Question for Short Debate (Lords) on Body Mass Index - Apr 22

Friday, 23 April 2021 08:34

Asked by

Lord Addington
To ask Her Majesty’s Government what assessment they have made of the effectiveness of Body Mass Index as a medical guideline.

Lord Addington (LD)
My Lords, this is a subject of which I have spoken in the past, but what inspired this debate in my name was the report and subsequent publicity from the House of Commons Women and Equalities Committee, chaired by Caroline Nokes MP. The report points out that on an arbitrary line with an ideal point in the middle, when it applies to people, most are not at that middle point. When that is used to identify health, you are effectively saying that a lot of people are not healthy. That idea is suggested as a good guide to what one should be—I have spoken about it in the past. However, not everyone is in the middle. The guide says that one should be X height and X weight.

The report spoke about the damaging effect of body image, predominantly among the female population, particularly the young. It is yet another thing that says, “This is what you should weigh, look like and be.” But it should not be just like that. It is worth remembering that in the current environment this applies also to males. It is increasingly applied to all young people and, indeed, the whole population. There is an accepted norm. The internet has exacerbated a situation that has always been there.

Most of us in this debate will have spoken about retouching photographs and making sure that they are idealised versions of people. That is now taken to a new level. Some of the work that we have been doing was referred to in a debate on a Private Member’s Bill last week regarding restricting plastic surgery. These issues are adding to the problems, but if this approach is taken as a medical guideline, you are getting the wrong information on which medical procedure might be taken. Given the information that is put out, along with the press coverage, we should be worried.

I wish that I could have given some of my time to other noble Lords taking part in this debate. With conditions such as anorexia, someone can be told, “You are not light enough to receive help for that eating disorder, because you don’t hit a certain point on the graph.” Regardless of what that person’s frame or exercise patterns have been, by taking that decision, one is actually making someone’s medical condition more difficult to treat because somebody is looking at the guideline and saying, “This is where you should be.” This is a difficult situation for everybody. Certain medics will be better at this than others.

Here, I should probably say why I took an interest in this issue in the first place. According to this measure, I, like everybody I played rugby with, was dead a while ago. As somebody who once had somebody put a hand on his shoulder and say, “You were born to play prop forward,” I possibly have a bit of an axe to grind. To use myself as an example, I once had a neck injury and a chap—he became best man at my wedding and I was best man at his—looked at me and said, “You’ve got a neck injury? What neck?” We have to carry a bit of this.

This approach does not work for people like me. We are constantly told to lose weight. I remember being told by a doctor when I was having a check-up for some insurance, “Well, according to this, you are too heavy,” and in the same week being shouted at by a coach, “You’re not eating enough for my exercise programme.” Of the two, I know which one I listened to. But if you take this type of information that pays absolutely no attention to physique or exercise pattern, you will get bad answers, which do not help with any form of general public health pattern. You cannot say, “This is what you should be.”

I know that we are trying to move slightly away from this approach. I have heard people say, “Take certain measurements and get the relationship across.” If you do a calculation like that, you are still going to get it wrong, even if it is slightly more accurate slightly more often. Medical professionals should be looking at somebody individually. If they cannot do that, they should withhold an opinion. I know that it is more convenient to look at a chart and say, “You are X height, you should be X weight,” but it does not work. It never has.

I have done some work on this in the past. This approach was invented in the late 1950s, I think, although the noble Lord may have better information. It was thought that it would do as a general guideline. We have got bigger since, with higher protein diets, and are slightly taller and bigger-framed. It is out of date even for an active person who is not carrying any muscle mass. If you are any form of athlete or taking any form of physical activity, you will acquire some muscle mass and muscle is much heavier than fat. Get a person healthy and fit and make sure that they do not hit your medical targets: why do we still have this? It does not seem to work at any conceivable level. It is telling people to attain to something and repeating the messages, “Nobody is perfect” and “Do something else”. It encourages damaging behaviour. It gives wrong information to medical professionals, who often look at somebody and say, “Ignore it.” Why are we still using it? Can we not just take it out and ask for assessments? An assessment is looking at somebody and assessing their activity patterns. Otherwise, we are going to continue to have these problems.

This is either wasting printing paper or slowing certain people down from getting the help and treatment that they need. Adhering to it makes it more difficult to get early treatment for eating disorders. Everybody knows that you must get in early, establish the patterns of behaviour and convince that person to change those patterns of behaviour. Anything working against that should be removed.

