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A LACK of commitment from governments means Australia is “not even at first base” in dealing with the public health pandemic of obesity, says a leading expert.
Stephen Colagiuri, professor of metabolic health at the University of Sydney’s Boden Institute of Obesity, Nutrition, Exercise and Eating Disorders, told MJA InSight that the recent National Health Summit on Obesity had shown that the health community had a plan to tackle obesity, but added that political action was also needed.
“There is no magic bullet, but at the moment we are not even at first base in having a meaningful engagement with government,” Professor Colagiuri said.
“The main issue is government – mostly the Commonwealth and to a lesser extent the states – not being committed to recognising that obesity is a major problem.
“A lot of [the obesity problem] is blamed on individual behaviour and personal responsibility, rather than governments taking responsibility and trying to contribute to the solution.”
Professor Colagiuri was commenting on an article published online by the MJA by Professor Nicholas Talley, Pro Vice-Chancellor of Global Research at the University of Newcastle and Editor-in-Chief of the MJA.
Professor Talley told MJA InSight that Australia needed to redouble its efforts across the board.
“We haven’t taken a coordinated national approach to try and reduce the problem, and there is evidence internationally that there are more things we could do that would make a real difference.”
He said this approach must be multipronged to be effective, because one initiative on its own, such as promoting exercise, would not work.
“Politicians are interested, but as always, the issue is prioritisation of problems. However, I would argue that this one needs to be prioritised higher than it currently is.”
The MJA article summarised the concerns raised at the National Health Summit on Obesity, which was coordinated by the Council of Presidents of Medical Colleges and held on 9 November 2016.
With experts, clinicians, public health practitioners, researchers, educators, town planners and the food industry representatives in attendance, a six-point plan was agreed to by consensus. This included immediate steps that medical schools should implement to equip doctors to better manage obesity, calls for doctors to lead by example in their jurisdiction of influence, and recommended regulatory steps the government should seriously consider to tackle the crisis. The most controversial recommendation was the consideration of a sugar tax, but accumulating evidence supports its public health benefit.
Ms Jane Martin, executive manager of the Obesity Policy Coalition said that the complexity around personal responsibility “almost lets government off the hook”.
“They can say ‘well it’s up to individuals, parents and families’, rather than saying, as stated in this article, that obesity is an environmental problem.”
Professor Talley said that there were important things that governments could do at all levels to address obesity.
“At the local and state government level, healthy planning for cities and new suburbs could really make a difference in terms of obesity in the long term by ensuring there are ways to encourage walking and cycling. It’s not just obesity that would benefit, but other health problems as well.
“One of the things that came out of the summit is that health is missing from the table when there are discussions about town planning, and so the health profession needs to step up and be at the table, but government and the planners need to encourage this as well,” Professor Talley, who is president of the Council of Presidents of Medical Colleges, said.
Ms Martin said the significant role the food industry played in obesity was compounded by powerful alliances.
“These companies spend millions and millions of dollars on advertising and that creates a lot of allies in the marketplace.
“They have huge budgets, which make it difficult for groups like us to compete with because they are very influential,” Ms Martin said.
Professor Colagiuri said that there were parts of the food industry that were taking some voluntary action in terms of food labelling.
“But in terms of any serious contribution, they are obviously active in discouraging any non-voluntary steps that would force them to make changes that may contribute to the improvement of the situation. The food industry is part of the complexity of dealing with obesity and part of the solution. This needs to be on more than a voluntary basis when they feel inclined,” Professor Colagiuri said.
Ms Martin said that when it comes to taking political action, “it’s much less contentious to stick to the middle ground and do things like education campaigns – it’s not going to get pushed back by these really powerful industries”.
She said that while education could be very impactful, it was crucial to also take the policy steps outlined in the article.
“The ultimate problem is that government will have to do something, as it did with tobacco control very successfully, but to get to that point they were forced to take on the industry and do things that were heavily criticised.”
The Department of Health was contacted for comment but did not respond by deadline.
Podcast with Professor Nick Talley available here.
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I wholeheartedly agree that tackling the obesity epidemic requires a coordinated and multi-pronged approach. I work in a Chronic Disease Management clinical role in a public health service where many of my patients have problems with excess weight. Whilst I encourage individual responsibility in tackling weight issues, a person’s environment also has a huge impact on a person’s choices, and therefore, their health.
Just look at The Alfred Hospital’s Healthy Choices program, where they slashed the consumption of sugary drinks by putting them behind the counter (and therefore not visible), using a traffic-light system, and increasing the price of sugary drinks. All this was achieved with no reduction in the overall number of drinks sold – with a little encouragement, people simply made healthier choices. This is behavioural psychology 101 – if we make it easier and more attractive to make healthy choices, most people will make them.
