Obesity Epidemic in Australia Submission

Committee Secretary Department of the Senate PO Box 6100 Parliament House Canberra ACT 2600 Phone: +61 2 6277 3228 Fax: +61 2 6277 5829 [email protected]

Submitted online Monday 9th July, 2018

Dear Committee Secretary,

That Sugar Movement: Submission to the Select Committee into the Obesity Epidemic in Australia

That Sugar Movement congratulates the Senate on its formation of a Select Committee into the Obesity Epidemic in Australia, with a focus on childhood obesity.

That Sugar Movement is a profit-for-purpose organisation that partners with individuals, organisations and government to create healthy lifestyles and better public health outcomes. It is recognised as a leading advocate for healthy eating and a global platform for sharing tools, techniques and the need for change.

While we observe the debate on what a comprehensive public policy looks like, obesity rates among our children and adults alike are increasing year-on-year. Australia now has the sixth largest obesity rates within the top ten OECD countries.

• 1.4% of boys and 1.2% of girls aged 5-17 years were obese in 1985. A decade later that number had tripled to 4.7% of boys and 5.5% of girls in 1995. • 21.5% of girls and 20% of boys were either overweight or obese in 1995

Observing a need for social change, That Sugar Movement has formulated its own response, investing over $700,000 of private funding to offer capability-building programs for individuals, early learning centres, schools, and workplaces. That Sugar Movement also gives back to Indigenous and at-risk communities and helped establish the Mai Wiru Sugar Challenge Foundation, an indigenous-led initiative that runs nutrition programs in central Australia’s APY Lands.

Our work with 900 primary and secondary schools across Australia and New Zealand provides direct experience in understanding the prevalence, causes, harm and economic burden of childhood obesity.

That Sugar Movement has been responding to public enquiries regarding food and nutrition to our online community of 400,000 individuals since the launch of That Sugar Film in 2015. Our experience confirms the issues surrounding why and what people eat - and more importantly, how we change behaviour, are complex.

That Sugar Movement has reviewed the considerations of the Select Senate Committee into the obesity epidemic in Australia and provide our response accordingly.

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As much as policy must support sustainable change over time, we believe individuals must also be empowered with information and access to clear, accessible information to make healthy choices today. In short, a collaboration between public policy and personal responsibility.

Accordingly, we urge the Committee to consider the following measures to create immediate impact.

1. Tighter controls around marketing messages and advertising scheduling for children across retail outlets, TV and digital media;

2. Clearer food labelling, specifically disclosure of added sugar content, regulating appropriate serving sizes, tighter control around front of pack health food claims.

3. Nutritional literacy programs in primary and secondary schools, equipping children with basic food knowledge and cooking skills*.

4. Wholly or partially subsidised nutritional literacy programs for individuals and families*;

5. Incentives for early learning centres to provide nutritional literacy programs among their educators and kitchen staff*;

6. Incentives for community groups and organisations who provide nutritional literacy programs to their staff as part of their wellness program*, and

7. Health promotion educating consumers around basic nutritional literacy, with a focus on lower- socioeconomic areas*.

Those marked with an asterisk indicate areas of existing capability offered by That Sugar Movement.

The outcomes for government and health networks include a reduction in preventable chronic diseases such as type 2 diabetes, obesity, improved oral health, reduction in hospital admissions and increased nutritional literacy among children and adults to support increased healthy eating and active living.

That Sugar Movement has the infrastructure, public endorsement and the expertise to deliver national programs and is ready to scale. Accordingly, we seek to partner with government and like-minded organisations to agree a way forward and improve the wellbeing of Australians.

A profit-for-purpose organisation, our growth strategy is independent of external funding, with plans to expand into US, Canada and UK markets within the next 12 months.

We thank you for the opportunity and welcome further discussion regarding our submission, specifically how we can tackle Australia’s obesity crisis together.

