Ciara Conway (Waterford, Labour)
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This is the final meeting in a series of meetings the joint committee has convened on the issue of tackling childhood obesity. It is intended that in the next week or two the joint committee will consider adopting a report on this matter under the stewardship of Deputy Peter Fitzpatrick who has kindly volunteered to be the rapporteur for the committee on this subject. In this regard, I welcome from the W82GO! childhood obesity programme at Temple Street Children's University Hospital, Dr. Sinead Murphy, consultant paediatrician and clinical lead; Dr. Aoife Brinkley, senior clinical psychologist; Ms Grace O'Malley, senior physiotherapist; and Ms Kizzy Moroney, paediatric dietician. I also welcome Ms Richelle Flanagan, dietitian and president, Irish Nutrition and Dietetic Institute, and Ms Emma Ball, community dietitian manager, HSE north west.

Before we commence, I wish to advise that while witnesses are protected by absolute privilege in respect of their evidence to the committee, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against a Member of either House, a person outside the House or an official by name or in such a way as to make him or her identifiable.

Members are reminded of the long-standing parliamentary practice to the effect that members 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.

I invite Dr. Murphy to make the opening presentation.

Dr. Sinead Murphy:

On behalf of the W82GO programme at the Children's University Hospital, Temple Street, and the Irish Nutrition and Dietetic Institute, I thank the joint committee for the opportunity to present on the enormous challenge and growing epidemic of childhood obesity. We also thank Deputy Mary Mitchell O'Connor for her introduction to the committee. We are grateful for this opportunity to have the voice of the children of Ireland heard in the report on obesity that is about to be published.

I will begin by contextualising our role in childhood overweight and obesity. I am a paediatrician and the clinical lead on the W82GO! childhood obesity programme which was established eight years ago by a group of committed, enthusiastic health care professionals in Temple Street Children's University Hospital. The W82GO! programme, including my position as clinical lead, is funded entirely by the Temple Street fund-raising arm, Children's Fund for Health, and a research grant awarded to one of our team members by the Health Research Board. When the grant expires the service, the only one of its kind in Ireland, will be forced to cease. We have joined forces with the Irish Nutrition and Dietetic Institute in the belief that, together and with the support of the Oireachtas, we can address the obesity catastrophe with the urgency it deserves.

I propose to provide some facts and figures on childhood obesity. Recent figures show that 31.8 % of Irish seven year olds are either overweight or obese. This accounts for more than one in four of our schoolchildren, which translates as 100,000 children who are obese and 300,000 who are overweight. The problem begins in childhood and is beginning earlier and earlier. Currently, 6% of three year olds are obese and the figure increases to 10% among lower socioeconomic groups.

Ireland ranks fifth highest among 27 European Union countries in terms of the incidence of childhood obesity. As with many other things, childhood obesity disproportionately impacts on lower socioeconomic groups. This fact must be considered when addressing potential solutions. Given the catchment area of Temple Street, the children's hospital probably deals with the largest proportion of children in the lowest socioeconomic group of any hospital in the country. The position in respect of childhood obesity is becoming steadily worse and is not stabilising in any way. Moreover, we know that 70% of obese children will become obese adults.

With regard to co-morbidities, the essential and extremely worrying fact is that children are already showing the ill-effects of overweight and obesity in childhood. We do not wait for them to become adults because they are already in trouble. Unless these children are provided with the treatment they need when they need it as a matter of extreme urgency, they will have a shorter life expectancy than their parents. Having worked for so long to achieve longer life expectancy, we are set to reverse this achievement by choosing to do nothing.

Over the past five years, the W82GO! team has collected data on the co-morbidities in children who have attended for treatment. By co-morbidity we mean conditions with which the children suffer and which are related to their obesity. We found that 70% of the children in question, who are aged under 15 years, have musculoskeletal problems; 40% have high cholesterol levels; 50% have high blood sugar and insulin levels, which means they are about to develop early type 2 diabetes mellitus; and 30% have breathing problems. It is a matter of grave concern that in respect of the mental health of these children and young people, we found that 60% reported psychological difficulties such as poor self-esteem and depression, with 11% reporting severe bullying. If left untreated, these children will become adults who are obese, in whom the complications of obesity such as stroke, heart disease, infertility and increased risk of multiple cancers are well recognised. This possibility can be prevented.

As with all health issues, tackling childhood obesity has cost implications and we are aware of the cost concerns that arise. The allocation of funding to the pandemic of childhood obesity is patchy and wholly inadequate. I do not believe any official funding is provided for childhood obesity. The cost of adult obesity to the State is in excess of €1 billion per annum. This cost will continue to rise unless childhood obesity is addressed.

If left untreated, the average child who is obese, of whom there are 100,000 in Ireland, will cost in the region of €5,000 per year as a result of direct treatment for co-morbidities, in other words, attending for various medical opinions, surgery and other interventions arising directly from their obesity. Addressing the problem reduces costs and produces savings. Service provision for the treatment of childhood obesity is urgently required.

We sometimes skirt around the fact that childhood obesity is a highly complex issue. If the problem is not addressed as a matter of extreme urgency, it will have far-reaching consequences for the children in question, their families, future generations and a health care system that is already under massive pressure.

Ms Emma Ball:

As Dr. Sinead Murphy has mentioned already, a gap analysis carried out by the INDI in March 2013 showed that 88% of the country has no access to a community based obesity treatment programme for children and their families. While children who are obese can be referred for individual dietetic consultation, this service is not available in all parts of the country. We do however have programmes developed in the community which reflect evidence and best practice, national and international. I shall provide an outline of the Up4it! programme which is a cross-Border prevention and management childhood obesity programme led out by Co-operation and Working Together, CAWT, and funded as part of INTERREG IVA funding. HSE West - Letterkenny, Youth and Family Services and HSE - Dublin north east, Cavan and Monaghan and the Border Counties Childcare Network, BCCN, were two pilot sites in Republic of Ireland with a further two sites in Northern Ireland. This was a multi-disciplinary programme with nutrition, physical activity, emotional well being and behavioural change components. There was a healthy lifestyles for families, prevention programme, with a child under five years. It was an eight week programme with two follow-up sessions at week 16 and week 36. There was also the Making a Difference management programme for families with an overweight-obese child aged eight to 11 years. This was a 12 weeks programme and had four follow-up sessions up to 48 weeks. Both parent and child attended the management programme. The programmes were designed to suit the families' needs, were skills based, for example, had cooking components, food labelling, shopping and were delivered in local community settings. More than 585 families participated over two years from 2011-2013. For the management programmes, 61% of the referrals to the programme were classified as either self referrals, community or voluntary group referrals, with 41% of participants referred by nursing staff, primary care teams or general practitioners. The programmes were fully evaluated by CAWT. Data analysis was completed by the Northern Ireland Centre for Food and Health at the University of Ulster. Its analysis of 146 children enrolled to management programme during quarter three to quarter 5 of the CAWT project showed statistically significant reductions in both body mass index, BMI z score and waist circumference z score levels over the course of programme and follow-up sessions to 48 weeks which showed a longer-term sustained weight change. There were also statistically significant improvements in their perceptions of their body image over the course of the programme and all other targets set at the beginning of the project were achieved. To see the human benefits of investing now and for the future of our children, we will let the words of our patients speak for themselves. The following quote is from a 12 year old girl who attended the programme in Cavan-Monaghan:

What I liked was finding out what was wrong with my diet. I was eating too much of everything; not eating enough fruit and vegetables and eating too much junk like all children my age! I liked knowing how to fix my diet and the dietitians helped with that. Since completing the UP4IT! programme, I have joined the athletics club but before the programme I would never have wanted to do anything like this. I am also playing indoor soccer and thinking of joining the local GAA club. My diet and the family's diet is also healthier.

