RURAL DOCTORS ASSOCIATION OF AUSTRALIA 1POLICY POSITION

Overweight and obesity in Australia

There is a worldwide obesity epidemic. Obesity levels across the globe are almost three times what they were in 19751.

In Australia, there are multiple causes contributing to the rising rates of overweight and obesity, and halting and reversing the trend will require significant effort and investment over the longer term. No single policy or program will be sufficient to address these increasing rates or their consequences, and there must be initiatives that target the general population as well as specific population groups, including rural and remote Australians. Current evidence suggests that overweight and obesity is more prevalent in rural and remote communities, particularly those that are disadvantaged.

A comprehensive, co-ordinated, sustainable and bipartisan strategic approach to connect overweight and obesity policies and programs at all levels of government and across sectors will be necessary to make a difference. This strategy must be:

• developed in parallel with nutrition and physical activity strategies as key aspects of the prevention and management of overweight and obesity issues • closely aligned with other national health strategies and initiatives • informed by the Australian and international evidence • supported by operative frameworks that set out clear and achievable targets and timeframes • underpinned by adequate and secure levels of funding for consequent programs and initiatives to achieve desired outcomes.

All options to tackle overweight and obesity as a significant and burgeoning preventable health issue should be considered. Identifying and addressing issues for rural and remote Australians and the prevention of childhood overweight and obesity must be priority areas for action and may include, but not be limited to:

• recognition of and support for the central role that rural doctors and primary health care plays in preventing and managing overweight and obesity in rural and remote areas • provision of appropriate education and training in relevant areas for all health professionals involved in providing information, advice, treatment, counselling or other support to people experiencing problems with overweight and obesity in rural and remote areas • Commonwealth and jurisdictional review of food supply and security, including identification of communities at risk of limited healthy food supplies in remote areas and actions to redress the issues for these communities • development and dissemination of a range of multi-media educational resources about overweight and obesity as health risk factors • promotion of healthy lifestyles • legislation to restrict food and beverage products that may be harmful to health • taxation measures.

Policymakers and planners must ensure that adequate and secure funding underpins programs and initiatives to maximise the likelihood for success in rural and remote areas.

1 World Health Organization Fact Sheet http://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight Viewed 28 November 2018.

RURAL DOCTORS ASSOCIATION OF AUSTRALIA POSITION PAPER RDAA Overweight and Obesity in Australia Policy Position

RDAA believes the following specific measures should be implemented:

• strategies to support rural and remote doctors and their practices to prevent and manage overweight and obesity health risks and harms in rural and remote communities, including o funding general practice telehealth consultations as part of a cycle of care o making viable innovative models of care whereby a range of health professionals, including dieticians and physiotherapists, can be employed in rural general practices or be part of a mixed service model o developing guidelines for GPs and practice staff to work with parents and carers on nutrition and weight management of children • up-skilling of practice and community nurses, Aboriginal Health Workers, and other rural and remote health professionals in nutrition and counseling through the development and provision of relevant education and training modules • targeted social marketing campaigns to improve health literacy by providing health messages and community education that resonates with rural and remote Australians (for example, anecdotal evidence suggests that the light-hearted and humorous tone of the Northern Territory’s No Germs on Me campaign to promote the benefits of regular face washing and hand washing with soap had broad appeal in rural and remote Australia, particularly with children) • Commonwealth and jurisdictional review of issues related to food security and affordable healthy food options in rural and remote communities and actions to address these issues, including improving access to fresh fruit and vegetables through introducing breakfast programs in schools, childcare centres (including home childcare) and pre-schools in rural and remote communities • community and local government collaborative projects to provide exercise appropriate areas and equipment in rural and remote areas • engagement with rural and remote Aboriginal and/or Torres Strait Islander communities to develop local initiatives • regular review and strengthening of national and jurisdictional food standards, labelling and advertising requirements (including mandated accountability for breaches) to mitigate against the high levels of consumption of cheap high-saturated fat, high-salt and high-sugar packaged and fast foods and sugar-sweetened beverages (SSBs). These requirements should be nationally consistent and include o point-of-sale and vending machine restrictions in hospitals and health facilities, schools and entertainment venues that primarily target children and young people o restrictions on advertising and promotion, including offering “up-sizing” (particularly to children) o mandatory, clearly visible front-of-package labelling.