Regards

Damon Gameau Vera Skocic Founder and Director General Manager That Sugar Film, That Sugar Movement That Sugar Movement

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Why That Sugar Movement

That Sugar Movement started as a documentary titled That Sugar…Film, written and produced by Australian actor, Damon Gameau. The documentary follows Damon’s journey of consuming products perceived as “healthy”, for 60 days. Clinically monitored throughout his journey, Damon depicts how and why various health halo foods are perceived as beneficial to health, yet regular consumption can increase health risk.

The documentary was subsequently condensed as a learning tool to help educate Indigenous groups in the APY lands, for whom dietary support and education were withdrawn by the government. This version was taken further and developed into a curriculum based school kit for primary and secondary schools to which over 900 schools across Australia and New Zealand now subscribe.

With our origins in health promotion and education, we have invested over $700,000 to date in tools and information, to build capability and help all Australians navigate different settings.

• That Sugar Film, distributed in over 25 countries and languages;

• That Sugar Book and That Sugar Guide recipe and information publications

• Public endorsement via a global online community of more than 400,000 individuals;

• Over 10,000 downloads to date in Australia of That Sugar App, developed in partnership with BUPA and The George Institute for Global Health;

• 900 schools in Australia and New Zealand who have adopted our School Action Toolkit,

servicing children from Years 5-10;

• An early learning resource for educators and families of children aged 2-5 years, currently being trialled in 25 Early Learning Centres in partnership with Bendigo Health;

• An online consumer program, providing key nutritional information, tools and techniques to identify hidden added sugars, and how to combat them over 30 days, and

• An eight-week corporate wellness program for organisations and their employees.

All programs• A national and content health promotionare designed campaign, by our 6 quSpoonsalified in nutritionists June, encouraging and dietitians, Australians align to stickto the Australianto Dietary the recommended Guidelines as sixset out teaspoons by the NHMRC. of added sugar suggested by the World Health Organisation. The average Australian consumes approximately 30 teaspoons.

• All programs and content are designed by qualified nutritionists and dietitians, and align to Australian Healthy Eating Guidelines and the World Health Organisation.

The prevalence of overweight and obesity among children in Australia and changes in these rates over time;

The proportion of people who are obese and overweight has been increasing over the past 20 years1, with just 40% of the adult population considered overweight or obese in 1980. Today, this figure is a staggering two in three Australian adults.

1 Australian Institute of Health and Welfare, Australia’s Health 2018, 2018

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Among children, rates are also rising, with 2009 Australian Institute of Health and Welfare [AIHW] data indicating children aged 5-14 years old having a prevalence for overweight or obesity at a rate of 23%. The ABS Australian Health Survey of 2011-12 (2013) estimated 25.7% of Australian children were either overweight (18.7%) or obese (7%). This equates to 1 in 4 children who are either overweight or obese, almost 720,000 Australian children.

The ABS Australian Health Survey (2015) found 27.4% of children were overweight or obese, an increase of approximately 5% in as many years.

Table S4.10.2: Proportion of overweight and obese children and young people aged 2–17, by age, 2014–152

Overweight All children but not Obese obese Age group % % 2–4 11.3 8.7 5–7 14.6 10.0 8–11 21.0 6.0

12–15 21.2 6.9

16–17 24.7 7.9

Total aged 2–17 years 18.4 7.5

Total aged 5–17 years 20.2 7.4

International perspective

Prior to 1980, obesity rates among OECD countries were generally well below 10%. They have since doubled or tripled in many countries, and in almost half of the OECD, 50% or more of the population is overweight.

Data from the Government Office for Science in the United Kingdom is featured below, which plots obesity rates of children across eight countries, including Australia. Between 1985-1995, obesity rates grew approximately 8% in Australia.

In 2010, OECD data measured obesity rates among Australian children aged 15-17 years at 22% for boys and 24% for girls. It observed the obesity epidemic had spread further in the past five years, noting obesity and overweight rates had increased by a further 2-3% in Australia, France, Mexico and Switzerland3.

