Oireachtas Joint and Select Committees
Wednesday, 21 March 2018
Joint Oireachtas Committee on Children and Youth Affairs
Tackling Childhood Obesity: W82GO! Weight Management Service
9:30 am
Alan Farrell (Dublin Fingal, Fine Gael)
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I welcome our guests, representatives of the W82GO! Weight Management Service at Temple Street Children's University Hospital, to the committee meeting. I welcome Dr. Grace O'Malley, chartered physiotherapist and multidisciplinary clinical lead, Dr. Sarah McGuire, senior clinical paediatric psychologist, Ms Nicola Sheridan, senior clinical specialist physiotherapist in paediatrics and Ms Michelle Strahan, senior medical social worker in child protection. They are most welcome to this morning's committee meeting.
Before we commence, in accordance with procedure, I am required to draw witnesses' attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by the committee to cease giving evidence on a particular matter and continue to do so, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable.
I remind members and all our guests to switch off their mobile phones or put them on flight mode, because whether they are on or muted they will interfere with our electronic communications systems, which will affect the broadcast quality and the job of parliamentary reporters.
I advise witnesses that any submission or opening statement submitted to the committee will be published on its website after the meeting. I understand the witnesses will make a short presentation today, followed by questions from members of the committee. I call on Dr. O'Malley to make her opening statement.
Dr. Grace O'Malley:
On behalf of the families who attend the W82GO! Weight Management Service at Temple Street Children's University Hospital, and its staff, we thank the Chairman and the committee for the invitation to present on the challenge of addressing childhood obesity. Temple Street hospital, as a national acute paediatric hospital, sees up to 145,000 children per year, promotes healthy lifestyles for all children, which includes the prevention of overweight, obesity and dental decay and the promotion of a healthy diet, exercise and optimum dental health, in addition to treating multiple clinical conditions.
I am joined by representatives from the W82GO! multi-disciplinary team, namely, Dr. Sarah McGuire, senior clinical paediatric psychologist, Ms Nicola Sheridan, clinical specialist physiotherapist in paediatrics and Ms Michelle Strahan, senior medical social worker in child protection.
I will begin by contextualising our role in childhood obesity in Ireland and highlighting that we can represent only one small part of a larger discussion related to the complex social challenge of obesity in children. As such, we will focus solely on the treatment of clinical obesity in children and adolescents and recommend that additional stakeholders are invited to present on other aspects related to this issue.
The W82GO! clinical service was established in Temple Street hospital 14 years ago and, as with many worthy endeavours, the initiative was commenced without dedicated clinical funding but survived on staff commitment and research funding from the Temple Street Foundation and the Health Research Board of Ireland. Thereafter, temporary seed funding from the Health Service Executive was secured and service development was facilitated.
Since 2017, some funding has been provided by Temple Street hospital, thanks to the vision and growing understanding of the childhood obesity problem by the hospital's executive team. This understanding is founded on scientific evidence, including some stark facts. These include the fact that 20% of children and 25% of adolescents in Ireland are overweight or obese; the fact that children with obesity are at increased risk of health complications at an early age; the fact that admissions to UK paediatric hospitals for weight related issues have quadrupled over ten years; and the fact that children with obesity are more likely to develop serious adult diseases, such as type 2 diabetes, cardiovascular disease and many cancers.
The most recent data from the Irish arm of the WHO childhood obesity surveillance initiative, COSI, study run by the national nutrition surveillance centre at UCD, reveal that the estimated number of primary school children with clinical obesity and morbid obesity is around 6.5%. From Growing Up in Ireland data we know that, in addition, approximately 6% of 13 year olds have clinical obesity. This means an estimated 80,000 children and adolescents in Ireland have clinical obesity. The rates of clinical and morbid obesity are nearly double in schools with high levels of disadvantage. This is particularly worrying because these children are even more at risk of morbid obesity and cardiovascular ill-health in adulthood.
In Ireland, those with clinical obesity can receive multidisciplinary treatment at Temple Street. However, they currently have to wait nearly two and a half years to see the treatment team. For adolescents who will age out of paediatric services, this is particularly unacceptable.
A multitude of comorbidities are associated with obesity. An estimated three quarters of children will develop health complications at an early age, including physical and mental health complications. In Temple Street, we are conscious of the impact of childhood obesity on families. We approach this issue from the perspective that family re-education and support are essential elements in changing the eating and exercise patterns of our patients. We are also conscious that this can be particularly difficult for families with financial challenges or who have complex social circumstances. We work to support families to address issues that can cause barriers to the successful treatment in the child’s home.
The UN Convention on the Rights of the Child demands that those who are already obese and who may have comorbidities must have access to early treatment in childhood in order to avoid progression of associated conditions. The most recent estimate of the lifetime economic and health care costs incurred due to childhood obesity indicates that the amount involved is over €4.5 billion. Treatment needs to be available for all children when and where they need it. Research tells us the intervening early and in a holistic manner is essential if we are to manage this condition. A staged approach is recommended based around the needs of the child.
The children of Ireland urgently require timely access to treatment in primary, secondary and tertiary care. At primary care level, GPs and public health nurses who are interested in this area must be provided with the appropriate resources to treat obesity including access to practice nurses and to the paediatric health and social care professionals, HSCPs, working in the community. They often deliver the bulk of childhood obesity treatments. In addition, public health nurses will be unable to identify and act for infants and young children at risk of obesity if they do not have funding and staff dedicated to the delivery of infant and child health.
At secondary care level, any child in Ireland suffering with the physical or mental health comorbidities of obesity needs timely access to a general paediatric service. Areas with large populations - for example, surrounding the satellite centre currently being built at the Connolly Hospital site and the planned centre at the Tallaght hospital site - need integrated services which must be clearly planned and implemented in the children’s hospital group as a matter of urgency. Only then can we ensure better access for those most severe coming into tertiary services.
At tertiary care level, discussions on obesity service provision have commenced between the HSE and the Children’s Hospital Group, CHG. However, transparent planning and implementation engaging all those involved in the care of these children is needed. Of particular concern is the lack of health and social care professional involvement at executive level in the CHG. This will no doubt have a direct impact on children with obesity whose care is, in the main, delivered by HSCPs. New services at the new children’s hospital will also need to plan for the inclusion of bariatric procedures in line with best practice guidelines for those adolescents most severely affected. My colleagues will now update on our service in Temple Street and on progress to date in the area of childhood obesity.
Ms Nicola Sheridan:
As previously highlighted by my colleague, our team in Temple Street treat children who are clinically obese. To explain this further, the average nine year old in Ireland weighs 34 kg, that is 5 stone 5 lb. The average nine year old attending our clinic is 55 kg, or 8 stone 9 lb. In keeping with the ICGP and HSE algorithm for childhood obesity management, all the children referred to our centre are clinically obese. In the past 14 years since inception, we have treated over 1,500 children with obesity. Specifically, between 2014 and 2018 we have had over 4000 attendances. In 2017, 49% of patients were aged under ten years, 29% were 11 to 13 years and 22% were 14 years or older.