Lots of truth in these comments. As health professionals, can we also “look in the mirror”? I work with an obese cardiologist, and an obese diabetes educator. Our hospital has great staff health campaigns – heavily attended by the fit staff, hardly at all by the overweight and deconditioned staff. I know many GPs who could do with losing a few kg…
Of course many health practitioners model a healthy weight and lifestyle. But perhaps one way to lobby for change is to accept what ‘doesn’t work’. Health practitioners know what to eat, how much to exercise etc and the consequences of overweight. I’m guessing we are just as capable of employing all the same excuses as other shift workers (like long-distance drivers) and sedentary office-based workers.
No answers intended here – just an acknowledgment of how overweight creeps in to become acceptable, and is only a ‘problem to be addressed’ when the secondary disease appears.
Let’s start at the beginning!
Intense education of pregnant women, on control of sugar in their diet, & healthy eating for a healthy baby.
Promotion of home prepared baby foods with very small amounts of added sugar & salt.
Don’t buy unhealthy sweet or processed foods.
Spend the $$’s on fruit & veg.
Before going shopping, eat & drink at home so you & family do not feel hungry.
Daily exercise as a routine.
Sweet cake & biscuits for special occasions only.
Rather than encouraging everyone to ride bicycles, ( many people are not able or fit enough to ride them, would be dangerous or in danger, and there is the danger of exposure to vehicle exhaust fumes), we should be improving public transport so people don’t have to drive everywhere. I live in a semi-rural area of Sydney. There are a few buses per day, and that’s all. I have to drive everywhere. It would take me hours to ride a cycle to work even if I could.
I recently lost 12kg on an overseas holiday, where I ate mostly a big breakfast, no lunch, had dinner, and walked a lot seeing galleries etc and the sights. On return, I was surprised to find I’d lost weight and my Type 2 diabetes control improved out of sight. I figure if I can do that, anyone can, by increasing exercise. I have lost more since.
Obesity is multi-factorial and I think we need cheap or free public clinics to address it. We also need effective ant-obesity drugs. I am not convinced about bariatric surgery except for extreme morbid obesity. I have a friend almost die after it, and I always wonder why the patients who have it still stay fat, although losing a fair bit of weight. We also have to motivate people to change, which is the hardest thing of all. BTW someone mentioned Cathy Freeman – she must’ve been one of the fittest people in the world, yet she has Type 2 diabetes.
Describing obesity as multi-factorial unfortunately doesn’t advance our management; it amounts to throwing our hands in the air and saying it is too hard too tackle, or worse still having the medical profession arguing about which aspect to tackle first. This is evident from the comments above. Yes, it is multi-factorial, but there is ample evidence that some factors are very important and they can be tackled in a relatively simple and inexpensive way. Thus the modern consumption of sugar through processed food is far more than was eaten 50 or 100 years ago. Certainly a tax on food is regressive and will tend to hurt those members of the population least able to afford it. However why we continue to provide a tax break to corporations to promote these toxic products is beyond me. Denying the manufacturers of processed food containing sugar a tax deduction for their advertising and promotional budget and using the revenue thus generated to compensate advertisers of food not containing sugar so that they can promote their wares would be a good start and should have no net effect on the cost of food, since it is not a tax on the food or sugar content but rather a lack of deductibility for advertising expenditure. Further, one really cannot claim that advertising doesn’t work. Clever corporations would not spend many millions of dollars on this if it had no effect on consumer behavior.
We need to address the lack of exercise in our environment. Due to our poor planning both adults and children are highly dependent on motor vehicles. This problem can be addressed by the introduction of safe cycle paths separate from the road by a kerb or similar physical barrier. Apparently the average distance cycled is 5km. The average electric bicycle trip is 9km. if bikes could be easily carried on trains and buses this would make most parts of our metropolitan areas safely and quickly accessible.
These changes would see the average Australian resembling the European BMI rather than progressing toward that of the USA
I’m afraid i have to disagree with John B Dixon. We must not normalise or condone morbid obesity. Overweight is the new normal. Severe obesity is the new “overweight”. Morbid obesity demeans the individual and impacts on those around them (especially on planes!). It is not wrong to treat these people differently. But don’t call them fat or they get really upset with you for discriminating! It is not an insult. It is a statement of verifiable fact.