The reality is that even though we have evidence-based, best practice programmes on our doorstep, they are not being sustained. The Up4it! CAWT funding ended in March 2013. While there are small pockets of local funding being provided in a number of locations throughout the country to promote obesity programmes there is no dedicated, sustained funding to tackle this issue. In our local area, HSE west in Donegal, Sligo-Leitrim is exploring ways to sustain the project using a community development approach partnered with primary care teams but we urgently need for the Department of Health and the HSE to commit to resourcing the roll-out of successful models of best practice in the community and to ensure these programmes are incorporated into the policy document.

In Northern Ireland the project's programmes, CAWT, have been extended for a further one year delivery by the Public Health Agency while it puts in place in place its longer-term plans. The project's programme approach and outcomes will however shape the Public Health Agency's future specification for children's programmes.

Ms Grace O'Malley:

As previously highlighted by Dr. Sinead Murphy, our team in Temple Street is seeing children who are clinically obese. To put that into context, the average 9 year old child in Ireland weighs 34 kg, 5 stone 5 lbs. The average nine year old attending our clinic is 55 kg, 8 stone 9 lbs. We have seen over 400 children to date and as of today there are 150 children on the waiting list. These children have the greatest need for urgent holistic care. As outlined by Dr. Murphy they have myriad physical and mental health complications. We know from other EU experiences they are most effectively managed as outpatients of a paediatric hospital where they have access to the multiple specialties they require. More than 40% are from deprived to severely deprived areas, therefore, we see at first hand the effects of inequality on health outcomes.

Our patients range from 18 months to 16 years old and we receive referrals for specialist management from all over Ireland. From a study of 196 children who attended our treatment programme we have seen a significant reduction in obesity in line with best practice internationally. The obesity levels of children on our waiting list however continue to rise.

The W82GO! programme is delivered in the evening as a family-based group programme and uses facilities in Temple Street and in a nearby school. The group programme is delivered to children aged six to 12 years and aged 12 to 16 years. For children who are under six or who are not appropriate for the group programme, we see them on an outpatient basis. Unfortunately, due to the HSE staff embargo this service has had to be cut back significantly.

The treatment aims to improve nutrition, improve fitness, increase physical activity levels, improve emotional well-being and family functioning. We deliver educational and practical sessions to improve health literacy and empower families to make healthy lifestyle choices. Families learn how to shop and to read food labels.

At a European Union level it is clear that the Irish State is not meeting its duty of care to its children. Denmark, a country with a population of 5.5 million people, has an annual spend in the region of €10 million on childhood obesity treatment whereas in Ireland currently the spend on childhood obesity treatment is zero. Unfortunately, treating the problems of childhood obesity, as outlined by Dr. Murphy, has a cost. Approximately €5,000 per child is the current cost of treating co-morbidities such as breathing problems, or surgical orthopaedic issues.

Ciara Conway (Waterford, Labour)
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We will now take questions from committee members.

Robert Troy (Longford-Westmeath, Fianna Fail)
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I welcome and thank the panel of ladies who have joined us to give us their opinions. It is clear that early childhood is a critical time in assessing the beginning of the movement towards obesity. The figures and statistics provided are startling, particularly the fact that Ireland is the fifth worst of the 27 EU countries and that one in four of our schoolgoing children is either overweight or obese. This has rightly been described as an epidemic which is in urgent need of attention. Our attention must be given to the fact that currently there is no treatment. I commend the Temple Street fundraising committee for the work it is doing voluntarily to tackle this issue. Am I correct in my understanding that by the end of this year no funds will remain to deal with it? That is a concern.

No single initiative will solve this problem. We must look at a number of steps to tackle it such as physical activity, healthy eating, education of both educators and parents, marketing and the media. As legislators, we must embrace the issue and give it the priority it deserves. Very little, however, can be done without funding. The delegates have cited Denmark as a country of a similar size to ours. It is spending €10 million per annum in this area. If the Minister for Health and the Minister for Children and Youth Affairs were to ring-fence €10 million a year to deal with the issue here, would that be adequate to tackle the problem we are facing? If we do not invest this money, could the problem end up costing us €1 billion?

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join the Vice Chairman and my colleagues in welcoming our guests. I acknowledge the useful and important audiovisual presentation made recently in the AV room in which many of those present participated and which was organised by Deputy Mary Mitchell O'Connor. The testimony of the young women who presented their stories - the young girl from Carrickmacross in my constituency and the other young woman in her teens whose testimony has been mentioned again this morning - was powerful. The more people who hear their testimony the better.

The timing of this discussion is hugely important, not only in the context of the committee addressing the issue. Deputy Fitzpatrick, as rapporteur, is dealing with the preparation of the committee's report. I welcome this, but it is regrettable that we have not had an opportunity heretofore to hear these relevant voices. The timing is also hugely important in the context of the upcoming budget. As the date of the budget is being brought forward to October, this is a key and crucial time to impact on the Department of Health's proposals for health funding in 2014. This is not just about influencing our report but also about flagging to the Minister the importance of providing continued support. The support is not coming from the Department, but it is important that it take responsibility for funding the programme addressed by the Temple Street initiative which is the only programme addressing the issue of clinically obese children.

I am mindful of and more familiar with the community aspect of this issue. Community supported projects such as the CAWT supported Up4It project need to be rolled out universally. We will never get beyond the top of the iceberg unless we build in necessary supports. This comes down to the provision of resources. We need a bold and definite commitment on the part of lead voices in political life if we are to see a reversal of the trend outlined. We must recognise that if we do not provide the resources, we will build up a requirement for significant and ever more limited public funding in the future. Provision of resources to tackle this issue will result in a huge saving in the future.

I have a few questions about the statistics cited by Dr. Murphy. In terms of the committee's engagement with the Minister and its opportunity to impact on the real decision makers, we are just advocates, not a decision-making body.

Ciara Conway (Waterford, Labour)
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The final speaker in this section is Senator John Crown.

John Crown (Independent)
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I apologise to Dr. Murphy if I sound reduplicative, but the point she made was so important that it needs to be emphasised. Perhaps some of our colleagues who do not work in the health service might have missed the nuance of it. There is no statutory funding available for the provision of the obesity service at Temple Street hospital. It was set up completely through voluntary fundraising and moneys raised for research resources. I know what the answer will be, but this is the most profound point that must be made today because it underlines how remarkably lacking in seriousness the service provision part of the health service is in tacking this problem. Has any consultant been appointed in paediatrics or paediatric endocrinology with a special interest in obesity who is funded or has a clinic devoted to the needs of children with weight problems? I have an ancillary question, although it may not be a fair to catch Dr. Murphy with it on the hop. Does she have any idea of the number of paediatric specialists or paediatric endocrinologists per head of population in Ireland compared to the European averages? I imagine it is rather low. I know in the case of paediatric surgeons that the numbers are absurdly at the bottom of the charts.