Treatment is provided in line with current best practice guidelines and patients are offered group-based family treatment or individualised treatment, based on the health care needs of the child. Over the past four years, we have seen rates of non-attendances reduce and rates of attendance increase. Providing services to children and adolescents presenting with a range of complications is challenging because 40% already have risk factors for heart disease, 17% meet the criteria for having the metabolic syndrome, 40% have significant and severe mental health problems, and 75% have experienced bullying, with 11% experiencing severe bullying. Unfortunately, a number of the children seen have a history of self-harm or suicidal intent. These children have complex needs and as we know from other EU experiences they require access to the paediatric specialties. Over 40% are from deprived to severely deprived areas and rates of homelessness have become more common. As such, we are seeing at first hand the effects of inequality on health outcomes for these children.
Dr. Sarah McGuire:
Since 2013, some substantial progress has been made. In 2016, the Department of Health launched the obesity policy and action plan and the HSE established the healthy active living programme. To address the needs of those already with obesity, in 2014 and 2015 we collaborated with the HSE to train community health professionals in obesity management and a pilot treatment intervention for children was delivered yielding useful information for future planning of services. In 2017 the HSE appointed a clinical lead for obesity, Professor Donal O’Shea. He has acknowledged the need to provide obesity services in the CHG. There has been improved collaboration at Government level and in 2018 the Joint Committee on Education and Skills is convening to address the issue of obesity in children. Further work is required, however. For example, the CHG recognised obesity as an issue in paediatric health care in its 2016 operational plan. However, to date, there have been no definite signals on whether or how the new children’s hospital will provide the level of service currently available to those attending Temple Street. The hospital will indeed be built according to bariatric specifications however the blueprints for the required clinical services are yet to be clarified. In addition, community paediatric dietetic posts promised by the Government in 2013 have not yet fully materialised and GPs and public health nurses are not yet resourced to provide treatment at a primary care level.
Dr. Grace O'Malley:
We implore the joint committee to ensure that all stakeholders are invited to present to it in order to ensure full representation on this important issue. We recommended invitations to key individuals including the HSE clinical lead for obesity, Professor Donal O’Shea, and Ms Sarah O’Brien, the national lead for the healthy eating active living programme. We also recommend invitations to representatives from: the CHG; the Irish Nutrition and Dietetic Institute; the Institute of Community Health Nursing; the Psychological Society of Ireland; the Irish Society of Physiotherapists; the Irish Association of Social Workers; the Irish Institute of Public Health; and the Department of Education and Skills. I think that reflects the complexity of this issue. It is a whole societal approach. It is important to hear from everybody.
The following initial steps are recommended by our team: the development of an implementation plan and evaluation framework for the provision of services to children and adolescents with clinical obesity throughout Ireland; securing sustainable Government funding for the provision of such a service; consistency in delivery of treatment services using service frameworks, referral pathways and professional, appropriately trained, staff with performance management and evaluation; and a review and standardisation of educational content pertaining to adult and child obesity in the undergraduate curricula of all health professional degree courses. As outlined in the launch of Healthy Ireland, we would like to see a whole-system approach to improving population health. While public health efforts will focus on population approaches, we need to start with the most vulnerable children who need timely access to clinical services now.
Alan Farrell (Dublin Fingal, Fine Gael)
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I thank the witnesses for their opening statements. Their remarks provided stark reading when I was going through then yesterday. I want to note, with appreciation, the suggestions made. All flippancy aside, we were only discussing it prior to the witnesses coming in. This is the first of what we believe will be very extensive hearings on the matter of childhood obesity. It is important that we started off with persons with a great deal of involvement dealing with the aftermath. Our intention is to thoroughly investigate the witnesses' role in dealing with this problem and then, hopefully, working backwards to try to get back to some of the causes and preventative measures that could be taken at an earlier age.
All comments and contributions are very much appreciated. I will open the debate up to the floor and will start with my colleague, Deputy Sherlock.
Seán Sherlock (Cork East, Labour)
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I was very impressed by the submission because it gets to the nub of the issue and provides a set of recommendations that are easily digestible for generalists such as ourselves. I welcome the submission that has been provided here today.
I tend to ask rapid-fire questions, if I may. The W82GO! team is a multidisciplinary one. How many multidisciplinary teams are in this country?
Seán Sherlock (Cork East, Labour)
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Is the W82GO! team the only one?
Seán Sherlock (Cork East, Labour)
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Why has the team not been replicated throughout the regions? Why must a child who presents in Cork, Kerry or Limerick travel to Temple Street Children's University Hospital in Dublin?
Dr. Grace O'Malley:
Securing posts has been an issue. There also may be an issue with the level of interest by health professionals as the condition is relatively new. We did not see the condition in paediatrics in the past ten or 15 years. It takes time for professionals to develop an interest in a certain sector. Demand is also an issue. There are larger populations in Dublin or Cork. As 6% of the national population are affected then only a small group of children, who are severely obese, will need this type of treatment. The bulk of treatment and prevention must happen in community care. In order to develop specialised management one needs numbers. Like any centre of excellence around the country, one cannot develop experience without a throughput of patients.
Seán Sherlock (Cork East, Labour)
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If I understand what has been said correctly as a layman, is it appropriate that severe cases are referred to the centre of excellence in Temple Street Children's University Hospital? Yes.
As a former Minister of State who had responsibility for research, I note the team has clinical leads and I seek to understand both the resourcing and the research element in this regard. The W82GO! multidisciplinary team receives funding from the Temple Street Foundation and the HSE. Have peer-reviewed research papers and outputs been produced? Obviously the research is peer reviewed as Ms Sheridan has nodded her head. I seek an insight into what is happening on the research side.
Seán Sherlock (Cork East, Labour)
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The HRB.
Dr. Grace O'Malley:
The latter research is on psychopathology in the children who attend our unit. We also receive funding from the Royal College of Surgeons in Ireland via its strategic academic recruitment, StAR, programme for a PhD to look at connected health. We have published extensively and we also publish with international best centres in this area. From a research point of view, we have managed to establish a clinical service that is not burdened by research but which brings in additional funding to complement our work. We are really committed to evidence-based practice.
Seán Sherlock (Cork East, Labour)
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I am happy to hear from other people on this matter. Research is a particular area of interest for me because I know that strong peer-reviewed research leads to successful outcomes. It has been stated that as many as 145,000 children attend the hospital every year and the team has extrapolated a figure of 4,000. Am I correct?
Seán Sherlock (Cork East, Labour)
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Yes. Am I correct to say that there were 4,000 attendances in the years 2014 to 2018, inclusive?