The causes of the rise in overweight and obesity in Australia;

In March 2018, That Sugar Movement commissioned the services of behaviour change experts The Shannon Company, to understand the barriers and motivators to healthy eating. Quantitative research

2 Source: ABS (Australian Bureau of Statistics) 2015. National Health Survey: first results, 2014–15. ABS cat no. 4364.0.55.001. Canberra: ABS.

3 OECD Obesity Update 2014, http://www.oecd.org/health/health-systems/obesity-and-the-economics-of-prevention- 9789264084865-en.htm

July 2018 Submission to the Senate Committee in the Obesity Epidemic in Australia Page 4 of 15 was also conducted with 321 Australians, online in March 2018, to measure consumer adoption of That Sugar Movement 30-day education program.

Source: BBC News: Health4.

This research confirmed the existence of inaccurate attitudes around calorie intake, marketing references such as “low fat”, “fat free” to greatly influence poor food choices and consumption. Household income, life stage, language and cultural influences, and cooking skills also played a significant role. Worryingly, screen time was positively associated with snack and sugar-sweetened beverage intake, while sedentary behavior itself potentially serving as a cue for consumption of energy-dense snacks.

Self-efficacy was the most important determinant of nutrition behavior, whereby one’s willingness to change behavior increased as their confidence with the subject matter grew. The research also suggested a need to provide educational content as well as including more instructional intervention components which apply knowledge to achieve the desired behavior.

Importantly, the need to make smaller, more palatable dietary changes rather than adopting an all-or- nothing approach was considered key to creating sustainable change. Conversely, making wholesale, drastic changes drives a short-term outcome.

The data issued by the Australian Bureau of Statistics confirms similar drivers to childhood overweight and obesity, not surprising given parents’ influence on children’s food and lifestyle habits. These include food availability and choices, advertising and marketing messages, parental responsibility and education, as well as the role of school and family. Lower physical activity, and a correlation between obesity and socioeconomic status are also discussed briefly.

4 BBC News: Health. (2008, January 02). Obesity: In statistics. Retrieved from http://news.bbc.co.uk/2/hi/health/7151813.stm

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Food Availability and Choices

Foods aimed at children particularly breakfast cereals, confectionery, lunchbox items and juices are higher in excess fat, added sugar and salt. These products are often marketed as healthy, while the nutritional excesses are not addressed.

This misinformation is impacting our children’s food consumption, with the ABS recording intake of free sugars were the highest among teenage males (aged 14-18 years) in 2016. This cohort consumed on average 92g (23 teaspoons) of added sugar per day, with the top 10% consuming 160g (38 teaspoons) of added sugar per day - more than six times the six teaspoons of added sugar recommended by the World Health Organisation for additional health benefits5.

Advertising and Marketing

The WHO found that the advertising of unhealthy food influences children’s food preferences, purchase requests and consumption patterns (WHO 2010). The average Australian child will be exposed to 35 hours of food advertising on television over the course of a year, of which over half will be for unhealthy foods6.

The Australian food industry responded in 2009 with initiatives to limit the exposure of unhealthy food advertising to children, but a recent study showed there had been no subsequent change in this exposure in Australia from 2011 to 20157.

The thousands of public requests for information That Sugar Movement has received from parents to date suggests a need for clear, accessible information. Australian food labels need to distinguish between natural sugars and added sugars. Foods may have nutrition claims that detract from the fact they are possibly laden with sugar like such as “low in fat, high in fibre, low GI” or use buzzwords like “organic, all natural, lite.”

Evidence increasingly suggests food marketing encourages children to eat more unhealthy foods rather than changing brands. Halford et al (2004) 8 demonstrated how children ate more snack foods after watching food commercials compared with toy commercials, with obese and overweight children particularly affected.

Obese children ate an extra 2000kJ of snack foods immediately after watching food adverts compared with toy adverts. (Slightly less than half the daily energy requirement of 4500kJ per day). Normal weight children ate an extra 1046kJ of snack foods after watching food ads compared with after watching toy adverts.