My final question is more of a medical or psychiatric question. Does Dr. Murphy believe there has been a subtle cultural effect as a result of the probably misguided focus on the causes of eating disorders in the previous medical generation in making parents afraid to talk about weight, weigh their children or raise concerns about issues to do with being overweight? People probably erroneously believed one could take a psychiatrically or mentally healthy child and convert him or her into an anorexic by giving him or her a focus on such issues.

I may have to step away for a while to go to the Seanad and apologise if I do not hear the reply in person. I hope the panel will not take it as disrespect. I will be coming back to hear it later.

Ciara Conway (Waterford, Labour)
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Is Dr. Murphy happy to answer those questions?

Dr. Sinead Murphy:

Yes. How should I respond?

Ciara Conway (Waterford, Labour)
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If Dr. Murphy wants to do it by group, that is fine, or if there are key themes or particular questions she wishes to answer first, please do so.

Dr. Sinead Murphy:

Since Senator John Crown is here but may have to leave, we will start with his questions. He heard it exactly and clearly. There is no funding available. It is entirely from research funding, that is, from a grant given by the Health Research Board to one member of the team. It is funding various parts of the work, including the technology aspect, and trying to bridge the gap. It is excellent research. There is also fundraising by the fundraising body in the hospital at Temple Street.

There are no appointments, medical or otherwise, to this programme. There are no consultants with a special interest in paediatric obesity. I do it as part of my work. As Ms O'Malley said, the allocation is, at most, one day a week. One would need 14 days per week to begin to address this issue at Temple Street hospital alone. We are grossly under-resourced. Traditionally, paediatric endocrinologists would have dealt with this issue, but, as Senator John Crown has pointed out, there are approximately 1 million children and six paediatric endocrinologists in the country. That is the answer. They are dealing with paediatric diabetes, congenital adrenal hyperplasia and all of the thyroid and growth issues. Clearly, paediatric obesity does not get the time it deserves because there are not enough paediatricians appointed to deal with the issue. That is clear.

Senator John Crown referred to cultural effects. There are parents who are fearful of mentioning being overweight in case they might turn their children into children with anorexia. Part of our role as advocates for children and as health advocates is to educate parents in order that they know this is not the case. I have sat in clinics with a child weighing 120 kg while the mother behind the child was signalling to me not to mention the issue of weight. When such children go out to play, everyone they meet calls them fat and does not talk to them. This is not right and it only makes matters worse. Certainly, we need to be able to address this issue properly and educate parents in order that they know that it is an unhealthy lifestyle. We need to move the focus from weight onto health. That is what our programme and the Up4It! programme are about.

That brings me to the need to educate GPs. At Temple Street hospital we run several evening sessions at which we educate GPs and invite them to attend interactive information evenings. We have made a conscious effort at these sessions in recent years to concentrate on this issue and inform them about our service, although now we almost have to keep them a secret because we cannot deal with the influx of referrals. We also talk to them about how to talk to their patients. Should a patient present with something else we would like to be able to encourage GPs to have the time and resources to measure him or her, plot him or her on centile charts and, in a completely non-blaming way, explain to the child and parents that in terms of growth the child is doing well in one direction but in another is not healthy or where we would like him or her to be. However, one must have an option.

Deputy Caoimhghín Ó Caoláin mentioned drawing the attention of GPs to this problem and whether they were aware of the Up4It! programme. They are not because it is not available as the funding is not available any more. It is a difficult issue because, on the one hand, we can educate GPs on how to bring the issue to the attention of parents, but then, on the other, GPs have to explain that the parents and children must go off and deal with it. There is nowhere to send them to and that is the subject of our appeal to the committee today.

Ms Richelle Flanagan:

I thank the committee for inviting us to make a presentation and its very informed questions. I reiterate what Dr. Murphy has said. In respect of the figure of €10 million, that would certainly be a very good start and would allow us to put into action the outcome and evidence based programmes we already have in place. I read in the newspaper on Tuesday that the Minister had talked about moving to an outcome-focused health system. We have programmes that show outcomes; therefore, let us start using them to tackle the obesity epidemic. To put the figure of €10 million in context, it costs approximately €10,000 to see 15 kids; with that money one could have 1,000 programmes and see 15,000 children who were overweight or obese. There is a multiplier effect because this is a family-based programme; therefore, we are not dealing with the child and the parent but extending into the family - two parents and two children, for example - who also benefit. The cost per session in the Up4It! programme is the same as in the weight programmes in communities that do not have a multidisciplinary focus. It is very good value for money, providing outcomes that, as Dr. Murphy has mentioned, have long-term effects. We know that it is much more difficult to keep the weight off adults with obesity. It is better to get in early with children. It would be a very well spent €10 million and most welcome.

For some reason people tend to think obesity is not a disease. It is. If one's child was suffering from any other disease, one would be at the door hollering to have him or her treated. It is scandalous that there is no HSE-funded childhood obesity programme in the acute setting for children who have fractures. It beggars belief.

In reply to the question about whether we have had the opportunity to present to the Department of Health, we have been banging on the door about several initiatives with regard to chronic disease and obesity and consider our call is falling on deaf ears. We want to see some action taken for these children. The talk is all of prevention and we understand prevention is the best approach, but the clinical services to manage children's obesity have been missed out on. That is one of the points we want to get across today: kids who are suffering from adult disease in their childhood need treatment.

On the question of a national post, we agree that there should be a focus on childhood obesity in the paediatric stream. We need an overarching national post to deal with obesity in general for adult and paediatric services. That is part of the problem. We have a very fragmented and small service; in 88% of the country there is no access to childhood obesity treatment programmes; in 73% there is no access to prevention programmes tailored to meet the needs of obese children. Part of the problem is that there is no one driving the agenda.

With regard to referral pathways from GPs, Ms Ball said GPs were referring children to the Up4It! programme, but as Dr. Murphy said, it is not available. If it is not in the mind, there is nothing available to which people can refer to.

In response to Senator John Crown's question about the misguided focus on eating disorders, safefood has compiled reports to show that parents do not recognise obesity in themselves, let alone in their children. That is the problem and we have to help them. This is not blaming people but about putting the supports in place. That is a very important point. Research shows that GPs are unsure about how to have the conversation with parents. We all need to step up to the plate in our clinical services to deal with this issue. We want Deputy Peter Fitzpatrick to recognise in his report that we would like to see the clinical services integrated with prevention programmes. The two have to be part of tackling the problem.

Deputy Caoimhghín Ó Caoláin mentioned the roll-out of the Core programme. It would make sense when there is a programme that costs only €600 per family to roll it out. Similarly, the W82GO! programme is evidence-based and we call on the Government and the HSE to start funding it. Providing €10 million would be a fantastic start.