Seán Sherlock (Cork East, Labour)
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It has also been stated that 49% of patients in 2017 were aged under ten years. Is the unit conducting live research into the types of children who attend in terms of demographics, backgrounds and the psycho-social elements? Does all of that form part of the research? There are short, medium and long-term effects. I note that the unit is part of Growing Up in Ireland - National Longitudinal Study of Children. Has the research and study had a bearing on the issue? Fundamentally, this committee wants to find ways to stamp out obesity. What tools are needed to tackle the problem? To me, research is one element. Obviously resources are required to be invested in the clinical area. If I have read the situation correctly, there are not enough clinicians working in the sector as it is relatively new. What can we do about that aspect?
Dr. Grace O'Malley:
Yes. While my colleagues can also comment on this matter, at undergraduate curricula level there is very little education in this field. Therefore, recently qualified health professionals have a pretty inadequate knowledge of this field because it is relatively new. Without question, the curricula need to be examined. Based on that, graduates will have scientific evidence because we know that the problem is far more complex than just eating too much. We know there is a huge epigenetic component. Epigenetics is like a light switch, by which I mean one has the ability to switch something on or off. Let us say a person is predisposed to gaining weight and leads a lifestyle whereby he or she is very stressed, not sleeping and eating ultra processed foods. That switch gets switched on and then he or she is more likely to become obese. Conversely, if a person is predisposed to obesity but that light switch is kept turned off, he or she is less prone to develop obesity.
Seán Sherlock (Cork East, Labour)
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I want to discuss the statement that families with financial challenges are more likely to be prone to obesity and 40% of the children who attend the unit come from seriously deprived backgrounds. How do those facts present themselves? I am open to hearing about this matter from other witnesses too.
Ms Nicola Sheridan:
The first time that people meet clinicians is when they attend our intake unit. In the past month, five children who have been in a homeless situation over the past three or four years have attended our unit. Even though their parents were working, the family could not access cooking facilities and the children developed the habit of hoarding and hiding food because they felt insecure and stressed. Another issue is that sometimes, due to the educational attainment of people who come from a deprived background, they do not understand the necessity for good quality food and leaning how to cook and so on. Many cheaper food options are heavily marketed and are widely available to the extent that eating healthily is difficult to do.
Having safe places for children to play is another factor. In many areas children do not feel that is safe to play outside of where they live. When we asked them whether they play outside of their homes they told us they were scared to do so due to shootings on their road or because of a real fear of being shouted at and bullied. It is no surprise then that children are afraid to play outside and their parents are afraid to let them do so. When I was growing up I played outside in my area all of the time with my family, neighbours and friends. When I asked some of the children who attend the unit whether they have played hopscotch, I was surprised to learn that they did not know what it was, which is sad. While parents may know the value of play, there is fear. In addition, people have busy lifestyles.
Seán Sherlock (Cork East, Labour)
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Is that element the exception or the norm?
Seán Sherlock (Cork East, Labour)
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How can we disrupt that dynamic and improve things? People have called for safe play environments for children.
Seán Sherlock (Cork East, Labour)
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Ms Sheridan is advocating a common-sense approach.
Seán Sherlock (Cork East, Labour)
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As a layperson, I will ask whether the witnesses think the solution is as simple as getting children to become active.
Seán Sherlock (Cork East, Labour)
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There is a psychological aspect too.
Seán Sherlock (Cork East, Labour)
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I have one last question.
Alan Farrell (Dublin Fingal, Fine Gael)
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One last question.
Seán Sherlock (Cork East, Labour)
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I thank the Chairman for his indulgence. Let us say the witnesses were given a magic wand tomorrow that granted them all of the resources they needed. What would the development of an implementation plan and evaluation framework for the provision of services to children and adolescents with clinical obesity throughout Ireland look like in real terms?
Would it be a case of staging what Dr. O'Malley is doing and scaling it out to the regions or would it be a question of adding more layers of resources to what she is doing with her team?
Dr. Grace O'Malley:
We would look to international best practice in this field. A hub-and-spoke model is usually recommended. Under this model, there would be a tertiary centre that can provide bariatric procedures in the most severe cases and spokes coming out from that hub. Thankfully, the UK's clinical excellence institute has already developed a whole framework. The Deputy referred to data. As part of the audit we do every year, we check how close to the standard we are and work with the business intelligence unit in the hospital in looking at the annual figures. When we look at non-attendances, for example, we try to see how we can change the communication on the letters we write to parents to ensure they feel welcome to come to the hospital. There is often an idea in health care that we should say "Tough - you are out the door" to those who do not attend. We have a duty of care to the child. If a parent is finding it difficult to attend, we must find out why that is the case and try to address those reasons.
Seán Sherlock (Cork East, Labour)
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Can I take it from Dr. O'Malley's request for increased funding that there a shortage of funding?
Dr. Grace O'Malley:
Our team is currently working part-time. We are okay at the moment. There needs to be a plan in place for the new hospital that will be established when the hospitals amalgamate. We need to have funding for a clinical lead - probably a paediatric endocrinologist - for the most severe children at the national children's hospital. Funding will be needed for general paediatrics as well because we currently receive referrals from multiple consultants in the hospital. All of this could be done through general paediatrics. We are the health and social care professionals arm of a service which, in the new hospital, will also need to involve more nursing and dietetic hours as well as endocrinology hours and general paediatrics.
Seán Sherlock (Cork East, Labour)
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Will Dr. O'Malley explain why endocrinology will be needed?
Dr. Grace O'Malley:
These children are much more prone to developing glucose problems, so their metabolism is affected. Early type 2 diabetes is also an issue. If a 15 year old is going blind in one eye because he or she already has diabetes, that is a huge issue. We have had situations like that in the past. Those children need an approach that is very different from the general childhood clinical obesity approach.
Alan Farrell (Dublin Fingal, Fine Gael)
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I will come back to Deputy Sherlock after we have heard from Senator Noone.
Seán Sherlock (Cork East, Labour)
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How many bariatric procedures have been carried out?
Dr. Grace O'Malley:
No such procedures are done in the public health system for children and adolescents. Some children might be going to the UK, but we are not aware of any child who has gone there from our hospital. Best practice involves providing bariatric procedures to adolescents in the most severe cases because it is lifesaving surgery for some teenagers.
Seán Sherlock (Cork East, Labour)
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Are people losing their lives as a result of not having bariatric procedures?
Seán Sherlock (Cork East, Labour)
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Does Dr. O'Malley have figures for the number of people who have died?
Catherine Noone (Fine Gael)
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It is great to have Dr. O'Malley here. I thank her for the important work she does. As the Chairman said, we have invited her in at the outset to highlight the seriousness of this problem. I have felt for a number of years that I have been bashing my head off a brick wall in raising this issue. It is starting to come into focus now. I am grateful to the Chairman for putting it on the committee's agenda. Dr. O'Malley has given us a list of organisations that should ideally attend the committee's hearings on this issue. Perhaps we have already invited many of them. I think the Irish College of General Practitioners needs to come before us. Surely the introduction of free GP care for those under the age of six gives us an opportunity to track the likelihood of obesity arising in a child. I understand that children are first weighed by GPs at the age of two. Dr. O'Malley will correct me if I am wrong. Does she think we need to face up to issues of societal embarrassment when we are dealing with families? There is a reluctance to ascribe fault. GPs should be able to tell parents that their children are becoming obese and that they need to do something about it. A more mature approach to children's health needs to be taken at that stage in order to prevent them from being brought to Dr. O'Malley at a later stage. Surely the fewer children she sees, the better.