A range of taxation measures that could be used in combination with each other and with non-tax measures to reduce unnecessary consumption of sugar should also be considered. Revenue raised from taxes should be hypothecated to:

• provide targeted funding for the prevention and treatment of overweight and obesity health harms being experienced by people in rural, remote and very remote areas • support the primary sugar industry to refocus and adapt to changes to mitigate against financial and other stressors that contribute to these health harms.

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Background and detailed position

The overweight and obesity epidemic has been a global and national public health issue for several decades. Overweight and obesity has become one of the leading causes of preventable illness and death in Australia. As such, unless it is effectively managed, overweight and obesity will be the most significant health-related challenge for this country into the future and a continuing drain on health resources.

The individual and population health implications of overweight and obesity and strategies to address them, including for children, have been the subject of a range of inquiries and research. Despite efforts to address the issue there has been a marked increase in numbers of overweight and obese people in Australia since the 1980s2,3. The most recent data indicates that nearly 2 in 3 (63%) adults and more than 1 in 4 children are overweight or obese in Australia4.

The causes of overweight and obesity in Australia are complex: biological, familial, psycho-behavioural, social, cultural, environmental and lifestyle factors all play a part5,6,7. Changes in each and all of these factors have contributed to the rise of overweight and obesity across the population. There is also a link between income as a social determinant of health and likelihood of obesity8,9,10.

The chronic conditions associated with being overweight or obese can compromise the capacity of people to fully participate in economic, social and community activities which in turn further compromises their health. It is important to note that health harms associated with obesity are not limited to physical health harms. Mental health is also impacted at all ages.

Effectively addressing these health outcomes of overweight and obesity will be challenging, particularly in rural, remote and very remote Australia where a range of unique circumstances impact on health policy and program implementation and service delivery. Although recognised as a National Health Priority Area there is as yet no national strategy to combat the rise in overweight and obesity. Overweight and obesity remains a burgeoning public health issue in Australia.

Given the enormity of the overweight and obesity response task, prioritising effort and investment will be difficult but unless there is immediate action to arrest the rise in prevalence of overweight and obesity, the negative consequences for individual and population health and for the health system will be substantial and burdensome.

A national overweight and obesity strategy that aligns closely with other national strategies and initiatives will be necessary to halt and reverse the overweight and obesity trend.

A strategic approach that is bipartisan, multi-faceted and holistic, and encompasses targeted and sustainable individual, community and population-wide policies and programs, is necessary to prevent and manage the effects of overweight and obesity and the impact on Australians. It will require Commonwealth Government leadership with clearly articulated lines of accountability to develop and deliver strategies to combat this epidemic and provide national coordination of related programs.

2 Parliament of Australia E-brief: Overweight and obesity in Australia. Issued 5 October 2006. https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/Publications_Archive/archive/obesity Viewed 28 November 2018. 3 Australian Institute of Health and Welfare 2018. Australia’s health 2018. Australia’s health series no. 16. AUS 221. Canberra: AIHW. p 231. 4 Ibid. p 188. 5 Steven Allender, Brynle Owen, Jill Kuhlberg, Janette Lowe, Phoebe Nagorcka- Smith, Jill Whelan, Colin Bell. 2015. A Community Based Systems Diagram of Obesity Causes. https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0129683&type=printable. Viewed 28 November 2018. 6 Campbell MK 2016. Biological, environmental, and social influences on childhood obesity. Pediatr Res. 2016 Jan;79(1-2):205-11. doi: 10.1038/pr.2015.208. Epub 2015 Oct 20. Available at https://www.ncbi.nlm.nih.gov/pubmed/26484623. 7 Adult Obesity Causes & Consequences. https://www.cdc.gov/obesity/adult/causes.html. Viewed 28 November 2018. 8 Australian Institute of Health and Welfare 2017. A picture of overweight and obesity in Australia 2017. Cat. no.PHE 216. Canberra: AIHW. p 8. 9 Kim TJ, von dem Knesebeck O. Income and obesity: what is the direction of the relationship? A systematic review and meta-analysis. BMJ Open 2018;8:e019862. doi:10.1136/ bmjopen-2017-019862 10 Australian Bureau of Statistics. 2011. Overweight and Obesity in Adults in Australia: A Snapshot, 2007-08 http://www.abs.gov.au/ausstats/[email protected]/0/94FD9A5A7AA9A106CA25789C0023DB4F?opendocument

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Particular attention must be given to rural and remote Australia where the highest rates of adult overweight and obesity exist11.