I could go on at length, but the danger of being totally self-indulgent is looming towards me, so I will conclude my remarks by asking the Government just a couple of questions. First, if this was proposed to the Government now, would they use it? Would they take and use an arbitrary level that does not correctly assess anything other than for a small percentage of the population? Secondly, if the Government would not take on something like that now, what would they recommend to doctors to assess health and well-being in the general population? Would it be easier to administer or not? The answer is probably not, but a bit of effort might help us to get a better public health outcome.

14:39:00

Lord Brooke of Alverthorpe (Lab)
My Lords, I am grateful to the noble Lord for tabling the Question. We may be debating some of these broadly related issues in even greater depth in the future, because the facts of life are that we have one of the unhealthiest populations in the whole of Europe. We now have some opportunities to review what we have been doing and what we might need to do in the future to improve our health. I have been given a good briefing by Diabetes UK, and I express my gratitude to it because I am one of those on the cusp of developing type 2 diabetes. That has been identified by two factors: a blood test and a BMI measurement with my doctor.

Without any doubt there are problems for those with eating disorders, and we need to address them, but we must be careful to ensure the right balance in dealing with the country’s health problems. The reality is that we have a greater problem—the numbers are much bigger—with people with excess weight than with those with too little weight.

While we acknowledge that there can be challenges in using and interpreting BMI as a measurement, as the noble Lord pointed out, the call for it to be scrapped could negatively impact on the care of those such as myself who are at risk of diabetes. Used appropriately, BMI can provide valuable information for care focused on individuals that does not discriminate against anyone. It is important that healthcare professionals take a person-centred approach to discussing weight and health, use appropriate language and consider the use of BMI based on individual circumstances. There are instances where the use of BMI may not be appropriate, so healthcare professionals should take a person-centred approach to weight and health. We hope that the integration of care outlined in the White Paper will boost the role of personalised care.

BMI is also an important tool for monitoring the population’s overall health and informing policy decisions. If we do not have that, we have to know what the alternative is to be able to make such assessments about the state of the nation’s health. Most recently, BMI data has been fundamental in the rollout of the QCovid population risk assessment, which identified 1.7 million people at increased risk of hospitalisation and death from coronavirus and enabled them to be added to the shielding list in March 2021. Without the use of BMI, that kind of population-based intervention would not have been possible and many lives would have been put at risk. I argue that we must retain what we have at the moment until something better is found.

14:43:00

Baroness Jenkin of Kennington (Con)
My Lords, I am grateful to the noble Lord for introducing the debate. BMI is used globally as a tool to assess a person’s size. It is a quick and cheap way to make estimations about an individual’s potential risk of disease or poor health. However imperfect a measure of health it is, I doubt that our discussion here, or the Select Committee’s report, will change the way doctors measure their patients and the risks to their health. The overall message of the report, however, drawing attention to the damaging nature of weight stigma and the consequences it can bring, is of course important.

Whatever measure used, what is also important is for healthcare professionals to feel able, without embarrassment, to discuss patients’ health and weight with them and, by using appropriate language, explain the long-term consequences of an unhealthy lifestyle. People need knowledge, support and encouragement, as well as a healthier environment, to make the changes necessary to improve their own lifestyles and thus take pressure off the health system.

Excess weight is one of the few modifiable factors for Covid, and our high obesity figures are one of the reasons why this country has been so badly hit. But even before the virus, it was clear that the unhealthy lifestyles so many in this country now lead were resulting in preventable diseases such as type 2 diabetes, liver disease, heart disease, some cancers, arthritis, the wearing out of hip and knee joints, and the discomfort of general ill health. Many of these conditions can be reversed by changing to a healthy diet. People need—and polling of up to 80% approval shows that they want—informed choices. The Government’s population-wide Better Health agenda is crucial to providing this. I commend them for the bold approach in the obesity strategy and urge them to stick to it.

Advertising works. If it did not then the food industry, particularly the ultra-processed and fast-food industry, would not do it. A KFC “Mighty bucket for one”, apparently the perfect meal for one person, contains 1,155 calories—over half the suggested intake. It is currently advertised everywhere. Young people are bombarded by paid influencers via social media. This needs to stop for their health’s sake.

