The next item is item 10—the short debate. And I call on Jenny Rathbone to speak to the topic that she has chosen.

Slides were shown to accompany the debate.

Diolch. Thank you very much, acting Presiding Officer. I've chosen the topic of 'Is obesity a disease?' (a) because today is World Obesity Day, (b) because today the Royal College of Paediatrics and Child Health reports that obesity continues to rise, and it remains the case that over one in four four and five-year-olds are obese—a pretty damning and sobering fact. And thirdly, when I met Novo Nordisk last week—a pharmaceutical company best known for their work on diabetes—I was asked whether I considered obesity to be a disease, and I said I'd need to think about it and get back to them. The reason for my reticence is that I was reluctant to medicalise what I've always seen as a social, political and economic problem, generated by an obesogencic food industry, and the overbearing dominance of the motor car over the last 60 years.

So, what is obesity? It may be rather hard for you to read but I'm very grateful to Rachel Batterham, who's the professor of obesity at University College London, for allowing me to use some of the slides from her recent presentation to the Royal College of Physicians, who, as you may recall, are the organisation that have led the way on getting the ban on smoking, and are also campaigning very, very hard on getting a ban on ensuring that we deal with the alcohol industry as well. So, the Royal College of Physicians is an important organisation. Anyway, the definition of obesity, which is a worldwide problem, is a disease in which excess body fat has accumulated to such an extent that health may be adversely affected.

It isn't just an inconvenience—obesity actually shortens your life by between three and 10 years. Obesity prevents people from living well, and we spend 10 per cent of the NHS budget alone on supporting people with diabetes. You may not be able to read the slide, but it doesn't just cause diabetes of the type 2 variety, but also cardiovascular disease, stroke, high blood pressure, coronary artery disease, and heart failure, and many other things besides, including infertility, incontinence, depression, anxiety and asthma.

Few people would argue, then, against the need to reduce obesity, given its life-threatening impact. Indeed, it has the capacity, in my view, to overwhelm the national health service. Now, the answer apparently is simple: if we eat less and exercise more, we get a proper energy balance, and we retain the right weight for our size. In the 1940s, the health advice was to sleep at least eight hours a day, ensure you do recreation—i.e. a complete change from the daily work, for the body and mind—the right food in the right quantities, and regular exercise. And that, during the second world war, was when the population was at its healthiest—but that was down to rationing. But we can see that the political, social and economic landscape has deteriorated enormously since the 1940s, and obesity continues to rise and rise. How many of us adhere to the mantra of the 1940s today, in a world that never sleeps?

So, the question we have to ask ourselves is: is the Healthy Weight: Healthy Wales programme bold and radical enough to deal with the size of this problem, and reverse our obesogenic lifestyle? Wales is applauded by obesity experts for being prepared to use legislation to change the food environment, in contrast to the dither and delay at the other end of the M4. We have to stop the food industry from targeting children to eat the wrong things: that is completely unethical. And I also hope that we will be able to use the reregulation of the buses, which is coming up in the next 12 months, as an opportunity to also outlaw junk food advertising on public transport. I think it's very important that we use our public procurement muscle to ban junk food from our NHS health centres and hospitals, and I applaud Cardiff and the Vale health board for showing the way by removing all junk food from 13 of its hospital cafes and canteens, which it will be extending to its two community hospitals later this year. This initiative has actually increased their footfall and their profitability, and that shows that all health boards ought to be following that pathway, and I expect we will get a national hospital retail standard to promote the healthy options in all the retail outlets on NHS estates. Cardiff and the Vale have developed an audit tool to track that what they are delivering is what it says on the tin, which is pretty important given that if you're eating the wrong food, you're going to be costing the health service even more time and money.

So, we absolutely need to apply the same rigorous standards for public procurement in our schools, and I hope that the refreshed healthy eating regulations are going to have some teeth, because with so many of our children living in poverty, and families that are most vulnerable to choosing on price alone, even if nutritionally they are very poor value, it means that the free school breakfasts and nourishing school lunches are a lifeline for such children. In addition, the school-holiday eating programme ensures that these same children are not starving during the school holidays.

So, I want to see governors and local authorities being much more rigorous in ensuring that what is being served up for children in our schools is compliant with the healthy-eating regulations. Estyn has a sort of hands-off role in this, in ensuring that governors and local authorities are doing that job, but don't themselves inspect, and in my experience, there's a great deal of work to be done in that area.