5 http://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/ 6 King L, Hebden L, Grunseit L, Kelly B & Chapman K 2013. Building the case for independent monitoring of food advertising on Australian television. Public Health Nutrition 16:2249–54. 7 Watson W, Lau V, Wellard L, Hughes C & Chapman K 2017. Advertising to children initiatives have not reduced unhealthy food advertising on Australian television. Journal of Public Health (Oxford) 39(4):787–92. 8 Effect of television advertisements for foods on food consumption in children. Halford JC1, Gillespie J, Brown V, Pontin EE, Dovey TM, Appetite. 2004 Apr;42(2):221-5.

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Given rising screen time among children and adults, communicating the importance of mindful eating cannot be overstated as part of a preventative approach.

Parental responsibility and education

A study by Hesketh et al9, 2005 examined parent and child perceptions of healthy eating and physical activity. Of the nine themes that emerged, the contradictions in messages children receive were reported to be a barrier to a healthy lifestyle. We encourage our children to eat their breakfast, vegetables, however their school, sporting and social environments provide contradictory, poor food choices.

A key issue is that, as our adult obesity rates indicate, parents are not sufficiently informed in providing correct guidelines to children, further highlighted by results from the Australian Health Survey

• ABS (2014) Australian Health Survey found, children aged 2-18 years averaged 1.8 serves per day and less than 1% usually consumed their recommended number of vegetable serves. • ABS (2015) Australian Health Survey found only 5.8% of children were eating the recommended fruit and vegetable serves. • ABS (2015) Australian Health Survey found 68% of parents believed feeding their children fruit juice was healthier than water.

These findings are supported by a report That Sugar Movement commissioned into the success of its School Action Toolkit across 900 Australian and New Zealand schools. Where teachers and children would respond positively to the messages contained in the curriculum and seek to adopt healthy eating behaviour, their efforts were greatly impacted – in some cases negatively, by their domestic and social environment.

The impact of social norms is significant. At home, children were faced with parents who perceived suggestions for healthier food options as a criticism of their parenting. This was further exacerbated by parents who were overweight and obese themselves and lacked the knowledge to provide appropriate alternatives for themselves or their children.

Note genetic factors strongly influence predisposition to gaining weight, however genetic conditions related to severe childhood obesity are rare.

Role of the school and early learning centres

In Australia, around 77% of children attend early learning education care. Some children spend the majority of their waking day in care, receiving up to 80% of their daily nutrition requirements from the centre. For these reasons, early learning centres offer an ideal environment in which to influence the eating habits of our youngest generations.

School canteens, sporting facilities and other recreational facilities often provide poor food choices for children, typically “fast food” options that are high in added sugars and unhealthy fats. Children trying to adjust their diet were limited by healthy food choices and found it difficult to sustain the lessons taught in the classroom.

9 Healthy eating, activity and obesity prevention: a qualitative study of parent and child perceptions in Australia, Health Promotion International, Volume 20, Issue 1, 1 March 2005, Pages 19–26, K Hesketh, E Waters, J Green, L Salmon, J Williams.

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Our dialogue with schools, peers and bodies such as the Principal Association suggest the commercial impacts for external providers to reduce the proportion of foods that are Red or Amber under the Traffic Light System suggested by the Healthy Eating Advisory Service difficult to adopt.

Recent initiatives by Curtin University and schools in Western Australia show that school food policies can positively influence school menus without affecting canteen profits10. Incentives may be considered for those schools and sporting facilities that support desired behaviour.

Similarly, the Australian Curriculum has a focus area on health and education that teaches children how to make healthy choices from F-10 however it is largely at the school’s discretion as to what elements are implemented and how health education manifests within their school.

Socio-economic status

The availability, affordability, accessibility and convenience of foods and higher exposure to processed foods plays a major contributing factor - where cheaper more accessible foods tend to be more energy dense and generally nutrient poor (NHMRC 2013).