Calorie labelling is crucial to success. Most people are unaware and polling shows that they want to know. Surveys show that 80% of adults do not know the calorie content of common drinks, which is substantial. A large glass of wine, for example, has around 200 calories, about the same as a doughnut. Unless people are supported and encouraged to move to a healthier lifestyle—and BMI is an important tool in the journey—with a better diet, a healthy weight and regular exercise, it will not just be Covid which affects them because the NHS, already under strain, will be unable to cope with the tsunami of obesity-related health issues coming down the track.

14:46:00

Baroness Wheatcroft (CB) [V]
My Lords, I am grateful to the noble Lord, Lord Addington, for introducing this debate and delighted to follow the noble Baroness, Lady Jenkin of Kennington. She takes food extremely seriously. I remember going to dinners with her when she took her own meagre dinner with her, because she was raising funds for charity by living on a very small amount to demonstrate not only that it is possible but the miserable lives that so many lead.

When we think of that sort of poverty and lack of food, to think of people in this country deliberately starving themselves is particularly difficult. Nevertheless, BMI is only part of identifying eating disorders. It is, however, a very important public health measure, and I agree with the noble Lord, Lord Brooke of Alverthorpe, that we should not throw out a measure which works helpfully as a public health guide. For instance, the shielding during Covid that was brought into play for those who had a particularly high BMI has proved effective.

Nevertheless, when GPs or other specialists use BMI it should be only part of an armoury of tools at their disposal. It is certainly not the only way in which eating disorders could or should be discovered. What is painfully clear is that people with anorexia are obvious just on sight; no GP needs to look at a BMI reading to spot anorexia. All too often, though, I fear that GPs are reluctant to diagnose eating disorders, in part because of the lack of services to deal with those conditions quickly when they need to be dealt with immediately. Anorexia is one of the most, if not the most, pernicious forms of mental illness and extremely hard to treat, but it is better caught early, as with so many diseases. Doctors use judgment and have to be relied upon to use it when wielding BMI as part of their armoury of tools.

Most important, though, is coping with the outbreak of obesity that has now hit this country, as the noble Baroness, Lady Jenkin, pointed out. Excess weight is a huge problem and really needs to be dealt with as a matter of urgency for this country. It was highlighted by Covid but it will become much worse, as many have put on weight during the lockdowns. BMI will be part of the measures for dealing with that.

14:49:00

Lord Moynihan (Con)
My Lords, the noble Lord, Lord Addington, will not be surprised if I turn to sport to assess the effectiveness of BMI as a medical guideline. Ashling O’Connor, one of the finest sports journalists of her day, wrote at the turn of the century about the need for the Ministry of Defence to take note of modern sports science after its long-held physical standards for new recruits were excluding exceptional candidates, including top rugby players. The Army’s weight limit, based on the BMI classification, was based on a calculation that divided height in metres squared by weight in kilograms. That would have discounted many Olympic gold medal winners.

Much was made at the time of the case of the two finest Olympians this country has produced. Sir Matthew Pinsent would not have been admitted to the ranks, as he weighed more than 17 stone, because, standing 6 foot 4 inches, his BMI would have been above the limit of 28. Sir Steve Redgrave—five times rowing gold medallist in an exceptionally tough endurance sport and in my opinion the finest athlete this country has ever produced—would only have sneaked in under the bar, with a BMI of 27.6. Ray Stevens, winner of a silver medal in judo in Barcelona in 1992, would definitely not have qualified at 6 foot and 15 stone, despite being able to bench press for 25 reps and run competitive half marathons. It is therefore not surprising that the English Institute of Sport discounts the outdated BMI test in favour of a more sophisticated method, such as skinfold callipers which squeeze subcutaneous tissue, and dual energy absorptiometry and body scanners measuring bone density.

Of course, we should place BMI in context, which, with slight variations over time, is your weight in pounds times 703 divided by your height in inches squared. Being based simply on height and weight, it takes no account of body fat percentage, muscle mass, bone thickness or genetic disposition to a certain frame. It assumes that everyone has the same percentage of lean tissue and fat tissue and it takes no account of those athletes who clearly have much more lean muscle mass than the average person. These facts seriously challenge the base assumptions behind the BMI formula. It exaggerates thinness in short individuals and fatness in tall and muscular individuals. The higher muscle content—in other words, lean mass—in athletes skews BMI, as lean mass is approximately 22% denser than fat tissue.