Catherine Byrne (Dublin South Central, Fine Gael)
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I will start with a question because I then want to rabbit on for a while and I am sure the Acting Chairman will pull me in.

Of the 585 families participating, it is interesting to read that 61% are classified through community and voluntary group referrals. That is an interesting figure. When these families, particularly parents or guardians, are told about their children's health difficulties, what is their reaction? How do the parents feel about this? Do they take any responsibility? Do they feel it is their fault?

It is a pity Deputy Robert Troy has left because I wanted to ask him from where he would get the €10 million. I wonder for the past 15 years when Fianna Fail was in government why it did not bother putting money into these services, but I will not dwell on that issue.

I am delighted to see a full panel of women. It is the first time I have sat in this room-----

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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They are not just women. They are experts.

Catherine Byrne (Dublin South Central, Fine Gael)
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They are female, regardless of whether they are experts. We are all experts. I do not know how many of the delegates are married and have children, or are not married and have children, but I am interested. I grew up in a poor area, somewhat similar to the Temple Street area which I know very well. I do not remember seeing any overweight children where I grew up. I cannot even remember seeing any in school. People were on small wages, if they had any. There were no sugary drinks, except perhaps once a month if the lemonade man - that is what he was called - came around and we had a bottle of white lemonade. There was no such thing as Coca Cola or orange at the time.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I thank Ms O'Malley for contacting me in annoyance because paediatric experts were not invited to the committee, as their voices were not being heard. I am delighted they are here because their presence is important. She made the point that we spend €1 billion on adult obesity and if some of that money could be allocated to childhood obesity it would be a good thing.

Deputy Byrne referred to parents. There is an ideal world, but in reality there are parents who are struggling. It is very difficult to deal with a child who is overweight. Sometimes it starts at birth. A baby can be very large and a mother may not be able to breastfeed or may not be educated on what to do. It is not just about what children eat around the kitchen table. It is difficult for working mothers who do not arrive home until 7 p.m. to have to put something on the table. We should educate them.

I wish to address a question to Ms Moroney, who is a paediatric dietitian. How can her message get to parents? One delegate said something which really hit me, namely, that sometimes it is not about losing weight. Any of us who struggles with weight knows how hard it is to lose one pound. It is very difficult to starve an obese child in order to lose one pound. The point was made that children's weight should be maintained and they grow into it. It was a positive message to convey to parents, rather than telling them to starve their children to lose a pound. I would like the delegates to make that point in a more professional manner than me.

A delegate sent me an e-mail which I read. I understand €5,000 was sought. I could not believe a group of professionals were begging for €5,000 to roll something out. The issue is very important and I hope we can get €5,000 to start the summer camp the delegation wants to run to train trainers. Dr. Murphy mentioned educating the educators. I come from a teaching background. We probably need to go into the colleges of education. I know what goes on.

We all know about vitamins, fats and what we should be eating, but we need to examine how we translate that message to children in a classroom. It is very difficult for a teacher at the top of a classroom who sees two or three children who are very overweight to teach that subject. Other groups have said children should be weighed in classrooms. I am totally against that. Visiting nurses conduct hearing and other tests in schools. I understand that in the past they weighed children. Perhaps children could be followed up in a systematic, professional manner. If there is a problem, let us all deal with it. It should not be something we never mention.

I would like the delegates to comment on the smartphone application. I do not know what they are talking about.

GPs should mention weight as a matter of course when patients visit them. I tabled a parliamentary question asking the Minister about the education of our young doctors and saying they should be trained in how to deal with children presenting with weight problems.

We should try to make sure the delegation has a budget and that we deal with our children who have morbidities. We are constantly discussing cyberbullying, the suicide epidemic and mental health issues. As somebody who has dealt with children I have seen girls or boys in the classroom who dip their heads and do not want to engage with classes such as swimming or PE. They do not want to go into a swimming pool in front of their classmates, and I do not blame them.

Ciara Conway (Waterford, Labour)
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I will take all the speakers now, to be fair to everybody who is here.

Aideen Hayden (Labour)
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I would like to thank all the delegates. It was an interesting presentation and it is an interesting issue. The INDI has done super work in bringing this into the public domain. The evidence would show that no country has managed to reverse the trend of obesity. This is an international issue. I accept the delegates' point, but it is a European issue as far as Ireland is concerned.

I have a couple of specific points on funding. At this time of the year we start to get a lot of pre-budget submissions. Last year we received submissions from TASC and Social Justice Ireland, who suggested the introduction of a fat tax on certain products such as carbonated drinks. What is the view of the delegation on the introduction of such a tax? I ask them to comment on ring-fencing the proceeds of such a tax for the provision of services relating to childhood obesity, from the point of view of prevention and the administration of services for children who require clinical services.

I refer to the report of the INDI arising out of its proceedings in March relating to carbonated drinks and their availability in schools.

Ciara Conway (Waterford, Labour)
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I call our rapporteur, Deputy Fitzpatrick.

Peter Fitzpatrick (Louth, Fine Gael)
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I thank the witnesses for an excellent presentation. In the past 12 months we have heard what they said in their contributions, but we need action. We all agree there is an urgent need for obesity treatment services for both adults and children who are overweight or obese. The programme at Temple Street children's hospital and the Up4It programme are a great start but we need to find ways of funding those programmes and many others. In my report I will make suggestions on how to find those funds outside the box, so to speak. It is all very well for Deputies to come in here and ask witnesses if €10 million would solve the problem. The bottom line is that the money is not available and therefore we must think outside the box to find ways of raising the money. As rapporteur, I have many suggestions as to how we can do that, and I will consult with the Minister on that. There is little point in members' simply listening to the witnesses' contributions without promising some action. It is important that we realise that the country is bankrupt. We have a major issue with people being obese and overweight. We can talk morning, noon and night about that but we must come up a national plan on how to raise the funds to tackle it. I have many suggestions, and that is the only way to go forward.

We know that 100,000 children between the ages of one and four are obese, while 300,000 children are underweight. The problem begins in childhood. During my election campaign two and a half years ago I visited many estates and, as Deputy Catherine Byrne mentioned, I did not see any children playing football, running or playing tennis in the streets. When the parents opened the door I could see the children inside the house playing on PlayStations or other devices. In my area of Dundalk I met a man who was 29 stone. He asked me for help and I told him I would try my best to help but I asked him what he was doing about his problem. He replied that he was waiting for help but I told him that he had to start helping himself by getting out and doing some exercise. He thought I was being abrupt but I did not mean to insult him. I simply told him that he cannot just press a switch or lift the phone to look for help. I met that man 12 months ago and his weight has since dropped from 29 stone to 21 stone. He lost eight stone in 18 months and the only thing different he did was to get up out of his chair and begin walking in the estate. That man is a father and a grandfather. People think they can just lift up the phone and get help for this problem but they do not realise that they can help themselves.

The information the witnesses have given today is excellent, but it is alarming and people do not want to hear it. They said that 70% of the children they mentioned will become obese. If a child's parents are obese they continue that trend and follow their parents. We must try to get the parents and children to work together on the problem. The witnesses frequently referred to the family. It is important that a child gets into a treatment programme but it is great if they can get help from their mother, father or grandfather also. That is a fantastic support.