Now, obviously, it isn't just our relationship with food that needs to change, it's also that we need to do more physical activity. I know that the Deputy Minister is leading the charge on ensuring that £30 million in next year's budget allocated to local authorities to increase active travel routes will be used not just on nice-to-have tourist paths, but is starting to shift the obesogenic environment dominated by the car. In Cardiff, Ysgol Gynradd Gymraeg Hamadryad and Howardian Primary School have led the way on having active travel plans, but we really do need to expect all schools to have them in place as well. And I wondered, therefore, what conversation the Welsh Government has had with local authorities about implementing vehicle exclusion zones around all schools, as recommended by Sustrans, so that all pupils have to walk, scoot or cycle to school for the last part of the journey. This, I feel, should be seen as an integral part of the package, to make 20 mph the default speed limit in built-up areas, and change the way we use our road space. That is what I assume the £4 million on the road safety grant will be applied to, and perhaps the Deputy Minister could clarify that, or, equally, the £5 million for Safe Routes in Communities grant in next year's budget as well. We have to recognise that children can be enthusiastic ambassadors for being more active. They can help the adults in their lives to adopt more active lifestyles.

While I fully support all these measures, I now need to address why obesity isn't just a condition caused by lifestyle choices that we want to reverse. We also have to treat it as a disease in the same way we do with diabetes or any other disease. First of all, the stigma attached to obesity. The UK Parliament's all-party group on obesity has released the results of a survey this week on the stigma associated with obesity. The survey confirms that people living with obesity face high levels of stigma, which impacts on their lives, work and leisure, their personal relationships, and their likelihood of seeking medical advice from their GP. Seventy-one per cent of people with obesity felt stigmatised when seeking health advice or support. Many people, including doctors, do not understand that obesity is a chronic disease. They see it as a simple lack of willpower, laziness or refusal to eat less and move more. But I think we have to challenge that attitude because it simply isn't acknowledging the extent of obesity, which has to do with more than simply environmental factors.

If we can't prevent obesity, then we have an ethical duty to treat it. Some of the treatments that we offer to people who are overweight or obese are frankly ineffective, as this summary of a whole host of research papers demonstrates, were you to be able to see it. The conclusion of these academic papers is that two thirds of the people who submit themselves to dieting regain more weight than originally, before they went on a diet in the first place. So, why is that? Well, I think that it has to do with the fact that, originally, we lived in much more difficult circumstances than we do today. We are hard-wired to treat dieting as a famine, for which the only rational response is to recover the weight lost as soon as the opportunity arises. In addition to that, some of the challenges people face are genetic. Whether we are thin or fat is highly influenced by the genetic make-up of our parents. Does that mean that, as more of the population becomes obese, more of the children that we have also become obese? We have to start thinking about what our response needs to be.

The most extreme response, if you like, is bariatric surgery, but it is recommended by the medical experts as the most effective treatment for people with severe obesity. A close friend of mine, no longer with us, did have bariatric surgery, and it certainly did transform his appearance, his weight and his ability to live an active life. So, I think there is an enormous benefit to classifying obesity as a disease, because it would ensure, then, that we have a clinical pathway for treating these very complex cases. Bariatric surgery for treating people with severe obesity is associated with sustained weight loss over 20 years. In 95 per cent of cases, it reversed the patients' type 2 diabetes and changed their relationship with food, as well as, self-evidently, making it easier for them to get around.

The Portuguese Government is the only Government in the world to officially recognise obesity as a disease, although there is a host of medical organisations who commend this as a way of improving the way we treat diabetes. Elsewhere, the Italian Parliament voted to recognise obesity as a disease following a campaign by the obesity and diabetes cross-party group.

To conclude, I think we have to recognise that for some people who have a genetic predisposition to obesity, the services need to be tailored to help those people avoid the most serious consequences. But that does not, and should not, absolve us from our political duty to address the social and economic causes of our obesogenic environment, which will otherwise reduce people's life chances and, in my view, could cause the NHS to collapse.

Thank you, Jenny. I now call on the Deputy Minister for Economy and Transport to reply to the debate—Lee Waters.

Diolch yn fawr. I'd like to thank Jenny Rathbone for keeping the spotlight on this important issue, from the work that she is doing on the cross-party group on food and the cross-party group on active travel as well as the work in her own constituency. She is continually highlighting the causes and consequences of obesity and is an important voice in our Senedd on these matters.