Although BMI has been adopted by the WHO as an international measure of obesity, it lacks a theoretical basis, and empirical evidence suggests that it is not valid for all populations. What can be said in its favour is that it is simple: it is a rough and ready calculation to an indirect health indicator of obesity or being overweight. I would expect the use of BMI to decline as a useful test and new measures such as the Bod Pod and hydrostatic weighing to take prominence, not least by the World Health Organization.

Having heard my noble friend Lord Addington’s speech, I have no doubt that all his points, and those made by other speakers, will be taken into consideration by the Government. I look forward to hearing from the Minister.

14:52:00

Lord McNally (LD)
My Lords, when I entered this House, 25 years ago, it was my noble friend Lord Addington’s body mass that aided the House of Lords in becoming unbeatable in the annual tug of war with the House of Commons. I am very pleased about that.

Yesterday’s Question Time in the Lords gave us a dry run for some of the issues being raised in today’s debate when the noble Lord, Lord Robathan, drew attention to a report by the World Obesity Federation linking obesity and deaths from Covid. The full range of the debate about obesity was on show, from those advocating making obesity not socially acceptable to the noble Lord, Lord Bethell, making it clear that it was not the Government’s intention to shame those who are overweight.

If obesity is the health challenge that I believe it is then we need to get the science right. We have heard from my noble friend Lord Addington and the noble Lord, Lord Moynihan, reasons why we should give credence to the advice of Caroline Nokes and the Women and Equalities Committee on not using the body mass index for weight shaming and recommending that it should be scrapped. But as the noble Lord, Lord Brooke, indicated, we have also had advice from Diabetes UK, which says,

“while we acknowledge that there can be challenges in interpreting and using BMI as a measurement, the call for it to be scrapped could negatively impact on the care of those living with or at risk of diabetes.”

So the Committee will be interested to hear the Minister’s assessment of the validity of BMI in assessing weight and health risks.

I would also be interested in the Minister’s response to the challenges raised yesterday and today regarding poverty and obesity in both parents and children as well as the problems caused by the promotion, particularly to young women, of unrealistic ideals of body image, which all too often can lead to anorexia and other health harms. We must not lose sight of the fact that obesity brings with it ill health and threats to life, but countering it requires sensitivity and understanding as well as practical help based on sound science. It is a difficult path to tread. I look forward to hearing about that in the Minister’s reply.

14:55:00

Baroness Redfern (Con) [V]
I thank the noble Lord, Lord Addington, for introducing this short debate on the effectiveness of the body mass index. I am pleased to have the opportunity to contribute.

My focus will be to highlight the effect of childhood obesity, which we know is significantly increasing. This is where the Government urgently require further action in tackling significant inequalities in physical and mental health outcomes. It also represents a major challenge for the Government’s levelling-up agenda with regard to opportunities and outcomes for our young people.

The effects of weight bias and obesity stigma can be particularly severe for children. They can experience a greater chance of being bullied, leading to low self-esteem and poorer academic performance, which can severely affect their life chances. It is tragic, too, that many children growing up will also have associated health risks, such as type 2 diabetes, cancer and heart disease.

When used appropriately, body mass index can provide valuable information for care focused on individuals that does not discriminate against anyone. It is important that healthcare professionals take a person-centred approach to discussing weight and health, use appropriate language and consider the use of BMI based on individual circumstances.

There are also clear opportunities for highlighting the contents of food. Retail outlets also must step up and support a move towards much clearer food labelling, particularly with additional nutritional and calorific labelling on the front of packaging in our supermarkets, cafés, restaurants and takeaways. Let us not forget all those highly calorific soft drinks, which must be addressed. We need stricter guidelines regarding rules on advertising. Evidence shows that children who are already classed as obese or overweight eat more in response to advertising.

Weight loss has been shown to bring undeniable health benefits, so does the Minister agree that, in any new plans, front-line services should provide obesity support in all the right cases?

Finally, I support BMI measurements in the context of them being used for informed, holistic and person-centred care where appropriate and where they can provide valuable information for care.

14:58:00

Baroness Parminter (LD) [V]
My Lords, I thank the noble Lord, Lord Addington, for his passionate introduction to this debate.