A study by Hardy et al (2017) examined the 30-year trends in overweight, obesity and waist-to- height ratio by socioeconomic status among Australian children from 1985 to 2015. It identified significant disparities in prevalence rates between children and adolescents from low and high SES backgrounds began in 2010 for overweight, since 1997 for obesity and since 2004 for WHtR 0.5. Differences between SES groups have become larger over the past 18 years 11.

In the ABS (2016) survey it was revealed 34.7% of children in the lowest socioeconomic areas were overweight or obese, compared to 22.3 % in the highest socioeconomic areas.

Lower Physical Activity

Children are becoming more sedentary with the increased reliance on mechanical methods of transport and greater screen time exposure – the latter ranging from school work to entertainment, with the average Australian child reported to be watching an average of 2.5 hours of TV per day.

This is based on self-reported data from the Australian Bureau of Statistics National Health Survey12,

In 2011-12 the following figures were reported with respect to physical activity among children aged 2-17 years.

• an estimated 39% of children aged 2–5 did less than the recommended 180 minutes of physical activity each day; • 74% of children aged 5–12 and 92% of young people aged 13–17 did not complete 60 minutes of moderate to vigorous intensity physical activity every day. (ABS 2013).

10 https://thewest.com.au/news/education/curtin-university-study-shows-wa-school-junk-food-ban-success-ng-b88757303z 11 30-year trends in overweight, obesity and waist-to-height ratio by socioeconomic status in Australian children, 1985 to 2015, LL Hardy, S Mihrshahi, J Gale, B A Drayton, A Bauman, J Mitchell, International Journal of Obesity volume41, pages 76–82 (2017) 12 ABS (Australian Bureau of Statistics) 2013. Microdata: Australian Health Survey, 2011–12. ABS cat. no. 4324.0.55.001. Canberra: ABS. AIHW analysis of Expanded Confidentialised Unit Record File.

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Again, we note the link between increased screen time at home and in school.

The short and long-term harm to health associated with obesity, particularly in children in Australia;

Short term

Childhood overweight and obesity directly increases the risk of developing conditions such as sleep apnoea, breathlessness, reduced ability to be active, orthopaedic problems, gastrointestinal problems and non-alcoholic fatty liver disease (NHMRC 2013).

However it also plays a psychological role with overweight and obese children reported to frequently experience discrimination, bullying and teasing by their peers, which can precipitate into longer term mental health issues of poor peer relationships, poor psychological wellbeing, depression and anxiety (Griffiths et al, 200613; Hayden-Wade et al 200514; Sawyer et al 200615).

To ensure our content promotes a healthy body image among children, That Sugar Movement engaged the services of Eating Disorders Victoria in its development of the School Action Toolkit, and an early childhood expert in the design of its Early Learning Toolkit.

Long term

The long-term risks of persistent overweight and obesity include cardiovascular disease, diabetes, certain cancers, depression, anxiety, arthritis and premature mortality (Guo et al 200216; Reilly & Wilson 200617). The greatest risk is childhood overweight and obesity can persist into adolescence and onto adulthood, taking with it the combined health risks and economic burden to the public health system.

The short and long-term economic burden of obesity, particularly related to obesity in children in Australia;

Overall health expenditure grew faster than population growth between 2006–07 and 2015–16 in Australia. In 2008 it was estimated that the total annual cost of obesity was approximately $58 billion to cover the cost of health services, loss of productivity, carers costs and burden of disease (Access Economics 2008).

A 2012 study found for children aged 4-5 years old, being overweight had significantly higher pharmaceutical and medical care costs, resulting in a combined five-year Medicare bill of AUD$9.8m higher than that of normal weight children. Therefore clearly having a financial burden to the public health care system.