As she outlined in her speech, we already have around 600,000 adults aged 16 or over in Wales who are obese, and, more worryingly, 60,000 of those are severely obese. That number is increasing, with an estimated 10,000 more adults becoming obese each year. Over a quarter of the children in Wales aged four to five are overweight, including 12.4 per cent who are obese. These are disturbing figures. To directly answer the question that Jenny Rathbone has posed in this debate on whether obesity is a disease, that is a conclusion that the Royal College of Physicians have reached, as has the World Health Organization, which has classified obesity as a disease since 2016. So, in a sense, the question has been addressed by leading authorities.

We don't feel that recognising obesity here in Wales as a disease at this moment would lead to a different service response than we are already committed to taking forward. Our role is on the prevention and early intervention, as well as addressing some of the leading causes of obesity that Jenny Rathbone outlined, namely poverty, the environment and diet. For both adults and children, obesity rates rise with deprivation, with the prevalence 6 per cent higher among four to five-year-olds living in the most deprived areas, compared to the least deprived areas in Wales, rising to 13 per cent for adults.

Car-dominated streets contribute to our obesity crisis. Heavy traffic streets create what's become known as 'obesogenic environments'—places that discourage physical activity and contribute to the problem of sedentary lifestyles. One in four Welsh adults are now classed as obese, but that number drops significantly among those who are physically active. So, getting people out of their cars for short journeys produces multiple benefits, from cleaner air and less congested roads, to improved mental health and busier local shops.

And to try and answer the question that Jenny Rathbone posed about exclusion zones around schools, we have just refreshed the guidance for the Safe Routes in Communities project to put a far greater weighting on interventions that encourage behaviour change. And I've said that I met with all the road safety officers in Wales and set out my very clear expectations to them that we didn't simply want engineering-based solutions; we wanted solutions that were going to encourage modal shift and discourage car-based activities. It's now for them to come forward with proposals and we certainly would welcome proposals to have exclusion zones around schools where there's local support for that, and Jenny Rathbone is right: we do need to start thinking more radically about the type of interventions that we see around schools in particular. And it's my expectation, in the next round of maps—the individual network maps that local authorities produce next year for future active travel investment—that all schools in Wales be mapped on those plans, which will then result in infrastructure, linking them up to networks over the time of that planning period.

The food system, as Jenny Rathbone constantly reminds us, contributes to the obesity epidemic too. Easy access to cheap foods, high in salt, sugar, fats and additives, have encouraged a change in eating behaviour. So, to make a substantial impact will require a concerted and effective cross-Government approach, which is why we have set out in our 10-year strategy, 'Healthy Weight: Healthy Wales', published last October, themes around healthy environments and healthy settings. For example, we'll be consulting on legislation in the food environment over the summer, which will consider a range of future measures, such as price promotions, calorie labelling and drink purchasing. This is alongside investing in changing our physical environment in measures to encourage active travel and creating green spaces.

Obesity is significantly linked to health inequalities and we'll be looking at the role of behaviour change to encourage sustainable change. This is why we're developing targeted and tailored approaches, particularly with children and families. The risk of putting a disease label on obesity is that many people may feel that obesity will then be inevitable at a time when we want people to feel enabled to make healthy change—

Will you take an intervention?

I shall.

I just wondered how then you see us tackling the stigma, which the all-party parliamentary group picked up, because there's no doubt that people are feeling reluctant to approach their health professionals and partly because health professionals are not being sympathetic to the issue. 

Absolutely. Many people have told the Welsh Government about the daily stigma they have faced, which can be a prohibitive factor for them to make positive change, or patients being fearful of discussing their weight with a healthcare professional, as Jenny Rathbone has said. We will ensure that there is increased compassionate care within the NHS and that services are supportive and enabling. We know that having a consistent NHS response through the obesity pathway will help to play a significant contributory factor in this. However, what we cannot do is detract from the societal issues that we face to ensure that this is not an issue that defines the health of our population into the future. At this moment in time, we do not believe that treating obesity as a disease would help to change the momentum or the delivery that we will be taking forward through our ambitious approach through 'Healthy Weight: Healthy Wales'. Diolch yn fawr. 

Thank you. That brings today's proceedings to a close. 

The meeting ended at 18:51.