I applaud the Women and Equalities Committee’s work highlighting the impacts of the use of BMI on eating disorders and people’s mental health by disrupting their body image. Eating disorders are not niche. The 2019 NHS health survey found that

“16% of adults … screened positive for a possible eating disorder”.

Covid has increased the pressure on eating disorder services hugely, with referrals across the country increasing by 75% on average.

There is still an overreliance on BMI by GPs when diagnosing eating disorders to determine who is unwell enough to access treatment. Hope Virgo’s “Dump the Scales” campaign has literally hundreds of people, mainly young women, sharing how damaging it was to be told that they were not thin enough for treatment. It drives them deeper into this pernicious illness, which I know about from our family’s experience. Indeed, the evidence shows that early intervention is far better and offers the best hope of recovery.

The Government and the NICE guidelines are clear: BMI should not be used on its own as an arbiter of whether to offer treatment, yet GPs are still doing this. Why? First, there is inadequate training for GPs and other health professionals about eating disorders. The issue was identified by the Parliamentary and Health Service Ombudsman in his report on eating disorder services in 2017, in the follow-up report by the Public Administration and Constitutional Affairs Committee in 2019, and in the Cambridgeshire and Peterborough coroner’s prevention of future deaths report last month, to which the Secretary of State has to respond formally by next Wednesday. Will the Government now lead a strategy to improve eating disorder education in the medical profession, including embedding it in the curriculum? For GPs already in surgeries, a screening tool should be produced to ensure that, instead of relying on BMI, they ask the right questions of patients, with clear guidance on the language to use.

Secondly, GPs are using BMI to ration access to services as demand hugely outstrips supply. I welcome the Government’s recent investments in mental health funding, but it is mainly for children and young people, and only one in six eating disorder patients is under 18. Given the rise in demand, significantly exacerbated by Covid, without ring-fenced funding BMI will continue to be used to limit access to eating-disorder services, resulting in further unnecessary deaths.

15:01:00

Lord Bourne of Aberystwyth (Con) [V]
My Lords, it is a great pleasure to follow the noble Baroness, Lady Parminter, who spoke cogently on this subject, as she always does. I also congratulate the noble Lord, Lord Addington, on securing this important debate.

The past year has highlighted the importance of health and, specifically, of weight as a determinant of health. Just yesterday, as the noble Lord, Lord McNally, reminded us, the Minister stressed the importance of combating obesity and the historic challenge we have in our country in tackling obesity. Apart from age, it is the single most important factor in tackling Covid-19, for example.

I also welcome the broader message that the Minister has given out on more than one occasion about the importance of preventive healthcare and the accent we should all place on a healthy diet, an exercise regime, such as walking and cycling, and maintaining a healthy weight in so far as one can. I welcome any rebalancing of our approach to health in this way for the future. I think that is important and welcome.

I appreciate, as others do, that BMI is not a perfect guide to a healthy weight—far from it. For example, as we know, muscle is denser than fat, so somebody who has a muscular build will be heavier than somebody who does not, and different people may be susceptible to some diseases and so on. BMI clearly needs to be used alongside other factors—that is crucial.

However, from the perspective of getting the basic message across, there is no doubt in my mind that in tackling obesity the use of BMI is the right call to arms, although I accept we need to be very much alive to the mental challenge of the eating disorders that confront many people. It is undoubtedly the case, as the noble Baroness, Lady Parminter, has just said, that pressure from Covid-19 has increased problems in relation to finding treatment for eating disorders. I would welcome the Minister saying something on this when he sums up.

I also look forward to hearing from the Minister about what specific actions Her Majesty’s Government are looking at around whether to nudge people with incentives, or at least opportunities, to exercise across the country; whether to take action to influence diet, for example, through school meals, hospital meals and meals in other institutions; how we are going to control excess sugar and salt in our diets, possibly through restrictions; and how we are going to control the advertising of unhealthy foods and drinks. These are important issues that we need to confront for the future and one of the lessons that we can clearly learn from the Covid pandemic.

15:04:00

Baroness Altmann (Con)
My Lords, I too congratulate the noble Lord, Lord Addington, on securing this debate. I also support calls from the Obesity Health Alliance to extend calorie counting information to cafes, restaurants and takeaways, both to inform the public and to encourage providers to offer both healthier options and perhaps—one element that is little talked about—reduced portion sizes.

