OBESITY IN – A DECADE OF INACTION

Obesity in Australia A decade of inaction

Evaluating 10 years of government (in)action against the National Preventative Health Taskforce’s obesity policy recommendations

March 2020 1 ABOUT THE OBESITY POLICY COALITION

The Obesity Policy Coalition (OPC) is ACKNOWLEDGEMENTS a partnership between Council This publication has been produced by the , Victoria, VicHealth Obesity Policy Coalition with input from and the Global Obesity Centre at Deakin Kathryn Bloom, Kate Hagan, Katarnya University; a World Health Organization Hickey, May Hung, Jane Martin and (WHO) Collaborating Centre for Obesity Caroline Mills. Prevention. The OPC advocates for evidence-based policy and regulatory change to address overweight, obesity and unhealthy diets in Australia, particularly among children.

Policy areas in which the OPC has been particularly engaged in political discourse and advocacy since the recommendations of the National Preventative Health Taskforce were released in 2009 have included: * participating in the ongoing governmental process to develop and implement a system for front-of-pack labelling to assist Australians to make healthier choices * advocating for legislative reform to reduce children’s exposure to marketing for unhealthy food and drinks, and * pricing measures to reduce consumption and tackle high rates of overweight and .

opc.org.au OBESITY IN AUSTRALIA – A DECADE OF INACTION

INTRODUCTION

In June 2019, Health Minister Greg Hunt announced that the would develop a National Preventive Health Strategy – a 10-year plan to improve the health of Australians at all stages of life including by targeting modifiable risk factors for chronic disease.1 Public health leaders welcomed the announcement but noted that even with the very best strategy, benefits would only be delivered through effective implementation.2

It is timely, therefore, to reflect on the legacy of a major blueprint that had the ambitious goal of making Australia the healthiest country by 2020. In 2008, the Australian Government (Government) appointed a National Preventative Health Taskforce (Taskforce) to develop strategies to tackle chronic disease caused by tobacco, alcohol and obesity. After 18 months of work by some of Australia’s leading experts the Taskforce released a final report entitled Australia: The Healthiest Country by 2020 – National Preventative Health Strategy – The roadmap for action (Roadmap).3

The Roadmap outlined 27 recommended action items designed to reduce and control obesity in Australia. Preventative health measures were proposed for implementation in a staged manner from 2009. Specific recommendations were set out under 10 Key Action Areas as follows:

1| Drive environmental changes 6| Support the health workforce to throughout the community to support people in making healthy increase levels of physical activity choices. and reduce sedentary behaviour. 7| Address maternal and child health, 2| Drive change within the food supply enhancing early life and growth to promote healthy diets. patterns.

3| Embed physical activity and healthy 8| Develop effective community-based eating in everyday life. programs in low socio-economic status (SES) communities. 4| Encourage healthier eating and activity through comprehensive and 9| Develop effective interventions effective social marketing. among indigenous communities.

5| Reduce peoples’ exposure to 10| Build the evidence base, monitor marketing of unhealthy products. and evaluate the effectiveness of actions.

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In 2010, the Government published its Our analysis reveals that of the 27 response to the Roadmap, indicating its recommended actions, only one has been plans and intended actions in relation to fully completed, 20 have progressed each Key Action Area. to some extent, and six have not been progressed at all. Ten years on Australia’s obesity rates continue to rise, driving increases in Of note, for 11 of the 20 incomplete action noncommunicable diseases (NCDs) such areas, progress has stalled after a strong as heart disease, and start was made under the auspices of cancer. So, what happened to the vision of the Australian National Preventive Health Australia becoming the healthiest country Agency (ANPHA) and the National in the world? Partnership Agreement on Preventive Health (NPAPH), a partnership of the This review considers the Federal Commonwealth, States and Territories set Government’s response to each of the up to improve outcomes in the area of Taskforce’s recommendations and what, if preventative health. any, progress has been achieved in each proposed action. Modelled on an existing The removal of funding for this work in methodology and reporting structure, the 2014 saw progress falter and completely research analyses government reports, cease in many of the action areas which websites and media releases to assess were linked to these initiatives. the degree to which recommendations Most telling of all is the lack of progress have been considered, developed and on the overarching roadmap target of implemented since the Taskforce’s report.4 halting and reversing the rise in obesity This report represents an overview of by 2020. The Taskforce endorsed a target our research. A detailed analysis can be to increase the proportion of adults with found at opc.org.au. Progress for each a healthy body weight by 3% within 10 recommendation has been rated according years (set by the 2008 COAG National to a four-level scale as either ‘completed’, Partnership on Preventive Health). Instead ‘ongoing progress’, ‘progress stalled’ or ‘no the rate of overweight and obesity in progress’. adults continued to rise from 61% in 20075 to 67% in 2017–18.6

Ten years on Australia’s obesity rates continue to rise, driving increases in noncommunicable diseases such as heart disease, type 2 diabetes and cancer.