As a member of the British-Irish Parliamentary Assembly, I suggested that the assembly should prepare a report on this issue. There is a lot of useful stuff in the report, which was published recently. I am not sure whether my assistant sent it on. The assembly usually confines its activities to Scotland, Ireland, England and Wales. Representatives of those nations chat to one another about issues that affect them. I argued that there was no point in talking to one another in this case because we do not know what to do where childhood obesity is concerned. We decided instead to go to Amsterdam to examine the localised cross-departmental approach that has been adopted there. Obviously, there is some childhood obesity in the Netherlands. It is really interesting that local government has got involved in this issue in the Netherlands and I think we should look to mimic that approach. The main point I took from our meetings is that patience is the big thing we need. This problem did not develop overnight. It will take a long time to sort it out. Therefore, policymakers to be mindful of its gravity and complexity. I am tired of listening to colleagues in the Seanad and elsewhere saying that children with childhood obesity are just fat and if they eat less, they will not be fat. It is not that simple. I am grateful that there are psychologists here who can speak to that. I ask Dr. O'Malley to respond to the two points I have made.
Dr. Grace O'Malley:
Self-monitoring is part of normal practice that should be done everywhere. The HSE's "Make Every Contact Count" initiative is definitely a welcome one. It would be interesting to examine how GPs are resourced in the Netherlands by comparison with Ireland. As far as I am aware, the current contracts here do not provide for any treatment. That definitely has to be looked at. We cannot expect primary care practitioners to deliver treatment when they are not paid to do so. These patients definitely need to be treated by GPs and public health nurses, but the resourcing to facilitate this has to be guaranteed. There is no point in a family picking up the courage to go to see a GP who might not attach any priority to a patient in respect of whom he or she is not able to be paid. If a family gets a negative response or is not treated with the same dignity or respect that another patient would be treated with, there will be a reduction in that family's interest in attending again. The Senator has mentioned stigmatisation, which is a huge issue. Dr. McGuire will probably want to speak about this. We have done a lot of work on stigmatisation across all of our society, including the Government and the media. We need to have stricter rules on bullying people who are of a different shape. We have rules and laws that prohibit bullying based on gender, race and sexual preference, but nothing of that kind applies to body shape. To me and to my team, it is unacceptable that somebody of a certain shape should be bullied and stigmatised.
Ms Michelle Strahan:
I would like to speak about the complexity of these families. The families we see tend to have huge psychosocial issues and financial pressures. Improvements in areas like childhood poverty and family finances would help families to make some of the changes they need to make. I reiterate that this is a hugely complex issue.
Catherine Noone (Fine Gael)
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Approximately what percentage of these families are from that demographic?
Catherine Noone (Fine Gael)
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That is a huge percentage. There is a significant psychological element to this issue. Obesity can affect a child regardless of the family from which he or she comes. People say that it is the responsibility of the parents. As I know, one can have the best parents in the world but still end up with this problem. Sometimes it becomes an issue before parents realise it is happening. It is very difficult to know what to do at that point because if one clamps down hard, one could potentially give one's child many other issues. The child could become anorexic or bulimic. It is a very delicate balance for a parent.
Ms Michelle Strahan:
In some cases, there are other siblings who might not need the same kind of attention with these issues. It is hugely complex for families, especially if there are financial stressors on top of that. If a family that is struggling to pay the rent or to meet the cost of healthy eating manages to get a referral to a tertiary service like the one we provide, or an appointment in Temple Street, can it afford to pay to get a train to Dublin to attend such groups? Basic factors like that make things much more complicated for families.
Catherine Noone (Fine Gael)
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I have a few more questions. Can Dr. O'Malley tell us about a typical patient who is attending her services in order that we might learn more about how the life of a particular child unfolds when he or she has this problem?
Would Dr. O'Malley like to tell us about any particular child who sticks out in her mind?
Catherine Noone (Fine Gael)
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Of course. I would not like Dr. O'Malley to identify them.
Catherine Noone (Fine Gael)
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It can be very clearly identified.
Dr. Grace O'Malley:
Absolutely. In the case of a child on the more severe end of the scale, there may be parental mental health issues which may or may not be dealt with. The parent may not be accessing services and the child will often have a mental health issue as a result. This may not be a priority for the child and adolescent mental health services because it may not reach a threshold at which it will be deemed a priority. Because of these issues, however, such children may not be going to school. Educational achievement is incredibly important for health outcomes in the long run.
We see that kind of mix from a mental health point of view. From a physical health point of view, our general understanding of this issue is "move more, eat less". However, these kids will experience pain, so they are not able to exercise. As they may not be confident moving or competent in their motor skill, they are not the kids who want to join sports. They will be sidelined at PE or, depending on the ethos of the school, they may not be encouraged to participate because they do not achieve well in movement and games.
As human beings, we all know that food has a multitude of uses for us. We use it to nourish ourselves to help ourselves grow but we also use it to soothe ourselves. If a child grows up in an environment where food is used as a reward or where it is used to sedate or placate, a cycle is set up very early. As a society, we still think very simplistically about obesity. The new Horizon 2020 research call includes funding in the area of endocrine disruptors. There are huge issues around pollution, which can disrupt how hormones work within the body. Water pollution, air pollution and plastics within our food system can affect us. The same is true of ultra-processed foods. It is like climate change. The child or adult is a physical manifestation of the environment in which he or she is living. This does not just include the family home. It pertains to people's own biology, the family home and the society they are living in.
Catherine Noone (Fine Gael)
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I would like to ask about the role played by supermarkets and food producers. We will have a lot of these people before the committee. In advance of that, I am interested in Dr. O'Malley's perception of their role in this regard. I did some research on the deals available in supermarkets and how likely they are to drive consumer purchasing. Does Dr. O'Malley have any comments to make on that area?
Dr. Grace O'Malley:
Unfortunately, our senior dietician could not join us today. I am sure she would have some really interesting observations from a dietetic point of view. As part of our treatment, the dietician leads a supermarket trip where she brings families to the supermarket to learn how to read food labels and how to shop. We take it for granted. Speaking for myself, if we grow up with a privileged middle-class lifestyle, we do not really appreciate the skills we glean by osmosis when surrounded by capable, skilled parents. There is definitely an issue around the promotion of unhealthy ultra-processed products. The sugar tax is definitely going to help that, but we need to evaluate how promotions change within supermarkets. As the cost of one beverage goes up, are they promoted differently? We must also examine how they are marketed. The Sydney principles call for the regulation of food marketing to children but we have not been very good about moving on that in Ireland. The Irish Heart Foundation, whose representatives the committee will hopefully invite, has done a lot of work around online advertising, which is hugely important.