The witnesses said that the treatment required costs €1 billion a year. The health budget is €13 billion and €1 billion of that is going on treatment for people who are obese and overweight. The Minister will have to examine that.

The witnesses hit the nail on the head when they said that the food industry and the advertising agencies have a role to play in this area. That will be part of the funding requirement. A total of 88% of these children and their families do not have any treatment programmes available to them. When we get the funding we must organise these programmes but, as the witnesses said, it is important that these programmes are done throughout the country. There is little point in telling people they must attend Temple Street children's hospital or a cross-Border programme. That is an important point, and the Minister realises that. We have fantastic hospitals in Ireland ranging from small to medium to large. It is important that whatever funding we get is given to those hospitals and that clinical treatment programmes are opened up. The witnesses mentioned people being given a diet or health programme. The programmes the witnesses cited have been excellent.

I remember as a nine year old in school being asked to weigh myself, and I was an active child. I note that an average nine year old now weighs 34 kg, which is roughly 5.5 stone. When I was that age I weighed 6 stone and I thought at the time that I was overweight. From the age of nine to 12 I did not gain much more weight. I am now in my fifties and I am lucky that my weight now is the same weight as when I was in my twenties. We can all look for programmes and for this, that and the other to deal with this problem but people must want to address it themselves. When I meet friends they ask me how I keep myself healthy and fit and I tell them that I make sacrifices. If one goes to the pub and drinks four pints of Guinness, one could cut back and have three pints, or cut back on going to the chip shop for chips three or four nights a week. We have all had to cut back to look after ourselves.

Can the witnesses give me their top five ways to combat obesity and being overweight? It is fine to come in here and talk about this, that and the other but we need to keep everything simple. Most of the people who are obese or overweight come from deprived areas. The Government is not going to give any handouts. People need not think they can lift the phone and ask the Government to provide funding of €10 million, €20 million or €30 million to tackle this problem. I give a guarantee that in my report I will set out methods of funding and people will have to pay to help to fund these programmes. If Ireland as a society wants to go forward in tackling this problem, we have to think about ourselves. We must combat the problem of obesity and of being overweight. As I said here from day one, it is important to treat children and adults who are obese and overweight. I ask the witnesses to give me their top five ways to combat obesity and being overweight. The report will be out in two weeks' time.

I was very interested in a few of the statistics the witnesses gave. Their presentations were excellent. The time for talking is over and now we need action.

Ciara Conway (Waterford, Labour)
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The next speaker is Deputy McLellan. I thank her for her patience.

Sandra McLellan (Cork East, Sinn Fein)
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I welcome the speakers and thank them for their presentations. The figures presented are shocking. As a country we need to wake up and recognise that we have a problem. This is an issue that has been largely ignored but it is an extremely important one.

A number of the points I wanted to raise have been covered. I want to highlight the importance of education both at home and in school, to touch on a few points that Deputy Catherine Byrne raised and to speak about how society has changed. When I was a child there was no daytime television and therefore we were out all day. People spend a good deal of time sitting in front of the television today and with all the time young people spend on PlayStation and other devices they are not engaged in as much outdoor activity as they should be. Many parents lead very busy lives and often do not get home from work until late in the evening. Compared to the dinners we had as children when mothers worked in the home, dinners today, when many mothers do not get home some evenings until 7 p.m., may consist of fast food two or three times a week. Pizza and chips are the order of the day. Cakes were a treat when we were young but they are not so much of a treat today. We did not have fizzy drinks when I was growing up but they are the order of the day today. Therefore, society has greatly changed.

I wish to refer to the point about education in schools.

Ms Kizzy Moroney:

I thank members for their questions and for inviting us before the committee today. The meeting has been great. Members are all very well informed. There is so much to say and it is difficult to condense it.

I am grateful that the issue was raised about how parents feel when they come to us and how we approach the situation by saying things in a gentle way. It is frightening that we regularly sit opposite parents who do not know why they have been referred to us, so we are left with the challenge of explaining why they are present. Their faces drop. The child is present for the meeting. As Dr. Murphy said, growth charts are fantastic for GPs and practice nurses. The focus is on them and the issues are outlined so one does not even have to mention specific words. It is a case of bringing matters to a factual level. From a dietary point of view there is a lot we can do to address the issues. In terms of waiting lists, millions of resources have been developed and we can send out information. All the work has been done and the information is ready to go.

We often introduce food from a healthy eating point of view. Initially, we introduce more food involving healthier options. With high-sugar foods the appetite is satisfied in the short term but then the hunger kicks in again. One introduces foods from which energy is released more slowly. In effect, it is more food, which is a comfort for parents. It is not the case that one gives them too much. When one is educated on the food pyramid it is a handy resource, similar to the plate model in the UK. When one ticks all the healthy eating boxes, some of the unhealthy foods just subside naturally. When Dr. Brinkley speaks she might refer to behavioural change that one sees six to eight weeks before the proper behavioural change takes place.

We support parents and reassure them that there are 40 reasons why children are overweight today. For example, it could have to do with not being active, not having safe areas outside in which to play and not being allowed to run in schools. Food Dudes was a schools programme which Ms Flanagan might speak about. Because of technological developments children are not as active anymore. Cheaper food is higher in fat. We address food labelling in simple ways on the programmes. We give simple take-home messages along with the top five tips such as having less than 5 g of fat or sugar per 100 g of a treat food. We have little take-home messages on the programmes we run. We go through budgeting and what is achievable in the supermarket. If one is dealing with a large family, one focuses on bulk buying. We help families with budgeting as well. We try to encompass all such matters. Does Deputy Mitchell O’Connor want a further response to her question about what one says to parents during the first consultation?

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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No; what has been said is comprehensive. For parents listening, could Ms Moroney refer again to the concept of children growing into their weight and maintaining it?

Ms Kizzy Moroney:

With children who might be carrying a lot more weight or who are morbidly obese, we do manage that under health care professionals and state that there might be some weight loss involved. It is managed closely. Low-calorie diets are not validated for children as they are not appropriate for them. For younger children the aim is weight maintenance. It might take four or five years for them to reach proportionate height-to-weight ratios. It is a long process. As Ms Flanagan pointed out, the more people one educates the more it transfers to cousins, grannies and other grandchildren, and they will all start to come on board. That is the benefit of the multidisciplinary approach and lifestyle intervention programmes.

There was a question about waiting lists and what happens in the interim. Currently in Temple Street some children who might not be suitable for the programme go into an outpatient service. Again, there is a year-long waiting list for it. There are no community services and they might only get one appointment.

Ms Grace O'Malley:

I will answer a couple of questions together. The first question relates to parents' reactions. Sometimes we have parents who are utterly upset because they have been trying to manage their children's weight themselves but they do not have effective resources. We all take for granted that we can look after ourselves and we can manage ourselves but a lot of people do not have the emotional resources to do that. Many parents are depressed or have a low IQ. Instead of saying they can do something themselves, we need to empower parents, patients and citizens. We must help a little. We get either parents who are upset or parents who have been banging their heads off the wall trying to encourage their children - who are mostly teenagers - to change. No teenager listens to his or her mother or father. Sometimes coming to a health professional can really help because the child then takes the message on board.