Overweight and obesity is also not purely a function of an ageing adult population. The apparent increase in the prevalence of overweight and obesity among children and adolescents is a significant concern and must also be a priority focus.

At the time of writing this policy position a number of national health strategies and action plans are being developed. These include the National Strategic Directions for Australian Maternity Services, the National Men’s Health Strategy, the National Women’s Health Strategy, the Child Health Action Plan and the National Action Plan for Heart and Stroke. Alignment of a national overweight and obesity strategy (and nutrition and physical activity strategies) with these strategies and plans will be necessary to ensure efficiency and maximise effectiveness.

Utilising multiple policy levers at all levels of government and cross-jurisdictional alignment will be required to reduce overweight and obesity levels across Australia.

Cross-sectoral collaboration and the good faith involvement of the food and beverages, advertising and media industries, consumers, non government agencies and organisations, and all levels of government will be essential to develop and implement practical and effective overweight and obesity policies and programs.

Decreased levels of physical activity, increased consumption of unhealthy food and beverages and poor nutrition are key contributors to overweight and obesity and their health consequences and must be addressed.

Levels of physical activity and nutrition are key contextual aspects of the overweight and obesity problem that must be considered in any strategic response to the overweight and obesity trend.

Australians are becoming increasingly physically inactive with 81 per cent of Australian children not meeting the recommended guidelines and almost 70 per cent of adults being sedentary or having low levels of physical activity12. Factors influencing this trend include sedentary occupations and entertainment and transport choices. Physical inactivity is a significant risk factor for overweight and obesity and a range of chronic conditions that is made worse when coupled with a poor diet and nutrition.

Specific strategies to address these issues should be developed in parallel with a national strategic approach to reducing overweight and obesity levels in Australia.

Investing in and supporting rural and remote primary health care will be an essential strategic element to effectively prevent and manage overweight- and obesity-related health harms in these communities.

The unique circumstances that exist in rural and remote communities will require policy and program approaches that are innovative and flexible and can be adapted to local conditions. In these communities, poor access to healthy food and beverage options is not the only factor contributing to higher levels of overweight and obesity.

Poor access to exercise appropriate areas, to a range of health professionals, including dieticians, physiotherapists and mental health professionals, and to prevention and treatment options, can exacerbate problems. The chronic shortage of health professionals in these communities means that the burden of preventing and treating both physical and mental health harms associated with overweight and obesity most often falls to General Practitioners (GPs) and community nurses.

11 https://www.myhealthycommunities.gov.au/our-reports/get-report- file/hc27/publication/AIHW_HC_Report_Overweight_and_Obesity_Report_December_2016 Viewed 17 July 2018. 12 Commonwealth of Australia. 2018. Sport 2030. Canberra: Commonwealth of Australia. p16.

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Investing in support for rural and remote GPs and their practices to provide the patient-centred continuity of care necessary to prevent and manage chronic and co-morbid conditions associated with overweight and obesity will be essential to redress the poorer health outcomes and higher death rates being experienced by rural and remote people as compared with urban residents. Strategies should include:

• funding general practice telehealth consultations as part of a cycle of care • making viable innovative models of care whereby a range of health professionals, including dieticians and physiotherapists, can be employed in rural general practices or be part of a mixed service model • developing guidelines for GPs and practice staff to work with parents and carers on nutrition and weight management of children.

Identifying, developing and implementing mechanisms to improve access to a range of other health professionals and specialists providing clinical and other support for rural and remote people experiencing overweight- and obesity-related problems will also be required to redress existing health care inequities. They should include up-skilling practice and community nurses, Aboriginal Health Workers, and other rural and remote health professionals in nutrition and counseling through the development and provision of relevant education and training.

Working with consumers and other stakeholders to identify needs and develop population-wide and targeted health initiatives should also be integral to a national overweight and obesity response.

In rural and remote communities this work should be informed by a Commonwealth and jurisdictional review of food supply and security that identifies communities at risk of limited healthy food supplies and actions appropriate to the local context to redress the issues for these communities should be implemented.