In the realm of technology, retail stores are now using really pervasive techniques to draw people into the retail environment. Because the child is not really protected in the online world, there is even more vigorous marketing towards children. There is a big difference between different supermarkets. Some are much better at providing a balance between healthy foods and ultra-processed foods, but when one walks into some corner stores and local shops, one is confronted solely by ultra-processed food. That has to be addressed.
Catherine Noone (Fine Gael)
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Dr. O'Malley mentioned the sugar tax. Obviously its efficacy remains to be seen. Does she think we need to have a sugar tax on more of the items available in shops? Experts have said that if there is one item we should tax, it would be sugar-sweetened drinks. The big effect of that, even in advance of the tax's implementation, is the reformulation. A lot less sugar is going into foods because at the end of the day, these companies want to sell their products. It is all about profits. At the same time, there are still super-sugary milk drinks. God forbid we touch the dairy industry in Ireland but where do we go with this? As policy makers and regulators, there is only so much we can do without creating a complete nanny state.
Dr. Grace O'Malley:
Last year, the Government had the courage to bring in the sugar tax. We have to let that embed and must evaluate it. We do need a process by which to evaluate that sugar tax. Evidence shows that consumption can be affected by putting a tax on sugar-sweetened beverages. It is important to evaluate how that affects the economy and how it affects attitudes. As Senator Noone mentioned, reformulation has already started. That is a huge success already. Even before a tax take, we have seen a change in behaviour by industry, which would not have happened had the Government not given a strong signal. With regard to taxing other foods, we have to give this enough time to embed and evaluate it, to look at evidence internationally and see where we are going but that is a really positive sign. It is a brave step.
Catherine Noone (Fine Gael)
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What is happening with teeth? I hear about children having operations. Although I have not spoken to her in a long time, I have a friend who is a paediatric dentist. Children are having a lot of their baby teeth removed and then having their adult teeth removed. Does Dr. O'Malley deal with that? Obviously she is not in the dental area, but a referral from her must often be made to-----
Catherine Noone (Fine Gael)
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She would have the same views as Dr. O'Malley about the part-time nature of her role.
Dr. Grace O'Malley:
Absolutely, yes. She has been really active in advocating for liquid sugar reductions. We know that dental caries have increased. Separate to any influence on weight, having sugar-sweetened beverages will increase dental caries. The UK ran a study last year with the World Health Organization, WHO, examining sugar limits. The current guidelines are already too high to try to address. In the UK National Health Service, NHS, dental caries is one of the highest cost burdens. For the reduction in dental caries alone, forgetting about the long-term effect on weight, the sugar tax will be positive. However, we have to be able to evaluate that.
Catherine Noone (Fine Gael)
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It is hard to be a healthy adult when teeth are compromised at a very young age.
Catherine Noone (Fine Gael)
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I could be here all day.
Denise Mitchell (Dublin Bay North, Sinn Fein)
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I thank the witnesses for the presentation. I have a few brief questions. Where do the referrals come from and is there a geographical spread across the country? If a child attends the team's clinic and he or she is discharged, is there any community support for him or her afterwards? Another question concerns the programme itself. Can the witnesses tell us a little bit about what is actually involved? What does the programme do? Perhaps the witnesses can go into some detail.
I am of the opinion that this issue, like the topic of our previous report, will have implications across Departments. We have to look at it like that. I seek the witnesses' opinion on a few points. Local authorities have designated no-fry zones, particularly around schools, and the unhealthy vending machines have been removed. Where does Dr. O'Malley see this committee helping other Departments with ideas? I will touch on another issue. Am I correct in stating there is a waiting list of two and a half years for a child to attend the team's clinics?
Is it correct that the clinic has had only five children from a homeless background?
Denise Mitchell (Dublin Bay North, Sinn Fein)
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Will the witnesses give a breakdown? The number of homeless families with young children is rising. How many children from a homeless background come to the clinic?
Dr. Grace O'Malley:
We do not have accurate figures at present. It is only within the past month or two that we have formalised our assessment and we now note it.
I will respond to some of the questions and then my colleagues will comment. We are a tertiary hospital and all referrals from GPs, area medical officers or other hospitals come to a consultant, generally to a paediatric consultant or sometimes into endocrinology. We then receive referrals from a hospital consultant. Approximately 12% of our referrals come from the accident and emergency unit; 10% come from orthopaedics and then the majority, 40% to 50% come from general paediatrics and endocrinology, cardiology and a few other services.
Denise Mitchell (Dublin Bay North, Sinn Fein)
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Does Tusla refer patients to the team?
Dr. Grace O'Malley:
Anybody who would be connected with Tusla would be referred to the hospital via a hospital consultant first. In tertiary care all patients are under a hospital consultant and are then sent wheresoever they need to go in the hospital.
We offer group treatment for families who can be treated in a group scenario. That depends on where they live, the age of the child and how the child and the parents are functioning. If they are able to work in a group dynamic, we encourage that because we get a peer effect. It is really helpful for parents to learn from one another and the teenagers and children learn from one another.
For 60% of our patient population, we see them in one to one clinics. That is more of a traditional outpatient clinic. The child first comes to the hospital and is seen by a consultant paediatrician, an endocrinologist or another medical consultant. The consultant then refers the patient to us and we see him or her in an assessment clinic. Such children will have screening from a physiotherapist, a dietician, and a psychologist. We very much believe in holistic assessment in order that we can really try to unpick what is the factor for this family that is important. Our treatment comes out of that.Sometimes the child is eating very well and the family is fully educated on how to eat well but there may be an issue around sleep, there could be real stressors in the family and it may be an issue that is for a psychologist or for mental health. Very rarely there are genetic conditions but that is dealt with in a different situation. At other times, it is more of a social problem and we have to try to link in. My colleagues, Dr. Sarah McGuire and Ms Michelle Strahan will speak on how we link in with other community supports. There is no step-down service for a child with obesity.
There is a wonderful team working in Tallaght community and we can refer patients to them, if the child lives in that area. That is the problem with community services. One has to come from that community to access services in the community. There may be dieticians working in areas around the country but there is no standardised acceptance of referrals. Unfortunately the paediatric dieticians are under such pressure that they have to prioritise children who are peg fed, that is, where the child is fed through a tube in their stomach. If those children have complex disabilities they will be seen before children with obesity because there simply are not enough posts.
Ms Michelle Strahan:
Deputy Mitchell mentioned Tusla. We make referrals to Tusla if we feel there is a risk to the child's welfare in the future. Sometimes we can link them in with some additional services as a result of that, for example a family support service. That is usually when there are other issues going on in the family as well. It is not just that we can refer on to them as a follow up.