13 Griffiths LJ, Wolke, D; Page, AS; Horwood, JP & ALSPAC Study Team (2006) Obesity and bullying: different effects for boys and girls. Archives of Disease in Childhood 91 (2):121-5 14 Hayden-Wade, HA; Stein, RI; Ghaderi, A; Saelens, B; Zabinski, M & Wilfrey, D (2005) Prevalence, characteristics and correlates of teasing experiences among overweight children vs non-overweight peers. Obesity Research 13(8):1381-1392. 15 Sawyer, MG; Miller-Lewis, L; Guy, S & Wake M (2006) Is there a relationship between overweight and obesity and mental health problems in 4-5 year old Australian children? Ambulatory Paediatrics 6(6); 306 16 Guo, S; Wu, W; Chumlea WC & Roche, AF (2002) Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence. American Journal of Clinical Nutrition 76:653-658. 17 Reilly, J & Wilson, D (2006) ABC of obesity: Childhood Obesity. BMJ 33:1207-1210

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The Australian based Centre of Research Excellence in the Early Prevention of Obesity in Childhood research found the annual direct cost of just preschool children (aged 2-4 years) costs the Australian healthcare system $17 million per annum, with the cost to families of $367 a year compared to a healthy weight child (Brown 201718)

The Victoria Oral Health Alliance data indicates that more than 16,000 Victorian’s experience preventable hospitalisation due to dental conditions each year. Over 6,000 of these are children.19

The effectiveness of existing policies and programs introduced by Australian governments to improve diets and prevent childhood obesity;

School canteens

The majority of schools across Australia use a ‘traffic light’ scheme to classify foods sold in canteens— red foods are restricted, amber foods should not dominate and healthy green food should fill the menu (Hills et al. 2015). Strategies such as these support the healthy eating of Australian schoolchildren through increased availability and promotion of healthy food and drinks in schools (NSW Department of Education 2017)20.

Such policies have proved influential: a previous canteen strategy in New South Wales that used the traffic light approach saw a rise in the proportion of schools offering no energy-dense, nutrient-poor (red) food items on their menu, from 7.0% in 2007 to 22% in 2010 (Hills et al. 2015).

The following is an extract from Healthy Kids Association with respect to school canteen guidelines.

In Australia, each state and territory has developed and implemented nutrition policies and guidelines for their schools and canteens. Public schools are required to abide by these policies, and independent and Catholic schools are strongly encouraged to adopt them.

A list of canteen strategies by state are listed below.

STATE STRATEGY ASSOCIATION NSW The NSW Healthy School Canteen Strategy – Food and Drink Healthy Kids Association (HKA) Criteria W: www.healthy-kids.com.au https://www.healthykids.nsw.gov.au/downloads/file/campaig E: [email protected] nsprograms/TheNSWHealthySchool P: 1300 724 850 CanteenStrategyFoodandDrinkBenchmark_ACCESSIBLECOL A: Suite 1.02, 38 Oxley St, St Leonards 2065 OUR.pdf ACT National Healthy School Canteens Guidelines Healthy Kids Association (HKA) http://www.health.gov.au/internet/main/publishing.nsf/Conten W: www.healthy-kids.com.au t/phd-nutrition-canteens P: 1300 724 850 E: [email protected] A: Suite 1.02, 38 Oxley St, St Leonards 2065 VIC School Canteen & Other School Food Services Policy Victorian School Canteen Association http://www.education.vic.gov.au/school/teachers/health/Page W: http://www.vsca.org.au s/canteendown.aspx E: [email protected] Ph: 421 649 923

18 Brown, V, Majory, M. Baur, l, Wen, LM & Hayes, A (2017) The High Cost of Obesity in Australian Pre-Schoolers. Australian and New Zealand Journal of Public Health. 41(3) 323-324 19 Victorian Oral Health Alliance Joint Position Statement 20 Hills A, Nathan N, Robinson K, Fox D & Wolfenden L 2015. Improvement in primary school adherence to the NSW Healthy School Canteen Strategy in 2007 and 2010. Health Promotion Journal of Australia 26:89–92. Referenced by Australian Institute for Health and Welfare, Australia’s Health, 2018.