Curtailing the promotion of foods high in fat, sugar and salt is essential. A recent survey cited by Diabetes UK in its helpful briefing reports that 74% of the public support not showing advertisements for junk food before 9 pm, on TV or online. Why only 9 pm? Why should such foods be promoted for adults? Type 2 diabetes is one of the fastest-growing health problems. It accounts for 10% of NHS spending already, and obesity accounts for 80% to 85% of the risk of getting diabetes, with 12.3 million people estimated already to be at risk.

As others have said, Covid carried particular risks for people who were obese. There are significant other health risks as well, including heart conditions, some cancers and respiratory problems. BMI may be a handy starting point, a quick and cheap way for estimating the number of those at risk of health problems. It is crude—the noble Lord, Lord Addington, and my noble friend Lord Moynihan are correct that sports people will have particular muscle mass and bone density advantages which turn into disadvantages when measured on a BMI basis—but this issue needs to be built on. As we know, BMI is just one basic measure. It does not account for individual differences.

Of course, body image issues contribute significantly to mental health and well-being. They can bring on or reinforce a sense of inadequacy. Fat shaming, anorexia and bulimia tend to be indicative of mental health problems. BMI therefore needs to be supplemented by blood pressure, ECG, cholesterol and muscle mass assessments, as well as, crucially, mental health assessments that can spot problems that may otherwise soon lead to health issues.

15:08:00

Lord Thomas of Gresford (LD) [V]
My Lords, I congratulate my noble friend Lord Addington on securing this debate. Having played rugby with him—and you cannot get closer to the noble Lord than being in the second row pushing against his noble backside— I suppose that, according to his opening remarks, I should be dead.

I share my noble friend’s concern about the misuse of and over-reliance on the BMI. To create a lifestyle that is dependent on staying within its limits is a mistake. It depends where your fat is stored. If your weight is around your waist disproportionately, you may well be within the BMI range but nevertheless at risk of heart disease, diabetes and other conditions. Studies instituted by Mark Hamer at Loughborough University some three or four years ago demonstrated that waist-to-hip ratio was a far better body indicator of health and longevity than the BMI.

I thoroughly agree with the views expressed by the noble Lord, Lord Moynihan, and the expert research to which he referred. It shows, in short, that if you need braces as well as a belt to keep your trousers from slipping below your knees, you are in trouble—which I know, because that was my condition before I was diagnosed with Hodgkin lymphoma a couple of years ago. I have just now returned from my daily 7,000 paces with four inches off my waist and no braces. I cannot wait to get back on the water in a rowing eight—I hope that the noble Lord, Lord Moynihan, will share my desire.

Life expectancy is increasing, but that does not necessarily mean an increase in healthy life years; it may be extra years of chronic ill health. The Scottish health survey published in the British Medical Bulletin in 2011 showed that, in the 10 years between 1998 and 2008, waist circumference increased by 5 to 10 centimetres in both sexes at ages between 50 and 70 years without a corresponding increase in BMI. It was thought to indicate an unfortunate circumstance of gain in visceral fat mass and loss of lean tissue. Both are major determining factors of ill health in the elderly.

The Women and Equalities Committee in the other place was right to find that BMI has turned into a justification for weight shaming and body image anxiety among the young. But, as I have said, it can be equally misleading as a guide to a healthy old age and, for this reason as well, the use of BMI as a measure of healthy weight should stop.

15:12:00

Baroness Thornton (Lab)
My Lords, I congratulate the noble Lord, Lord Addington, on this debate, which has already raised many interesting issues. Indeed, the report of the Women and Equalities Committee into body image is not new. Over 40 years ago, Susie Orbach wrote Fat is a Feminist Issue; she challenged body mass index as a measure of—as she said—“nothing useful” and pointed out how it affected women’s self-image. On the 40th anniversary of FIFI, as many of us know it, she said:

“When you grow up absorbing the idea that food is quasi-dangerous, it is hard to know how to handle it. There are no end of experts selling their wares whose books and products end up generating enormous profits … So, too, with other food and diet fads. The desperation that exists to be at peace and dwell in our bodies clashes with the knowledge that such schemas promote or reinforce confusion about appetite and desire.”

The fact is that, 40 years on, it is still pretty grim:

“It’s a story of … destabilising the eating of many western women and exporting body hatred all over the world as a sign of modernity”,

as a way of medicalising and pathologising

“people’s relationship to food and bodies so successfully that vast industries would grow up to treat problems that these industries had themselves instigated.”