The situation is replicated around the western world. It is not unique to Ireland. We have issues of increasing food poverty. Through evolution and foraging for food our bodies are able to store fat when we need to find food. Now, we have an abundance of calories all around us with unregulated access. Our brains are not able to deal with that. We want this and we want that. We want sugar. That is what human beings do. It is a biological problem.

We do not have areas that are safe for children to play in. Many of the children in our catchment areas cannot go outside because the streets are unsafe, because of needles in the park or because they are teased by people in the neighbourhood. We have a breakdown in society and this is the physiological symptom. Our children are getting obese and depressed and it is a symptom of society as a whole. We have a perfect storm. That is why we all need to work together to make a change.

Fast food and takeaways are an issue. At the moment there is no regulation of the location of such retail units. Often they are very close to schools. We know from international research that if one has takeaways and fast food units close to schools one will have increased obesity in those areas. That is evident. Sugar-sweetened drinks are not recommended for children. The American Academy of Paediatrics does not recommend them for any child under 12, yet they are being shoved down children’s necks through advertising. We support the Broadcasting Authority of Ireland’s recommendations to limit the advertising of non-nutritious foods on children’s television and the Internet. Such advertising must be regulated. We already spend €1 billion on hospitals in this country.

Aideen Hayden (Labour)
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To be clear, Ms O'Malley is saying she would favour ring-fencing some kind of fat tax.

Ms Grace O'Malley:

I would, yes. We need to incentivise the consumption of healthy foods. It depends on where one lives in the country but a bottle of Coke in, say, a shop in inner city Dublin will be far cheaper than a bottle of water. If one wants to buy vegetables they will be far more expensive than a big bag of crisps and if one's children are hungry, one will give them something that is just calories to ensure they are not hungry. That is a problem because it leads to the creation of chronic disease.

We must be serious about front of label packaging. We can look to the United Kingdom for evidence of that, and we know that traffic light labelling works. I worked for a period with stroke rehabilitation and people who are rehabilitating, particularly those who are morbidly obese, must believe that they can change before they change but many of our clients who are morbidly obese have pain. They have biomechanical reasons they cannot exercise and therefore we need to encourage and help them.

With regard to the top five issues, from my point of view we have to look at treatment and prevention. First, we have to train people on the ground who want to be able to work in this area. We have general practitioners and practice nurses in place already but there is no training for them. That must be addressed. Second, we need to treat children who are obese because they will become adults who are obese. Third, we must regulate the food environment in terms of the advertising of non-nutritious foods. We must incentivise the consumption of healthy foods. Fourth, we need to seriously examine education and make sure that physical education is on the curriculum and that it is mandatory. Cooking skills should be on the curriculum to ensure that our children, the next generation, know how to cook for themselves. We are amazed that many parents do not know how to cook.

Ciara Conway (Waterford, Labour)
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We have not heard from Dr. Brinkley who may wish to contribute.

Dr. Aoife Brinkley:

I would like to pick up on the issue of personal responsibility and parental responsibility raised by Deputy Byrne and Deputy Fitzpatrick. That is an important issue. Those of us in this room, as clinical experts working in this area and as public representatives, have a responsibility to understand this issue. For parents, the issue of blame is devastating and as they become aware of the issue when they come in to hospital services, for example, they quickly take on that blame. That can be devastating for a parent and can make it very difficult for them to address the issue in an effective way. We have a responsibility to address that.

The issue of self-blame ties in to the issue of weight bias. As a society we are biased towards children and adults who are overweight. There is evidence for that internationally and in Ireland. As clinicians we often hold that bias. As parents we may hold that bias. We must be aware of that, and we must fight against it. One of the ways we can do that is to communicate the fact that this is a complex issue. It is not a simple issue. It does not have a simple solution. If we buy into the idea that it is simple and straightforward for parents to address this issue, that in itself can make the issue worse. If parents, in trying to address the problem, meet a clinician for a once-off consultation, is given advice and sent off to put that into practice, they are likely to fail. Some parents will succeed but if there is a complex background to the child's obesity, they are likely to fail. That means they are less likely to try to address the issue again in the future. The message that gives to the child is also very difficult and devastating.

We must understand that this is a complex issue. Many of the children we see come with myriad difficulties associated with and underlying their obesity. From my perspective, the emotional and psychological issues are paramount in the work I would do and they can represent significant barriers for the child and for the family in tackling this issue. If children are self-conscious about their weight or have experienced teasing, which the majority of the children we see have experienced, they are less likely to feel able to go out and play, go for a jog in the park or go for a run because they are well aware that other young people the same age as them may target them and call them names, point to them or talk among themselves and exclude them. Those are the real issues with which these children are dealing.

I reiterate that we have a responsibility to understand the complexity of this issue and the need for a complex response, not just simple messages. Obviously, they have a role to play but the children already obese and overweight need multidisciplinary input. They need input that recognises the psychological impact of the difficulties with which they are dealing, and the parents need support in dealing with what is a complex issue.

On the issue of clever funding, we are well aware of the restrictions on available funding. From our perspective in Temple Street children's hospital, we have had queries about information and training from professionals working within other hospitals, public health nurses and people working in the community. We cannot provide that currently because of the limit in our own resources. What we can provide is not sufficient. We need resources and funding to roll out that training. That is one way of providing clever funding because it is a minimal spend for a large impact.

On the issue Ms O'Malley mentioned about schools, because of the complexity of the issues we need multiple responses. There is a role for schools to play. There is a role for us as clinical services and for community services to play. There is also a role for prevention.

Ciara Conway (Waterford, Labour)
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Ms Ball had indicated.

Ms Emma Ball:

Yes. I want to pick up on some of the points discussed, the first of which was the comment about the 61% of referrals for the Up4It programme. That should have included self-referrals plus community and voluntary group referrals. That was quite significant. The approach taken with the CAWT programme was that it would be a community development led programme and not the statutory organisation delivering a programme. Part of that was looking at the experience of other programmes in terms of retention rates. We can have a fantastic programme but people drop out of it. Also, it is important to consider the hard to access clients who do not attend, DNA, for their appointments but who may have health risks.

The project went through a procurement process. In our area in Donegal a community and voluntary group, the Letterkenny Youth & Family Services, co-ordinated and delivered the programme in partnership with the health professionals. As a result, we saw there was a significant number of self-referrals because they were based in an area of Letterkenny. They already had after school services for families. They were already involved in parenting programmes. They had the knowledge in terms of bringing in and capturing those clients and as a result we had very good retention rates, both for the completion of the 12 week programme plus the follow on.

It is very important for any community programme that the community and the voluntary sector are included therein in partnership with the HSE and the primary care providers. At a local level, we have a children's services committee, which has prioritised tackling obesity for the next three years in County Donegal. We have brought in all the various community groups such as, for example, the Lifestart Foundation, the local sports partnerships and so on. Again, this pertains to creative funding and what these organisations can give to the programme. It may be they can provide a room in which to run the programmes and therefore one need not pay to rent out a room. Similarly, they may have kitchen facilities because, again, it is a skills-based programme in which we seek to have a cookery element. While there is a certain amount of goodwill funding we can gain from working with different groups, we need the statutory organisations, that is, the Health Service Executive, HSE, and the Department of Health to provide some element of funding. I agree that €10 million would be a fantastic start.