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STATE STRATEGY ASSOCIATION QLD Smart Choices Queensland Association of School Tuckshops http://education.qld.gov.au/schools/healthy/food-drink- (QAST) strategy.html W: http://www.qast.org.au E: [email protected] Ph: (07) 3324 1511 Support also provided by Nutrition Australia http://www.naqld.org WA Healthy Food & Drink Western Australian School Canteen http://www.det.wa.edu.au/healthyfoodanddrink/detcms/portal Association / W: http://www.waschoolcanteens.org.au SA Right Bite Strategy Healthy Kids Association (HKA) http://www.decd.sa.gov.au/eatwellsa/pages/eatwell/rightbite/ W: www.healthy-kids.com.au ?reFlag=1 E: [email protected] P: 1300 724 850 A: Suite 1.02, 38 Oxley St, St Leonards 2065 NT Northern Territory Canteen, Nutrition and Healthy Eating No association at present in NT. Policy http://www.education.nt.gov.au/about- us/policies/documents/schools/canteen-policy

Nutrition Australia also provides support for canteens across Australia, see website for contact details and support options for each state: http://www.nutritionaustralia.org.

Healthy Eating Guidelines

That Sugar Movement aligns with the Australian Dietary Guidelines, which recommends children should enjoy a wide variety of foods from these five food groups:

• fruit • vegetables, legumes and beans • cereals (including breads, rice, pasta and noodles), preferably wholegrain • lean meat, fish, poultry and/or alternatives • milks, yoghurts, cheeses and/or alternatives (children under 2 should have full fat milk, but older children and adolescents should be encouraged to have reduced-fat varieties).

Healthy eating from the five food groups (above) is essential for all children. Children should limit their intake of foods that contain saturated fat, added salt or added sugar. They should also be encouraged to choose water to drink.

Issues

• Guidelines are set as a guide and are not enforceable in early learning centres and schools, leaving the implementation of these suggestions at the discretion of the food supplier or educational facility. • Products for sale within vending machines do not need to comply to these guidelines

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• Lack of understanding among parents regarding portion sizes and how to interpret Healthy Eating Guidelines.

Evidence-based measures and interventions to prevent and reverse childhood obesity, including experiences from overseas jurisdictions;

The AIHW, Healthy Australia 2018 report lists several health promotion efforts of government and recognises that, to change a health behaviour, a mix of interventions are often used for greater effectiveness21.

Using the health promotion efforts to reduce the number of smokers aged 14 and over outlined on the following diagram22 as a benchmark, intervention measures over the next 25 years may include:

• Advertising restrictions to children >9.30pm • Apply 20% sugar tax to foods and beverages high in added sugar, with subsequent excise rises • Transparency in food labelling, specifically the inclusion of added sugars on nutritional information panels, and a review of the Health Star rating system aligned to Healthy Eating Guidelines • National health promotion campaign • POS advertising bans promoting products high>5g/100g in added sugar • Mandate 80:20 proportion of healthy foods available in public places, including early learning centres, schools, hospitals, universities, sporting events and community services. • Health warnings on packaging for those foods containing >10g/100g of added sugar • Tackling Indigenous nutrition initiative, reference Mai Wiru Sugar Challenge Foundation • Bans on POS displays featuring foods high in added sugar • Plain packaging and new larger health warnings

The challenge of course, is that we can’t wait.

If weight gain continues at current levels, some 80% of Australian adults and 30% of children will be overweight or obese by 2030, accelerating the need for nutritional literacy and education programs across Australia.

The role of the food industry in contributing to poor diets and childhood obesity in Australia;

Much has been written regarding the lack of transparency in food labelling, specifically the inclusion of “added sugars” on nutritional information panels on all foods and beverages.

That Sugar Movement supports this initiative and believes a foundational element to self-care and empowerment is the provision of accurate information which aids the individual in their decision making.

Listing sugar content on food labels as a total number suggests that all sugars – natural and added, are equally detrimental to health, which is incorrect and further confuses consumers.