Initiatives should include:

• development and dissemination of a range of multi-media educational resources about overweight and obesity as health risk factors • promotion of healthy lifestyles • engagement with rural and remote Aboriginal and/or Torres Strait Islander communities to develop local initiatives.

Legislative and taxation measures should be considered in conjunction with population health initiatives and support for the provision of prevention, early intervention and treatment services as part of a multi- pronged approach to halting and reversing the increasing overweight and obesity rates in Australia.

It is widely recognised that the food and beverage industries that have developed and marketed relatively cheap high-saturated fat, high-salt and high-sugar packaged and fast foods and SSBs have had a role in contributing to poor diets and overweight and obesity in Australia. These types of food and drink have become more and more easily available over the last 40 years and are heavily promoted. Industry logos and advertising campaigns and promotions have become an unavoidable part of everyday life, and sales techniques that promote “up-sizing” of fast food meals and drinks are common. Although healthier options are becoming more convenient and available, they can also be much more expensive. For example, bottled water providers have marketed their product as a premium product with a price tag to match. Bottled water is “more expensive than milk, soft drink and even petrol”13.

An increasing number of countries are introducing taxes on and regulating unhealthy foods and drinks in response to the growing body of evidence in relation to the health benefits and cost-effectiveness of

13 https://www.choice.com.au/food-and-drink/drinks/water/articles/bottled-water Viewed 27 June 2018

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using these measures to influence consumption behaviours14. Consumer behaviour is price sensitive but any taxation measures must be supported by a raft of other measures – including media campaigns, community education activities and measures to regulate marketing of unhealthy foods and drink – to challenge societal acceptance of the place of these items in everyday diets.

In Australia, there are a number of health-related, political and economic concerns impacting on efforts to reduce rates of overweight and obesity, particularly in relation to the use of consumption taxes. For example, while the potential health benefits of the imposition of a tax on SSBs (the subject of considerable media and other attention in recent times) are a compelling argument, the flow-on impacts on rural agriculture and processing industries in Queensland and NSW and on the local economies and health may be difficult to quantify.

The introduction of such a tax may also have a range of unintended consequences in rural, remote and very remote Australia. In many of these areas the supply of fresh fruit and vegetables and other healthy alternatives is problematic and even if available may not be at an affordable price. High transport costs related to distance and time to delivery, and the short shelf life of fresh produce also means that there is a limited range of not so fresh options in these areas. Produce is often of poor quality. Increased prices as a result of taxes may make little difference in these circumstances, and may further disadvantage rural and remote people.

It is critical therefore that any tax measure to reduce consumption of unhealthy foods and drinks are accompanied by measures to improve access to healthier options for people living in rural, remote and very remote places and by investment in agricultural research and innovation in relation to market and commodity alternatives (such as ethanol) and diversification and transition assistance to farmers to mitigate against any unintended consequences in local communities. These approaches could be funded by revenue derived from the tax.

Care must also be taken that discussion about the taxing of SSBs does not narrow perceptions of the problem by focusing on a single tax issue. Tax powers in Australia allow for the use of a number of taxation measures (within the limits of the Constitution) that should be considered in combination with each other and with non-tax measures to promote health and wellbeing or conversely penalise poor industry behaviours. They may include:

• levies with revenue hypothecated for various public health purposes or to offset any possible negative impacts on local communities through support for sugar cane growers and the restructuring or refocusing of the sugar production industry • tax incentives to develop changing the formulation of packaged food and drinks to decrease sugar content • subsidies for healthy food and drink production targeting rural and remote community access to healthier options.

Using taxation measures should be effective in changing sugar consumption behaviours and improving health outcomes for individuals and the broader population, particularly when used in conjunction with other regulatory mechanisms and with other strategies to inform and educate individuals and communities, train and support health professionals and support related initiatives. Australia’s tobacco strategy provides an excellent example of how this can work. However, it is also important to be wary of industry regulatory capture of such measures and possible circumventing of the system through the creation of new products.

RDAA will continue its efforts to engage with relevant stakeholders to address overweight and obesity issues in rural and remote Australia.

14 Linda J. Cobiac, King Tam, Lennert Veerman, Tony Blakely. 2017. Taxes and Subsidies for Improving Diet and Population Health in Australia: A Cost- Effectiveness Modelling Study https://doi.org/10.1371/journal.pmed.1002232 Viewed 11 October 2018

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