Another point to mention pertains to getting out the message to parents and again, this is looking at it being a positive programme. It is not being marketed as something like Slimming World or a weight loss programme but rather, the point is it is a healthy lifestyle programme. It is a skills-based programme that should be both fun and social and one would know this from the testimonials of those children who attended the programme, which were that they made friends and came back, that it was active and the children were doing something every week and it was not just about listening to someone talking at them. It is very important to have this fun, positive element to the programme, as well as it being skills-based, in order that the participants learn how to cook and the child learns with his or her parent how to make meals and how shopping can be done.

Another point I wish to mention relates to the weighing of children and the involvement of general practitioners, GPs. Nationally, a weight management treatment algorithm for children was developed by the HSE and the Irish College of General Practitioners, ICGP. It is available and there probably should be a little more training in respect of that. However, on the measurement of children, I must mention the public health nursing service and the school public health nurse service. Again, there are issues around the country in this regard. Because of the moratorium and the HSE embargo, this service is not available throughout the country. However, where school nurses are available, part of their remit is to measure the children at least twice - I think it may be in junior infants and in fifth class. In my local area, a questionnaire goes out to parents, prior to them coming into the school, asking whether they have issues. One question is whether there are issues with regard to food and nutrition. In addition, after the measurement and the health check take place, a report goes out to the parents that includes the child's weight and height and which ticks the box as to whether there should be any concern in this regard. In my area, the parent will be contacted and there is an option for the children to be referred through to the individual dietetic service. Unfortunately, either the school public health nurse is not available nationally or the dietetic service is very limited. Ideally, while an individual dietetic consultation can have a role, we would love then to be able to refer those involved onto something like the 12-week programme, perhaps after the first assessment. While some structures potentially are in place, it is not countrywide and has not been rolled out. I reiterate that much of the groundwork has been done and there does not need to be a lot of work done on developing programmes or systems. It simply needs to be implemented at this point.

Ciara Conway (Waterford, Labour)
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Before Ms Flanagan makes her closing statement, members have indicated they wish to ask three supplementary questions, which they promise me will be brief. I ask Deputy Mitchell O'Connor to proceed.

Mary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I ask Dr. Murphy to talk a little about breastfeeding, introducing solid food early and how that can have an impact on a child's life. Is intolerance of food also an issue? I also ask her to discuss thyroid problems because many women are being diagnosed with such problems later on as they get older. Is this being checked or is that an issue?

Ciara Conway (Waterford, Labour)
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Did Deputy Catherine Byrne have a question?

Catherine Byrne (Dublin South Central, Fine Gael)
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I simply wish to agree with Ms Grace O'Malley on the point about home economics in school, cooking and teaching children. I still believe that no matter where one lives in the city, one can buy decent vegetables and so on. I visit supermarkets all the time and there always are three-for-two bargains on sale. I see people buying cans of carrots for €1.75, when one could buy a bag of carrots that would last a week instead. This is the basic point in this regard. I have one question in respect of school meals and breakfast clubs. I was part of a parents group that introduced the first breakfast club in the country in Inchicore and Goldenbridge, where I live. It was because we had seen children coming to school who had nothing. What is Ms O'Malley's opinion on school meals and schools that deliver them? Does she think it is of benefit to children or is this a case of going to the extreme and doing things the children's parents ought to be doing?

Peter Fitzpatrick (Louth, Fine Gael)
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Ms Grace O'Malley made a comment that teenagers do not listen to their parents. However, teenagers do look at them and parents can set a good example. I acknowledge that when children are aged between 13 and 21 or whatever, they go through a stage of rebellion. However, if one looks at them in later years, they will have carbon-copied what their parents have done. Consequently, it is extremely important that the parents help in this regard.

Ciara Conway (Waterford, Labour)
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I invite Dr. Murphy to respond.

Dr. Sinead Murphy:

In respect of breastfeeding and weaning, there is no question but that breastfeeding is protective and is the best start a child can have from a nutritional point of view. It is somewhat strange but we do not do well with breastfeeding in Ireland. It is very socioeconomically dependent, like everything else. However, we certainly should be encouraging it, as well as encouraging facilities and so on for mothers to be able to breastfeed where at all possible. While breastfed children are less likely to be obese, there are so many contributory factors that it is very hard just to pull out breastfeeding. This just brings me back to exercise and children having the wherewithal to exercise and providing that for them. Exercise has become elitist in this country because there are not the facilities for children to go and play if they so wish, to walk to school if they so wish or to cycle to school if they had a bike. These are the types of children with whom we are dealing and we must bear that in mind. However, that is an aside.

Weaning is very important and we are bad at it. Children will be weaned as early as three months in some cases. Moreover, a little scarily, mothers will be advised to wean children at three months. This is a case then of educating, in that we talk about educating the educators and they are the pure educators, namely, the teachers. There also are the health care professionals who are going out and giving advice to these parents. They need to know what the advice should be and certainly, weaning at three months is not part of it. Moreover it happens and we hear frequently enough that mothers are advised to do this. This certainly is something that really requires quite a lot of attention. This will be very important from a prevention point of view as these are babies and hopefully we can prevent them from turning into overweight or obese children.

As for intolerance, I do not believe there is much of a relationship between food intolerance and being overweight or obesity. There is food excess and lack of exercise and as Ms Kizzy Moroney stated, there probably are 40 different factors - that probably is conservative - all contributing together. Food intolerance occasionally may play a part but I do not think it is one on which to concentrate. As for the Deputy's question on thyroid problems, that is one thing for which we screen. As members will be aware, all children are screened at birth for congenital thyroid problems with the Guthrie test. However, other thyroid problems can come on at any point in life and can contribute to being overweight. It is one thing that certainly should be checked for and again, that is part of education. In our programme, we screen all children for thyroid problems because one sees it and I can think of lots of cases in which children would come in and be battling and in which it is a case of thyroid problems. Unfortunately, most of the time, it is not an endocrine problem but is a problem pertaining to the toxic environment in which they live and the fact they are not enabled or empowered to do anything about it.

Ms Kizzy Moroney:

On the intolerances, it may happen that children or adults have some intolerances. It may be a co-morbidity of their obesity as such but when someone addresses and looks into his or her diet, he or she may find there is a little bit of intolerance. However, one finds that when a person's diet is being addressed, his or her hydration is improved. Consequently, that might be the bigger benefit for people, in that with improved hydration on foot of addressing their diet, eating regularly and all of that, they get better results from their intolerance symptoms.

Ms Richelle Flanagan:

I have a couple of points. In response to Deputy Fitzpatrick's question about breastfeeding, he may like to take it up with one of our research dietitians, Ms Roslyn Tarrant, who has done a great deal of research in the area of breastfeeding and weaning within the Irish female population. Our rates are definitely at the lower end. Those who are breastfeeding are the more well educated and those who have thought it through before they give birth, during the antenatal period. It is very much the case that we need to hit that point before they give birth, during the pregnancy and even before. It is shown that even grandparents have an effect on the child's level of obesity down the line. We need to get in as early as possible.