21 https://www.aihw.gov.au/getmedia/ad927157-6048-4140-9806-773ce953293e/aihw-aus-221-chapter-7-1.pdf.aspx 22 Australian Institute of Health and Welfare 2016. Australia’s health 2016. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW

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That Sugar Movement regularly receives queries from consumers regarding this topic, with many under the impression that cutting out sugar means reducing fruit and vegetable consumption. Greater transparency and education would reduce confusion.

The application of advertising and marketing messages regarding foods that are “fat free”, “organic”, or “low calorie” is misleading, with many of these foods high in added sugar and nutritionally deficient. Our proprietary consumer research suggested similar attitudes to these marketing terms.

Advertising featuring individuals eating inordinately large portions of food, such as a block of chocolate, a packet of biscuits, a bag of lollies on their own serves to normalise larger portion sizes.

Availability of high-sugar products in prominent end-cap retail POS displays, reduced pricing on high- sugar items also support impulse purchases of these items.

Alignment of foods with toys and cartoon characters has also been shown to increase their appeal with children.

Response from the food manufacturing industry

In May 2017, That Sugar Movement engaged the services of a qualified biochemist, nutritionist and dietitian to engage the support of the food manufacturing industry in a labelling program that would the state presence of added sugars on food packaging. Every four grams [4g] of sugar would be represented by a teaspoon, aligning with the recommended baseline applied by the World Health Organisation of limiting added sugar intake to less than six teaspoons [<25g] a day for additional health benefits.

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Support from the concept was identified difficult to implement, requiring significant changes to existing processes, likely food wastage, and potential negative impact of foods high in added sugars.

Where some product categories would be positively impacted by the proposed changes, these were few and represented a negative overall impact to organisational revenue, therefore considered an unviable proposition.

Products marketed within a healthy context were resistant as the teaspoon label, revealed the added sugar content, exposing the product as being unsuitable.

Rather than companies taking on the responsibility of marketing their product responsibly, adjusting their product formula or even altering the recommended serving size to fit within healthy guidelines, the truth of the teaspoon label posed an economic risk, therefore favouring profit over responsibility of public health.

What does a comprehensive public policy approach look like?

Government intervention in addressing food access, affordability, marketing and taxation remains essential to any significant change. However, the requirement for an evidence-based approach can mean the impact of an intervention model is tracked over a number of years as subsequent initiatives are deployed and assessed.

That Sugar Movement actively supports calls for public policy regarding sugar tax, restrictions on junk food advertising targeting children and the removal of sugary drinks from hospitals, education and sporting facilities, as per the Tipping the Scales report released by the Obesity Policy Coalition23.

It is our strong view a single measure will not halt the growing trend towards obesity and overweight in Australia, with immediate action required, as demonstrated with the strategies used to reduce tobacco use.

Our recommendation is an intervention model that applies a multidisciplinary approach to effecting individual behavioural change and public health outcomes, as per the Behaviour Change Wheel proposed by [Michie et al, 2011]24, which examined nineteen frameworks covering nine intervention functions and seven policy categories that could enable those interventions.

Given the impact of social norms on behaviour change, health promotion must consult and engage people within the community, rather than simply focusing on consumption of energy-dense foods and physical activity.

Increasingly programmes aimed at improving the health of children must be designed in partnership with children and parents (Potvin et al., 2003)25.

23 The eight critical actions Australia must take to tackle obesity, Obesity Policy Coalition, 2017, http://www.opc.org.au/what- we-do/tipping-the-scales 24 The behaviour change wheel: A new method for characterising and designing behaviour change interventions, Implementation Science, 2011, Volume 6, Number 1, Page 1, Susan Michie, Maartje M van Stralen, Robert West

25 Potvin, L., Cargo, M., McComber, A. M., Delormier, T. and Macaulay, A. C. (2003) Implementing participatory intervention and research in communities: lessons from the Kahnawake Schools Diabetes Prevention Project in Canada. Social Science and Medicine, 56, 1295–1305.

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Behaviour Change Wheel, Michie et al 2011