What is clear from this short debate is that it should come as no surprise that BMI as a single measure would not be expected to identify cardiovascular health or illness; the same is true for cholesterol, blood sugar and blood pressure. As a single measure, BMI is clearly not a perfect measure of health, but it is probably a useful starting point for important conditions when a person is overweight or obese.

The Select Committee said that it was

“not satisfied with the use of BMI as a measurement to evaluate individual health.”

On the other hand, as other noble Lords have said, Diabetes UK says that it provides

“valuable information for care focused on individuals that doesn’t discriminate against anyone.”

I dispute that, but it also goes on to say that it has been an important tool for monitoring the population’s health and informing policy decisions and has been fundamental in the rollout of the Covid population risk assessment, which identified 1.7 million people at increased risk of hospitalisation and death from coronavirus. Without that use of BMI, a population-based intervention would not have been possible.

The challenge for the Minister is how to reconcile these issues. I look forward to hearing his answer.

15:15:00

The Parliamentary Under-Secretary of State, Department of Health and Social Care (Lord Bethell) (Con)
My Lords, I too am enormously grateful for the successful efforts of the noble Lord, Lord Addington, in securing this important and insightful debate. Any debate on our weight, health and fitness is extremely personal and bound to arouse emotions. It certainly does in my household, and so it does in this Room. I very much welcome, though, a national conversation about these issues. It is the right time to be having it.

As noble Lords have pointed out, we face two major challenges. The first is that too many people are overweight or living with obesity. I have already spoken this week about this grave challenge faced by this country, which was clearly outlined by the World Obesity Federation report on Covid death. That is a real wake-up call. The Government have already swung into action to a degree. More is planned. We are trying our hardest to address the knotty problem that few countries have ever completed successfully.

The second issue that the country faces is that too many people have eating disorders that make their lives a misery and threaten their health. I am grateful to noble Lords who have spoken movingly on this subject. Although she did not speak this afternoon, I reference the noble Baroness, Lady Bull, who recently arranged a stakeholder session with me that gave me first-hand testimony from those seeking to address these important issues.

I fear that poor old BMI, the much-maligned metric and subject of this debate, has in some ways become a surrogate and a scapegoat in a battle between two groups that see these two big issues—obesity and eating disorders—as somehow in conflict with each other. I do not want to take sides in any such battle. While I always welcome policy dialectic and the battle of ideas to hammer out the most sensible policy on complex issues, I do not think this should be a zero-sum game with winners and losers on opposing sides. Instead, I would like to work towards finding a way through, because it is imperative that, as policymakers, government Ministers understand the impact of our policies in one area on our policies in another area and somehow find a way of tackling them both in a complementary fashion.

Before I try to do that, let me say a few words in defence of the poor old maligned metric, BMI. It is, as noble Lords have pointed out, a very simple calculation—body weight divided by the square of height. It has been used by the National Institute for Health and Care Excellence, the World Health Organization and countless health organisations around the world for decades as just this: a simple first step to establish if individuals might be carrying too much or too little body fat for their long-term good health. To answer the noble Lord, Lord McNally: as risk assessments go, BMI has proven value year after year, study after study, in countries around the world, for predicting premature death and many chronic diseases, including type 2 diabetes, some cancers and some heart disease. As my noble friend Lady Jenkin rightly pointed out, it is simple to measure and highly reproduceable. It does not require specialist equipment or clinical training, unlike many methods of assessment noble Lords mentioned.

None the less I recognise, as the noble Lord, Lord Addington, pointed out, that it is not perfect for all people. Muscly athletes are considered too fat, and it is problematic for the very old. It is not unique, and, as the noble Lord, Lord Thomas, pointed out, a measuring tape around the waist is also very insightful. But it works for most people very well. The reality is that most people who have a high BMI are also at risk of ill health and premature death. When establishing an individual’s health risk, the noble Lord, Lord Brooke, is right: health professionals must use follow-up measures and assessments as well, such as waist circumference. NICE is crystal clear about this and, as my noble friend Lady Wheatcroft pointed out, BMI is just the recommended first step in the assessment pathway.