As Dr. Murphy stated, there is definitely research to show that people are weaning far too early. The FSAI has launched new infant feeding guidelines, which are supposed to be rolled out through the public health nurses. The problem is that there are not enough public health nurses because of the moratorium on recruitment in the public service, as is the case with other health professionals. With regard to weaning foods, mums are using packaged products. That is something that needs to be addressed. There are guidelines about the safety of these weaning foods for babies but there are no guidelines about the levels of sugar, fat, etc. That might be something to be examined.

I read a report that stated that according to the legislation one can breastfeed in the workplace but one must give notice six weeks beforehand. Often, there is a lack of access to a place suitable for breastfeeding. Embarrassment is a big blockage. In that regard, one will also see in Ms Roslyn Tarrant's research that there is a fear that breastfeeding is not something that is acceptable.

One point I must make about breastfeeding is that the mums are blamed constantly for different things. We must be supportive and encourage them. The WHO supports exclusive breastfeeding, but it comes down to choice. Many working women are under a great deal of pressure in this economic time, and they must be given more choice. We must support them in their choices and encourage them to breastfeed as much as they can, whatever that may be. We need to have a more helpful society when it comes to breastfeeding.

On the comment made about the food guidelines, as the committee will be aware, the food pyramid and the healthy eating guidelines were relaunched last June through the Department of Health, the FSAI and the HSE, with the involvement of the Irish Nutrition and Dietetic Institute, INDI. They are a fantastic resource. They are not a weight-loss guide but I can guarantee that if people followed them they would naturally lose weight.

We were asked about the top five issues with regard to obesity. One can say the top issue is the food on the top shelf. People are snacking too much on high-fat or sugary foods and drinks. Portion control is another. The food pyramid tells people about appropriate portions. I gave a talk only yesterday in a workplace and it is always the case that people are astounded when I tell them that a portion of rice is 25 g. That is nothing. Thirty strands of spaghetti is a portion of carbohydrate. The messages we need to get out to people are about portion sizes and about the top shelf. Alcohol is another issue; people do not understand the amount of calories that are in the alcohol they consume - that is, 100 calories per 100 ml of standard drink. These are many of the messages contained within the food pyramid.

With regard to the food pyramid, it is wrong to denigrate something that is a public health document. When the delegation from "Operation Transformation" appeared before the committee, they did that. It was incorrect. They also mentioned that dietitians were not up to date. I represent dietitians and clinical dietitians, who are regulated by the statutory body CORU, the Health and Social Care Professionals' Council, which deals with protecting the public from poor information. We represent the expert view, just as physiotherapists and behavioural psychologists do, with our paediatric consultants. It is quite a complex issue.

The food pyramid is only for those aged five years and over. We do not have food guidelines for under fives. That is something else that should be put in the committee's report. I ask that there be food guidelines for under fives, along with a food pyramid and portion controls for children, because we need to start early.

With regard to what is available for children, much work is being done. There are websites such as littlesteps.eu. Members said that parents were listening in to this meeting. That website is a fantastic resource from safefood. There is also an initiative called way2live.eu, which is a combined initiative from the INDI and safefood. They are both great resources for empowering parents. The Food Dudes programme has proved to be fantastic. It is parents who affect children's choices, but when it comes to teenagers, their peers also have an influence. Children are affected by their parents' choices, but within the school setting, that programme, under which children bring in a fruit and vegetable, has been shown to be extremely successful. Like other programmes, however, it has not been supported enough. Breakfast clubs were mentioned. There is the Healthy Food for All initiative, under which HSE dietitians have helped to develop a resource for breakfast clubs in deprived areas.

There is much fantastic work going on, but we always come back to the crux of the issue - that is, the need to co-ordinate and replicate those initiatives that are working, which is not happening at the moment. There is funding, but if one wants to find better ways of utilising the funding, one should examine the programmes and move the funding to areas that are working. It is criminal that we are saying we need to find funding for something that is preventative. As we stated, 25% of the adult population are obese. By 2030, which is only 17 years away, the rate will almost double, to 47%. All of the chronic diseases are a direct result of obesity. To my mind, it is a no-brainer that one should provide the funding by finding it wherever one can. This will solve many of the other problems that are coming down the line.

Ms Grace O'Malley:

The school meals programme is a great initiative, although yesterday I had one patient whose mum had specifically asked four times for no biscuits to be included in the meal, yet every day the child comes back with biscuits in her bag. The programme is working, but we need to ensure we are providing children with the healthiest options and that there is proper oversight of what is in the meals.

Of course, parents are the biggest role models for all children and they are the most important people in the life of a child or teenager. When we are faced every day with parents who are struggling to do their best for their teenagers, we can see they need support. I do not mean that children do not listen to their parents - of course they do - but when one has a teenager who is dealing with changes in his or her own body and trying to be mature enough to deal with the fact that he or she is clinically obese, the parent needs help and extra support.

We need to be really clear about the fact that six months is the best age for weaning. It needs to be a message that everybody hears.

According to Dr. Anne Dee and Professor Ivan Perry in the safefood report, the majority of costs related to obesity and excess weight were indirect costs, and 60% of these were due to absenteeism. There is an opportunity to invest in human capital, which is the most valuable asset in the country. If we do not have healthy people we will not have an economy, because there will not be anybody working.

For patients who are waiting for services, there is a website, w82go.ie, which also has a section for clinicians. Deputy Mitchell O'Connor asked about smartphone applications. We have developed an Android app called Reactivate to try to bridge the gap in treatment and we have looked at providing remote treatment. It is a behavioural change app for teenagers which uses goal-setting to improve nutrition, activity levels, fitness, sleep and emotional well-being.

Ciara Conway (Waterford, Labour)
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Is there anything else Ms Flanagan wants to add?

Ms Richelle Flanagan:

I merely want to thank the committee for inviting us in. In summary, in order to tackle this issue effectively, we need progressive policy and adequate legislation, as discussed here. From our point of view, we need access to appropriate clinical services at community and hospital level. I hope we have demonstrated that there are services worthy of support which are making a difference.

Children who are obese with co-morbidities have a right to timely treatment. As with any child with a life-threatening disease, children who are overweight and obese have the right to timely identification and treatment in the community to help prevent the development of adult diseases during childhood.

Ciara Conway (Waterford, Labour)
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On behalf of members, I thank all our guests for their very informative and challenging presentations. The committee's remit covers both the Department of Health and the Department of Children and Youth Affairs. Unfortunately, the under-fives have been neglected during the years. We have been dealing with some very disturbing stories that have emerged in regard to some crèches in Dublin. The Government, for the first time, has formulated an early years strategy. The delegation should consider having an input into the strategy on healthy eating guidelines for the under-fives. It is stark that we do not have such guidelines. I encourage the delegates to make a submission in the coming weeks, which the committee would support. I thank them for attending and members for their patience. I wish our rapporteur well in the production of his report.