps the previous owner exercised an element of corporate responsibility.

We need to start bringing planning and control into this conversation. If, as Professor O'Shea states, we are planning for 40 or 50 years ahead in terms of impact and we only get to do so every ten years, unless we act now, the knock-on effect of the work of this committee and the Joint Committee on Health could last for two or three decades. That is a stark message.

I read all the submissions before the meeting. Even as a parent of two small boys, both of whom are relatively healthy, I think about what I place in my shopping basket. I buy smoothies, which are 100% fruit, but I may need to make some decisions on the issue of treats.

I was a councillor for seven years before my election to the Dáil in 2011. During that time, I was involved in a couple of development plans and local area plans. The development plans were fairly standard and the local area plans included planning for infrastructure in a certain zone, perhaps a field or whatever. We heard about porous pedestrian routes. The local area plans in which I was involved has very few such routes. I am from an urban environment. A development zone on the outskirts of town will have walking routes if it is primarily residential. The norm, however, is for older communities to resist access for new communities. They may not oppose entry to the community but they do not want others to be able to pass through because they do not want teenagers coming into their area as they perceive it may result in anti-social behaviour. This presents a serious problem in terms of healthy lifestyles because parents will not allow their children to cycle if they are blocked from accessing a route. We have to learn from that. I mean no disrespect to local authority members but we cannot rely on local authorities taking a uniform approach. This means a national approach is required and this should be done through primary legislation.

We have already seen the effect of the sugar tax, even though it has not yet been implemented. Senator Noone referred to saturated fats and Professor O'Shea referred to food labelling. While food labelling is important, perhaps the print on labels must be larger. We should discuss what effect a 50% increase in the size of the lettering used to identify the sugar content on packaging would have. Given the positive impact of previous changes in areas such as smoking and drinking alcohol, perhaps we should start making changes in the area of food. I ask the witnesses to make some general observations.

Professor Cecily Kelleher

The Chairman's observations are good and very much in the spirit of the discussion. I reiterate the point I made about the power of the public sector to make a difference. The Chairman touched on the issue of planning, which is crucial. We are about to make a significant investment in primary schools because of demographic changes. As part of the process, we have the power to proof the planning for these schools and identify, for instance, what types of catering facilities could be provided. We discussed the difficult issue of children leaving schools to buy items in private supermarkets. We should ask what power the public sector has to make the changes. This will be crucial because it is a step we can take.

If we take the history of public health, if this committee had been meeting 100 years ago, it would have discussed infant mortality, slums and poor housing, all of which were effectively addressed by planning. Subsequently, the 1947 Health Act had a major influence on public health nurses and others. We can do these types of things. We should examine all the options for their effectiveness because they work. While I agree that issues around taxing specific products, labelling and working with industry to improve product availability are all important, there are also many means by which we can change patterns of consumption immediately, including altering the environment in workplaces and health settings. We could and should do these things. We should proof public policy in these types of areas, carry out urban planning accordingly and ensure we think of these kinds of pieces.

Professor Donal O'Shea

As pillars, participation, drop-off, education, control and planning are very good and the only others I would add are effectiveness and evidence.

I refer to labelling and the question was asked as to whether the industry would oppose traffic lights. It was an Irish vote that swung it away from traffic light labelling and that was unfortunate.

As to the decisions made here, ten years ago we said that if we did nothing we would need obesity surgery for our adolescents. We did nothing and, ten years on, we now have agreement that we will have obesity surgery. In the emirate countries the obesity surgery programme begins at the age of five and that is what can happen if nothing is done. We are talking about it for our teenagers and not our under-tens but continuing to do nothing is not an option.

Dr. Murphy spoke about the intervention of a particularly good public health nurse, which is heartening to hear. As a parent, I know certain visits take place where measurements are taken and information is stored. What effect would it have if we increased public health nurse intervention throughout a child's life to include recommendations on healthy eating, sporting participation, height-weight, the PMI index and other clinical steps? How many extra nurses would we need to deliver that?

Dr. Sinead Murphy

I would not like to put numbers on it but the effect would be dramatic. The little boy to whom I referred just happened to be lucky to hit upon a motivated public health nurse who knew what she was talking about and had the confidence to deliver the message compassionately. There needs to be training of the people in post but that would not cost very much money. It also needs to be equitable because, at the moment, an enormous number of children are referred to a hospital service because there is no community dietician. There needs to be significant investment, not only in public health nurses but in all healthcare professionals in the community. We would need to gather the evidence but I have no doubt that the evidence would be overwhelmingly in favour of it and that there would not be a great cost relative to the gain. The current cost of childhood obesity is enormous and will not change unless we do something about it. It would be a really positive measure.

Where are we going in terms of childhood obesity, mortality rates and impacts on society if we do not have serious intervention? Lifestyle and foodstuffs have changed so dramatically that the life expectancy of my sons is ten years greater than mine, and I was only born in 1977. When they have children it might be dramatically higher again but is it only for the lucky few who have healthy lifestyles and participate in sport, while everybody else is doomed to obesity?

Professor Donal O'Shea

It is encouraging to see the stabilising of childhood obesity but it disguises the separation to which the Chairman referred. We are living longer but with more years of chronic disease, which we already cannot afford in our hospital setting as it is filling the trolleys. Historically, we have shown the capacity to change and to introduce public health changes. The WHO has looked at the Healthy Ireland framework and said that, if we were to do it right, it could be a template. We are seeing some shoots in respect of this. Three Ministers got together to launch the healthy eating standards for DEIS schools and secondary schools a few weeks ago and there are now minimum standards for catering in secondary schools. That is a start and if they are rolled out and there are popular health catering awards, such as those of the Irish Heart Foundation, they can work. We have to be positive and progressive but we must resource it.

Professor Cecily Kelleher

It is very important to feel we have the power to make a change. I could give the committee dire projections of what the statistics will be, and we already know there has been a rise in diabetes in the population data. We have heard about the burden of disease happening in the hospital environment but many people have made effective changes. Two decades ago we would still have been dealing with major problems with coronary heart disease related to smoking but we have had a major impact on smoking and now we are dealing with problems related to obesity. We have to take a vigilant approach to public policy to make the changes we need to make.

Recent research shows we plateaued out in respect of this 2015. Did certain policy interventions get us to that stage?

Professor Cecily Kelleher

The situation has only recently stabilised, which is why Professor O'Shea emphasised the need for evidence. Public awareness has increased and many sectoral efforts are being made. We need, however, to be able to link trends to intervention data.

Professor Donal O'Shea

One in four of our kids is overweight or obese. However, despite the toxic environment driven by the food and drink industry and our sedentary lifestyles, 75% of people are of normal weight. It is amazing that the human body is still trying to maintain health. If we get it right, we will reduce the figure from 25% to an acceptable figure, whatever that may be. In respect of adult obesity, I have always thought it would be 10% or 12% as we will always have overweight and obese people, but the figures have gone up dramatically in the past 40 years.

Professor Cecily Kelleher

There are more and more people with morbid obesity but we can shift it back again.

Dr. Sinead Murphy

We have not got anywhere near a good understanding of what causes this. If it were as simple as we sometimes think it is, we would all be morbidly obese but we are not. It is important that there is a lot more investment in research at all levels, not just in public health research. Until we understand it better, we will be unlikely to tackle it properly.

Professor Cecily Kelleher

Even five years ago we would not have appeared before this committee to say we wanted to shift responsibility for this to transition-year students and preparing mothers but the evidence base has improved greatly as regards intervention at those points.

I thank the witnesses for their participation.

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