Yes there are a complexity of contributing factors, and doctors aren’t all on the same page. That is why disinformation by powerful vested interests is still so effective in paralysing government action. Let’s get some simple messages across about taxing sugar, not just in soft drinks, but also its ubiquitous use in processed foods. And with that must go the constant WHO message that more than 5tspn of sugar a day is BAD for you. And for the morbidly obese a balanced diet is way too late. Let’s agree on low calorie, low carb as the best way to get weight down below dangerous levels.
KISS or no one will listen.
Getting fat or obese does not happen overnight. The person can see it happening, why wait til it’s at tipping point. It’s easier to put on the weight than to lose it. One can employ all the services available to him – even with government support but if at the end of the day that person chooses to live an unhealthy lifestyle, then all is wasted. Stop the blame.
No more excuses and live a healthy lifestyle.
Governments will probably only seriously engage in this major health issue when it becomes too expensive not to, or someone successfully sues the health system for not providing adequate access to treatment that can help someone with severe obesity and its related comorbidities.
Currently we readily provide treatments for the downstream effects of obesity (eg diabetes, hypertension, GORD, etc, etc) via the PBS (Federal Government) but do not readily provide access to specialised obesity services or bariatric surgery in the public hospital system (State Government). I wouldn’t be surprised if a legal case emerges soon.
Unlike smoking and excess alcohol consumption, where it not only affects the individual but those around them either via passive smoke, violence or road accidents, obesity is perceived only to affect the individual. Maybe a road accident secondary to severe obstructive sleep apnoea might be the catalyst for change!
Two significant contributors to Australia’s obesity crisis are the bicycle helmet discouragement of cycling since 1990, particularly among children, and the high-tax reduction in smoking which has been replaced by more frequent snacking.
It’s up to the medical community to decide if the long-term detriments of social engineering are worth the perceived short-term benefits.
Professor Talley wants to ‘encourage… cycling’, and as a hand surgeon with a subspecialty interest in wrist fractures, that would be good for my business!
Doctors should be aware that the human brain evolved to balance on 2 feet, with a foot base of nearly half a metre, at speeds less than 20 kmh (the sustained speed of an Ethiopian marathon runner). We lack the cerebellar processing power to stay vertical on a wheel base of 2 cm, at speeds often exceeding 40 kmh (Usain Bolt manages 36kmh for a few seconds). Every professional cyclist like Cadel Evans or Anna Meares has fallen off and sustained injuries.
As road vehicles, bicycles lack the basic safety features we take for granted in cars, such as seat belts, airbags, and reinforced doors – doctors campaigned for these to protect people in accidents. On the footpath, bicycles endanger pedestrians. I have operated on one professor of medicine who tripped over on the poorly marked kerbs of Sydney’s much-hyped bike lanes, as well as pedestrians struck by cyclists on the footpath and in pedestrian plazas like Martin Place.
One other problem with intense exercise such as cycling is that it requires high calorie consumption to keep functioning. Ironically, the high-sugar gels sold for serious bike riders would be targeted by a sugar tax. Looking at the BMI of former Olympians such as Dawn Fraser or Cathy Freeman, or the senior footy show panellists, youthful over-training may lead to lifelong poor dietary habits (ever wonder why McDonald’s sponsors the Olympics?), which then lead to obesity in later years. Walking is our natural means of locomotion, and should be encouraged.
One useful thing may be to mandate plain English labelling of calorie/kj values on all food products, so that every restaurant meal or take away coffee would have its calories clearly listed. Most product labelling uses very small print, and contains information which is difficult to interpret, e.g. a half kilogram loaf of bread which specifies the calories for the whole loaf, or for a 100 g serve, rather than the (much easier to understand) calories per slice.
The other elephant in the room, hiding behind the sugar cane, is total caloric load. A kilogram of wagyu scotch fillet, a bottle of Grange, and a King Island triple cream Brie – not much sugar there! A tax per calorie/kj would favour the broccoli over the potato, and the currently more expensive ‘premium’ low-fat mince over the higher fat. Foods with low energy density, like high-fibre vegetables, would be cheaper than duck-fat twice-cooked chips. All packaged foods are precisely measured, so it would require minimal additional government inspection to enforce this. However, all taxes on food, whether they are specifically on sugar or anything else, are inherently regressive, because total volume of food consumption is similar across all socio-economic groups. This makes it politically difficult to implement, as the precise aim of food taxation is to force people to eat less than they want to eat. ‘Starve the poor’ is harder to sell than ‘price tobacco so the poor aren’t harmed, but Mathias and Joe can still enjoy a good parliamentary cigar’.