Dr. Sarah McGuire:
In terms of mental health, some 60% of the children who present have some form of psychological issues and of that, 40% are significant or severe. We have some provision for one-to-one psychology if it is related to emotional eating or directly related to a barrier to making positive lifestyle change. If the issue is primarily mental health, we would be referring the child to the local child and adolescent mental health service. Access to that service is dependent on the waiting list.
Children who have a history of self-harm or suicidal intent are more adequately placed in the child and adolescent mental health services, CAMHS. Consequently, we sometimes must conduct a review and refer them on to CAMHS, requesting an urgent appointment. Access to those services is all determined by waiting lists as well.
Dr. Grace O'Malley:
Some communities will have cookery programmes and other activity programmes from the physical activity co-ordinator. We can refer to those when they are accepted. The administrative time it takes to figure out what is available in every community in the country is really difficult. It would be really helpful for teams like ours that operate out of one site if there could be a national database of what is available, where it is located and the acceptance criteria to get on a programme.
Ms Nicola Sheridan:
May I interject? I may have a tiny bit of silver lining. We often see after group, that children who hate PE and physical activity get the confidence to move. They become involved in groups locally. It might be that they go back to a team sport, which is less likely, but they often get involved in activities such as swimming, boxing or a teen gym because this is the first time they have ever had a positive physical activity experience where they are exercising together with people who are the same as them. There is no bullying, they are enjoying the experience and they can see the positivity of physical activity. That can take them into the community to an extent.
Tom Neville (Limerick County, Fine Gael)
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I have a number of issues that I wish to have clarified. I am coming to this issue from a mental health background. The witnesses mentioned co-morbidity. I am doing work on co-morbidity, be it alcohol or substance misuse and mental health issues. That would be the first focus in respect of what the witnesses mentioned about co-morbidity and what they would see as a solution to tackle it. From what the witnesses have said, these unfortunate patients may be falling between two stools. The same is happening with the mental health and addiction services. There are movements within the Government to address that. I seek a comment from the witnesses on that because it might be a way to highlight this issue, as well as other eating disorders. We tend not to think of obesity falling into the category of anorexia or bulimia. If I am using the wrong terminology, excuse my ignorance.
May I clarify whether the witnesses mentioned that approximately 40% come from the lower socio-economic background?
Tom Neville (Limerick County, Fine Gael)
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Will the witness clarify how the other 60% is broken down, if they have any figures around that?
The witnesses mentioned that it is a growing epidemic over the past ten to 15 years. Will they outline the top three or four reasons why this is such a phenomenon now, as opposed to years ago?
From the witnesses' experience in other jurisdictions where they have a sugar tax, do manufacturers actually alter their products by deviating from sugar but using alternative products that may be as damaging?
The witnesses have spoken about people who have issues with body image How much does the body image on social media play a part in this and can they give me an outline of what is involved?
Dr. Sarah McGuire:
In terms of the mental health, as I said about 60% of children and teenagers have a mental health component to their presentation. It is very complex. The children we see present also with a lot of internalising problems. They may have anxiety, for example, or become very withdrawn.
Sometimes they might refuse to attend school or leisure activities that they once loved. As much as 75% of that population experience some form of bullying with 10% of that being very severe, which has a huge impact on self-esteem. It is very difficult for families to be armed with education but then be expected to manage all of these issues. Parents are tasked with supporting those issues as well. They have a huge role to play in managing those issues and spearheading some of the management at home. That is why the unit is more family orientated and parents attend as well. Children with low self-esteem and maybe suffering anxiety too cannot be expected to run with all of this matter. There is an onus placed on parents to support their children throughout the process.
Dr. Grace O'Malley:
Comorbidity is comprised of two parts. First, I shall outline the physical comorbidities that go with obesity. Amazingly, the human body is able to store fat in every cell of the body, which is why the human race has survived so long. Unfortunately, it means that every organ of the body is affected by obesity. Unlike most other conditions, with obesity children and adults present with multiple comorbidities. In other words, heart problems, breathing problems, liver problems and mental health problems, which increases the complexity of the condition.
Second, there are social comorbidities that go with deprivation. We have encountered homelessness, parental anxiety, depression, financial distress, and sometimes substance abuse, and also unsafe neighbourhoods. There is a huge difference if a child grows up in a deprived area in Ireland. For example, advertisements and the food environment seem to be quite different.
Tom Neville (Limerick County, Fine Gael)
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What does Dr. O'Malley mean by different?
Dr. Grace O'Malley:
In general, there is a higher density of food marketing if one lives in a lower socio-economic area. Such areas also have more billboards and instore promotions for ultra processed foods when compared with higher socio-economic neighbourhoods. There is a greater density of fastfood outlets.
Tom Neville (Limerick County, Fine Gael)
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Is that driven by the marketers? Obviously it is.
Tom Neville (Limerick County, Fine Gael)
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Perhaps Dr. O'Malley cannot answer such a question.
Tom Neville (Limerick County, Fine Gael)
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Are the marketers practising market segmentation? Do they market processed foods to a lower socio-economic demographic because the people may be unable to afford to pay for unprocessed food?
Dr. Grace O'Malley:
Yes, potentially. The Deputy mentioned the no-fry zone. The call to limit fastfood outlets in areas of high socio-economic status is different from people who do not have as much of a voice in the public forum and where there is a greater density of fastfood outlines in lower socio-economic areas. The issue must be addressed by planners using a whole-of-government approach. The EU is considering the matter and it is an issue for all of Europe.
Community supports and mental health services have been mentioned. Understanding what the acceptance criteria of these services are is really important. Why do some services accept children with certain conditions but some will not even though they all receive funding from the public purse? We believe that every child needs to be able to access a service. Of course we accept that there must be prioritisation. If professionals have not been trained in a certain area, such as mental health services and obesity, then it must be acknowledged that the professionals need training and, importantly, such training must be provided.
In terms of determining the percentage of obese children who come from low socio-economic status, it is very hard to collect the data in a hospital. The only data that we have access to is the child's address, whether the child attends a DEIS school and, perhaps, whether he or she has private health insurance or a medical card. Collecting the data is not as easy as saying we think it is a certain percentage. Without questions around parental educational attainment, maternal educational attainment and income, it is very hard to get good data. We can use small area research unit data, based on the child's address, of whether he or she is from an area of disadvantage. We have stated that the percentage is in or around 40% but we extrapolated the figure from data that is four or five years old. The percentage may now be higher.
Tom Neville (Limerick County, Fine Gael)
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Let us assume 40% of the children are from a lower socio-economic area. Are the remaining 60% of children from a different bracket? Are they more from the middle classes?
Tom Neville (Limerick County, Fine Gael)
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Are the majority of children in the middle classes?
Tom Neville (Limerick County, Fine Gael)
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That percentage contradicts the argument made about take-aways being marketed more to lower socio-economic areas.