I hear the noble Baroness, Lady Parminter, loud and clear. I have read the stories to which she referred. I am extremely disappointed by them. It is not right and it is not recommended in the eating disorder commissioning guide. I agree that we need to listen to patients much better. I agree completely with my noble friend Lady Altmann that, in such cases, mental health assessments are absolutely essential. Similar safeguards apply to assessing whether someone is underweight, and of course it is absolutely true that conditions such as anorexia and other eating disorders require specialist assessment. NICE is looking at ways to improve the metric for ethnicity and other factors. None the less, given the large international evidence base underpinning BMI, its simplicity and its wide international use, I do not see it as likely that there will be wholesale change.

BMI is an essential tool in our battle against obesity. We have a huge problem in this area: six out of 10 adults and more than one in three children aged between 10 and 11 are overweight or living with obesity. In my briefing, I have page after page on the impact of obesity on the lives and futures of British families. It has a huge impact on the NHS, the causes of cancer and the causes of diabetes. It has an impact on women: obese women are 12.7 times more likely to develop type 2 diabetes and three and a half times more likely to have a heart attack than women who are a healthy weight. I could go on and on.

As the noble Baroness, Lady Redfern, rightly explained, it is children who are overweight or living with obesity who are sometimes affected the most. In particular, many experience bullying, low self-esteem and a lower quality of life. They are more likely to continue to be overweight or living with obesity into adulthood, which in turn increases their risk of type 2 diabetes, cardio- vascular disease and other chronic illnesses. We must do something to address this issue.

As the noble Lord, Lord Brooke, and my noble friend Lady Jenkin rightly said, during the pandemic we have seen a stark illustration of the impact of living with obesity. That is why we are acting. To answer my noble friend Lord Bourne, we are tackling the nation’s obesity with a new strategy. Published in July last year, it set out measures to get the nation fit and healthy, protect against Covid-19 and protect the NHS.

As my noble friend Lady Jenkin pointed out, there are many nudges in shops, on TV, on computers and on phones that encourage us to buy less healthy food. The Government are committed to restricting further the advertising of less healthy food on TV, and we are considering online restrictions on the promotion of less healthy food in shops. We are also committed to calorie labelling in restaurants and improving front-of-pack labelling on pre-packed foods. These actions are about helping people to make healthy choices.

At the same time, there is another issues that we must face: the national crisis around body identity and self-confidence, which, in some, manifests itself as extreme eating disorders or as mental health challenges. The Women and Equalities Committee report put it extremely well. Acute anorexia is a particularly distressing mental health condition that can ruin lives and cause horrible worries for the families of those concerned. That is why our mental health recovery plan is putting £500 million into work to ensure that we have the right support for people with mental illness, and I am encouraging further policy on positive body imagery.

I want to make my point clearly: I am concerned that there is a perception that these two agendas are somehow at odds with each other—that if we put calorie counts on menus, we will somehow trigger mental health episodes for those with eating disorders or reinforce a damaging body image culture, or that if we push our message on healthy lifestyles too much, we will stigmatise those with sensitivities about their body image. I simply do not accept that this needs to be the case. While I do not discount people’s lived experiences, it is important that we know what we are buying. The calorie count of everyday food available in fast-food chains is often absolutely shocking. The food we grab on the go or have delivered to our homes is now a big part of our diet, yet there is huge ignorance about what that food contains.

Collectively, we need to somehow work a way through this. The maths of it are really simple: there are 725,000 people with eating disorders in the UK. That number may be higher, as I recognise that some struggle to seek support and are not included in the figures. We must do everything we can to bring them the clinical support they need to address their significant mental health issues, so that they can live resilient lives and deal with the stresses of everyday living. At the same time, there are millions of schoolchildren and young people living with poor mental health. My DCMS colleagues are doing everything they can to address the challenges of social media in their lives.

In addition, there are 28.9 million adults in England who are either overweight or living with obesity. Somehow, we need to inspire those people to take on board a healthy lifestyle, which means changing their diets and taking more exercise. These are tough decisions that people can only make for themselves. It is not our business to deal in shame; we are dealing in honesty. That is where the BMI comes in, because it is a simple, unequivocal and, for most people, accurate predictor of risky lifestyles.

It is not beyond our intellectual capabilities to find a way through this conundrum. I am hugely grateful to the noble Lord, Lord Addington, for bringing us the opportunity to debate these sensitive subjects, and I hope very much that we can work together to find an answer to this challenge.