Alternatively, perhaps doctors just have to accept the reality that our species evolved in a prolonged ice age, and the fittest were those who could wolf down the most food before the actual wolves came to drive us off our kill. The benefit of global warming, opening up massive fertile plains for farming, is that food is abundant in the wealthy countries, even though our ice age bodies still desire to eat a whole mammoth at one sitting. The only definitive solution may be simpler versions of the current surgical stomach-shrinking procedures, or a pharmacological one such as an appetite suppressant with no side effects. Until then, obesity is the new normal. Replacing WWII era ration books with a smartphone ration app is not going to get anyone elected.
Another idea I overheard recently in my waiting room is that a new tax on all soft-drinks be imposed, similarly to that for cigarettes. I was reminded of this clandestine conversation when I was next grocery shopping. At least two mothers in the queue in front of me each had quite a number of 1.5L – 2L bottles of soft-drink in their trolleys (in the realms of 5-6 bottles per trolley) and very little in the way of healthy food items, let alone fruit and vegetables. Sadly, as I continued to observe, both individuals queued at the service counter and each purchased a packet of cigarettes.
I then began to think about the cost of these items against the levels of addiction. Pricing for cigarette packets are high, but obviously not high enough so to act as an effective deterrent. I’m not sure as to what benefit a new tax on soft-drinks will do to reverse the mindset that sustained replacement of proper food with these high-sugar-hit items will in any way lessen the onset of obesity, among other things (other than line the federal coffers to pay for things like Welfare, in a never ending vortex of poverty and self-harm).
An education programme including the labelling of said soft-drink bottles, regardless of flavour, company, or bottle size with sugar volume & content, pictures of morbidly obese torso’s, pictures of extreme cases of dental caries in children, and such like, needs implementing sooner than later, as an initial step in the remedial addressing of the obesity crises. Legislating for this will consume great swathes of time, money, and produce distress and no-doubt vitriolic outbursts from the broad consumer base (and the soft-drink manufacturers). Political demons will flout the idea as something to use as an election promise – whatever. But it must start, and soon.
My apologies for the post above it was meant for another issue.
It is time that we faced the issue of alcohol in our society with a more honest approach. A good starting point would be for those that are engaged in the advertising, manufacture, distribution and sale of alcohol to recognise that they are “pushing” a potentially lethal drug that has few health benefits.
“calls for doctors to lead by example in their jurisdiction of influence” – I think that we are a long way from being able to implement that.
Not even at first base. Stopping the use of demeaning pictures of individuals with obesity could be a start. The picture is offensive and not respectful of the issue another; just another cheap shot. There are hundreds of photographs freely available that depict people with obesity as normal within our community.
Sadly we don’t really understand relative roles any of the more than 100 determinants of this serious disease. We struggle to have any effect on the modifiable determinants, and fail to respect the genetic, epigenetic and metabolic program aspects of the condition. We simply say we need a range of public health measures and trot out the same list that we have failed to implement.
We treat those suffering for obesity with systematic bias, stigmatisation, discrimination, and neglect. Its their fault eat less and exercise more! They know it doesn’t work very well. Neglect – negligible access to life saving bariatric surgery in our public hospitals, no medication to treat obesity on the PBS listing, and bias against very low calorie diets that do work. ‘If it’s effective lets avoid it”. As medical practitioners we need to fight for tool to manage this disease of energy dysregulation just as we do to treat it’s complications diabetes, cardiovascular disease and cancer.
As medical practitioners we need to get our house in order at the same time as guiding our leaders.
We can but only start with a change in the demeaning use of images of faceless obesity epidemic.
And not only is our political response to obesity nearly 50 years outdated, but our regulator (AHPRA) has gagged one doctor (Dr Garry Fettke) from trying to make a difference both for his patients and through community awareness – stating that as a doctor he is not qualified to give nutritional advice!
This is a multifactorial problem that needs to be urgently addressed. Policies which address prevention are paramount. In addition we have in Australia in excess of 50% of the population who are currently either obese or significantly overweight. The state of their current weight poses major problems for the health budget in that the inevitable co morbidities shall add to the burden of disease and impact in a major way on available resources. A number of very good Australian studies have shown the way forward in addressing the latter problem. However State Governments that control the purse strings do not fund procedures which can cost effectively address the problem.
I ask for an evidence based look at the issues and strongly support the opinions expressed in this article as well as that by Nick Talley
At the 2 major hospitals in Sydney where I work the only food in the vending machines is chips and chocolate and the drinks are coke, fanta etc……..it is equivalent to having a cigarette dispenser. There is no attempt to address the problem at all.