Dr. Grace O'Malley:
We can only comment on the children who present at our unit. Let us consider national representative data such as Growing Up in Ireland - National Longitudinal Study of Children or the Childhood Obesity Surveillance Initiative, COSI. That data is representative data for the whole population and is, therefore, more accurate. It shows that children who attend DEIS schools are twice as likely to be obese. The W82GO! unit only sees the children who have been referred to us and the ones that come straight to the unit. If we have referrals of more children who live in a more deprived situation then they may be the ones that cannot come to the hospital and, therefore, do not attend. We can only comment on who we see.
The Deputy referred to the fact that obesity has increased over the years. Without question, the food environment has changed in the past 20 years. I do not think anybody would disagree with such a view. More ultra processed foods are available and marketed, particularly to vulnerable groups such as children. Sadly, children are considered to be a vulnerable group. Also, physical activity has decreased throughout our society. In terms of running, there is more litigation in schools. The matter must be considered. One cannot have a situation where children are not allowed to run about during break time at their schools due to a fear of litigation. Internationally, there is a sleep debt. It has been discovered that people sleep two hours less now compared with 50 years ago. A proper amount of sleep is important if one wants to manage hormones that affect weight. Children sleep less due their use of technology. I know that some Oireachtas committees have recently discussed technology usage by children. It is important that all of us switch off our mobile telephones at night in order to protect our health. There are more online advertisements, and people spend more time online and have more screen time. All of these issues feed into how bodies gain weight. Social media is another issue.
Tom Neville (Limerick County, Fine Gael)
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Do the witnesses think that people are more indulgent, as a society? I recall that my parents ensured that I knew a chocolate bar was a rare treat. They also did not buy large bags of sweets, chocolate bars, etc, or fall for instore promotions. Are people nowadays bombarded by marketing or whatever?
Tom Neville (Limerick County, Fine Gael)
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I am talking about society in general and I do not take away from the mental health issues associated with obesity.
Ms Nicola Sheridan:No.
Dr. Grace O'Malley:
We tend to expect more and maybe have less tolerance for the word "no". I am not referring to our patients. I mean all of us, as a society.
The Deputy referred to a nanny state. If we had not adopted such a view to the tobacco industry then we would not be in the good situation that we enjoy now. I personally think if we are looking after vulnerable people one wants a nanny. One wants someone who is qualified, knows what he or she is doing and has the best interests of the vulnerable person at heart. It seems I have a different perspective about the nanny state. I believe it is necessary if we want to protect public health.
Tom Neville (Limerick County, Fine Gael)
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Education is an important way to promote health eating.
Tom Neville (Limerick County, Fine Gael)
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Yes.
Tom Neville (Limerick County, Fine Gael)
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Let us discuss stigma. My question may be difficult to answer because what I am about to say is anecdotal. In terms of mental health, it seems young people are more open to discussing mental issues than the older generation. That means the stigma, by proportion, has reduced. The stigma still exists and is very prevalent. Do the witnesses believe the stigma associated with obesity is greater than that associated with mental health?
Alan Farrell (Dublin Fingal, Fine Gael)
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The witnesses' opening statement made for stark reading, particularly some of the statistics provided for our assessment. It occurs to me as someone who will go through this process with his colleagues over the next number of months - it could be six or seven months and well into the autumn before we complete it - that, when trying to figure out how to approach it and what the best model would be, there are three or four main themes, those being, food intake and education, psychology, and health, exercise and activity. If the witnesses put themselves in our shoes for a moment, how would they approach it? From my perspective, it is not just about physical activity, although that is an important aspect. A fear of litigation was mentioned. That situation is crazy. While I was in a primary school in my constituency not that long ago, I heard a teacher roaring "stop running" as I walked through the yard. I wondered why anyone would stop a child running. I would not mind, but it was on grass. I thought it might be the small break and the school had that element of discipline so I did not interfere, but it appeared strange. I did not remember it happening in my yard. I still have some of the scars on my knees from my old school yard.
This is an issue with which we need to try to get to grips. We must try to break the cycle of screen time and the other elements that the committee discussed in our previous reporting.
On the healthy eating side, ease of access to foodstuffs that are saturated in fat, sugar or worse is an issue. I noted the interesting discussion between Senators Noone and Reilly and Deputy Neville on sugar tax and its effectiveness. I was always concerned that a sugar tax might have a detrimental effect on certain socioeconomic groupings. That remains to be borne out, but it is positive to see the industry taking the initiative and opting for drinks that are less sugar sweetened. Senator Noone has done considerable work in that regard, at least from the perspective of public perception. It is noted and appreciated.
The other side of the situation is the question of psychological issues with food and food intake, be those relating to bullying, the body image issues that Deputy Neville alluded to or a failure to parent, which might be an abuse in itself or a result of abuse or lack of knowledge about how to parent in respect of food intake. There are multiple strands.
If the witnesses were involved in the process that we are going through, what steps would they take? Would they follow this thematic approach? Do they have suggestions?
Dr. Grace O'Malley:
Our action policy is excellent, so the committee should examine the policies that are available. That is important for implementation. The committee should link with the European Association for the Study of Obesity and the World Obesity Federation, which have considerable European and international experience of what are the low-hanging fruit that governments can pick. It can seem like there is too much to do.
Prevention and treatment must go together. We must look after children who are already obese and give them what they need to prevent progression. These are the kids with a red flag over their heads who will cost the health service more. There must also be prevention efforts. I agree with a sugar tax, but the provision of water is a significant factor and is included in the obesity policy. There should be an option in schools to drink from water fountains and to make that the norm. Often, we meet families for which the idea of drinking water is-----
Dr. Grace O'Malley:
Yes. They think that water is from the toilet. I have had children say that. Their understanding of water as a drink is not there.
The Government's approach to transport is important. Neighbourhoods could have walking school buses that facilitate walking to school. Online advertising is a major issue, and with the GDPR coming into force in May, the Government must be courageous on this front and protect people, particularly those under 18 years of age. As we discussed with Deputy Neville, planning is a further issue. We must ensure that we are not adding consistently to a food environment that encourages obesity.
When these legislative pieces are in place, industry will respond like it did with the sugar tax. There are many aspects of the food industry that are positive. For example, Ireland's fruit and vegetable growers are among the best in the world and there is a significant opportunity for them to tap into this market and encourage whole foods.
There is a large amount of data on what is the best approach to take initially. The Health Research Board-sponsored Centre for Health and Diet Research between UCC and UCD would be delighted to present its evidence to the committee, as would the Institute of Public Health in Ireland.
Alan Farrell (Dublin Fingal, Fine Gael)
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The need for a database of available services was mentioned. I presume that would be co-ordinated by the HSE. I cannot identify them, as I do not have a grip of the level of services across the regions, but I know of certain facilities that are available locally. Given the proximity to Dublin and Temple Street Children's University Hospital, we are fortunate to have that type of service available to us on our doorstep, albeit with significant waiting lists.
Regarding the proliferation of the types of service that will be required in future, the witnesses referred to the - I will not say "slow" - gradual process of eliciting interest in a subject matter such as this and how that might pose issues in terms of recognising if we are at epidemic levels or whether that is just a phrase used in the media. Maybe we are. We must qualify what an epidemic is and its significance in terms of its effects across the board on the State's ability to provide the level of medical and other care that is necessary. Are the witnesses aware of any programme whereby the State is in the process of providing the level of service that is required within each geographic district of the HSE? Has there been any call for the provision of the types of service that the witnesses would view as basic for children and young adults in particular, but also for their parents? One usually follows the other.
My final question is a societal one. The point about there being less tolerance in a nanny state was made. I see that in virtually every aspect of what I do. In the 15 years I have been doing this, people's traditional expectations of the services provided versus what is now the norm have graduated to the point of disbelief on my part. Is there a clinical way that this can be dealt with at the point of a young child's entry into the witnesses' facility? How would they tackle that? What level of involvement would they have with the child's parent? For example, would they tell him or her to say "No"?
This is a broad subject matter. I began looking at it and reading about it a month or so ago. I thought I could be reading for a month. The question of how to tackle it is important.
I have certainly gained a lot of insight. The opening statement and remarks have been incredibly useful.
Dr. Grace O'Malley:
From my perspective, the longitudinal studies - the Childhood Obesity Surveillance Initiative Ireland and Growing Up in Ireland - are essential from a population point of view so making sure they do not lose funding is really important for all aspects of health. We do not have a database. Investment in technology in the health service is very limited. Going towards the new children's hospital, it would be a very opportune time to develop a database that could be used and that could also link in with GPs. It is a huge ask technically because we then need unique identifiers. Trying to get that sorted has been challenging. We need a database as we would for rare conditions or infant deaths. In 2014 and 2015, we were involved with the HSE in training community practitioners in four areas of the country. It was a pilot initiative to see whether we could work with some community health care professionals to provide services locally. It was a really interesting project. We were very much operating on a wing and a prayer. It did not involve a huge amount of planning or communication around how we might get the best outputs from it but the community teams were really wonderful. They were very committed and we did our best to try and set up a system of sorts. What came out of that was some really valuable information about understanding the community and working with it before trying to say "do it this way" and understanding the needs of that community. From that work, we have a template on how we might go further. In 2014 and 2015, the Government and the HSE did commit some funding to experiment a bit. We got a lot of learning from that and we can build on that for a hub and bespoke model or to improve community services in the future.
Failure to parent was mentioned. We very rarely see a failure to parent. It is usually around capacity issues or opportunities for parents to parent because often both parents are working shift work and there is very little time when the parents are actually in the home in many cases. We very much work with parents. From a young age, we are working with parents and linking parents in with parenting programmes around how to say "No" and behaviour. Dr. McGuire will probably have more to say.
Dr. Sarah McGuire:
As we mentioned earlier, many parents might come from low socioeconomic backgrounds or have huge psycho-social stressors so they have other issues going on as well. Tackling this can be very overwhelming. A lot of the work we do involves supporting them to set smaller goals that are reachable and the inherent reinforcement that comes from reaching the goal allows the children to make progress in modelling that within the house. Maybe they have to make systemic changes in the house such as not bringing in treats. It becomes about the whole family as opposed to just the one person. Families tend to need support with that even to get started initially. When they come to the initial group, they are able to go away and put in some of those changes but they do need support around it in respect of getting started, keeping that motivation going and setting realistic goals.
Catherine Noone (Fine Gael)
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I have no problem with the nanny state policies, as my colleague knows well. I got an award recently for being Queen Nanny from a smoking group and actually turned up to receive it. I am all for whatever measures need to be put in place. There is a fine line between us actually taking over the parenting of children as a Government. Once a child is obese, it will be an issue for them in the vast majority of cases.
Catherine Noone (Fine Gael)
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It could even be more than that. Dr. O'Malley is the expert but I would say that once those fat cells are created, the person is constantly fighting that. They are fighting their body's wish to get back to what it was. I have heard Professor Donal O'Shea talk about the body's memory and wanting to get back to that space. It is clearly so important that we deal with this. Bariatric surgery is a big issue for the witnesses. Am I missing something? How short-sighted is it that we do not take care of these more quickly so that they do not cost the State much more in the long term? Can the witnesses explain something? Am I missing something? Who is missing something here?
Catherine Noone (Fine Gael)
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And the adults as well.
Catherine Noone (Fine Gael)
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If anything, the attitude is worse.
Catherine Noone (Fine Gael)
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When Dr. O'Malley says stigma, she means the stigma that health professionals working in the HSE or in the services generally display towards adults or children with obesity-----
Catherine Noone (Fine Gael)
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-----that they have eaten themselves into this situation so good luck to them. Meanwhile they must have supports in place for diabetes, cancer and all of these other conditions they will get over the course of their lifetime if something is not done at an earlier stage. It is an absurdity.
Catherine Noone (Fine Gael)
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It is the end stage.
Catherine Noone (Fine Gael)
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A lot of the time they get it and manage to circumvent-----
Catherine Noone (Fine Gael)
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We need to be really careful with the language we use in this space to say that parents are not doing well in certain circumstances. Do the witnesses think there is something to be said for the idea of having compulsory parenting programmes in this country? Is that a step too far? I have gone full-on nanny now but it is pretty serious.
Dr. Sarah McGuire:
Some parenting programmes operate in some places, although specifically for obesity, for example, there are The Incredible Years and Parents Plus. In some instances, some of the DEIS schools will facilitate that. The take-home message, if there is one, is that these children and their family situations are really complex so it is not necessarily passive parenting. There are so many different elements to it. Something we have also noticed is that these families need access to professionals because giving them the information in and of itself is not always enough to run with.
Catherine Noone (Fine Gael)
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The witnesses are dealing with the worst situations. We, as policy makers, are conscious of both children and adults and how an obese child can end up an obese adult; even if their mother is obese when she pregnant, there is a high likelihood that the child will be obese. A very interesting point was made about water. On a positive note, one thing we got from Amsterdam was that it got these bottles, got children to design engraving and made drinking water cool rather than just acceptable or knowledgeable. Drinking water has become cool because they have these special bottles. If as a society, we work on all the little things, eventually, with a lot of patience and hard work, this issue might start to reduce rather than increase.
Catherine Noone (Fine Gael)
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I think we learned from the road traffic stuff that when levels plateau, the focus goes a bit and levels start to go back up again. This will take years to sort out.
Alan Farrell (Dublin Fingal, Fine Gael)
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That was a very interesting discussion. The witnesses' presence and answers to our questions have been very much appreciated. Before we adjourn, I note on behalf of members my appreciation for the services of Dr. Emer Crooke. This is her last meeting as clerk of the committee. I note with appreciation her professionalism and courtesy over the past number of months in assisting me in the performance of my duty and indeed all members. On behalf of the members, I thank her and wish her all the best in her new role.