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SUMMARY OF FINDINGS

KEY ACTION AREA AND RECOMMENDATIONS RATING

1| Drive environmental changes throughout the community to increase levels of physical activity and reduce sedentary behaviour.

1.1 Establish a Prime Minister’s Council for Active Living and develop a National Framework for Active Living encompassing local government, No progress urban planning, building industry and developers and designers, health, transport, sport and active recreation.

1.2 Develop a business case for a new Council of Australian Government No progress (COAG) national partnership agreement on active living.

1.3 Australian and state governments to consider introducing health Progress impact assessments in all policy developments. stalled

1.4 Commission a review of economic policies and taxation systems, and develop methods for using taxation, grants, pricing, incentives and/or No progress subsidies to promote active living and greater levels of physical activity and decrease sedentary behaviour.

2| Drive change within the food supply to promote healthy diets.

2.1 Develop a comprehensive National Food and Nutrition Framework. No progress

2.2 Commission a review of economic policies and tax systems and develop methods for using taxation, grants, pricing and incentives No progress and/or subsidies to promote production, access and consumption of healthier foods.

2.3 Examine and develop systems and subsidies that increase the availability of high-quality fresh food for regional and remote areas, Progress focusing on regional and remote transport, and increasing the stalled production of high-quality, locally grown fresh foods that are available to the community.

2.4 Drive change within the Australian food supply by establishing a Healthy Food Compact between governments, industry and non- government organisations to reduce the production and promotion of Ongoing foods and beverages that are energy dense and nutrient poor, are high progress in sugar, saturated fats and salt which contain trans fats, by setting targets for these nutrients.

2.5 Introduce food labelling and front of pack and menus to support healthier food choices, with easy to understand information on energy, Ongoing sugar, fats and saturated and trans fats, salt, and a standard serve/ progress portion size within three years.

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3| Embed physical activity and healthy eating in everyday life.

3.1 Fund, implement and promote school programs that encourage Ongoing physical activity and enable healthy eating. progress

3.2 Fund, implement and promote comprehensive programs for Progress workplaces that support healthy eating, promote physical activity and stalled reduce sedentary behaviour.

3.3 Fund, implement and promote comprehensive community-based interventions that encourage people to improve their levels of physical Progress activity and healthy eating, particularly in areas of disadvantage and stalled among groups at high risk of overweight and obesity.

4| Encourage healthier eating and activity through comprehensive and effective social marketing.

4.1 Fund effective social marketing campaigns to increase physical activity Ongoing and healthy eating and reduce sedentary behaviour and support progress people to make informed choices about their health.

5| Reduce peoples’ exposure to marketing of unhealthy products.

5.1 Phase out the marketing of energy-dense nutrient-poor (EDNP) food and beverage products on free-to-air and Pay TV before 9pm within four years. Phase out premium offers, toys, competitions and the use of promotional characters, including celebrities and cartoon characters, No progress used to market EDNP food and beverages to children across all media sources. Develop and adopt an appropriate set of definitions and criteria for determining EDNP food and drink.

6| Support the health workforce to support people in making healthy choices.

6.1 Contribute to relevant national policies (e.g the National Primary Progress Health Care Strategy) to ensure key actions to improve preventative stalled health are considered and implemented in the primary care setting.

7| Address maternal and child health, enhancing early life and growth patterns.

7.1 Establish and implement a national program to alert and support pregnant women and those planning pregnancy to prevent lifestyle Ongoing risks of excessive weight, poor nutrition, smoking and alcohol progress consumption.

7.2 Support the development and implementation of a National Ongoing Breastfeeding Strategy in collaboration with the state and territory progress governments.

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8| Develop effective community-based programs in low SES communities.

8.1 Fund, implement and promote effective and relevant strategies and programs to address specific issues experienced by people in low- Progress income communities, such as lack of access to affordable, high quality stalled fresh food.

8.2 Fund, implement and promote multi-component community-based Progress programs in low SES communities. stalled

8.3 Provide resources for brief interventions from the primary healthcare Progress setting. stalled

9| Develop effective interventions among Indigenous communities.

9.1 Fund, implement and promote multi-component community-based Progress programs in Indigenous communities. stalled

9.2 Strengthen antenatal, maternal and child health systems for Indigenous Ongoing communities. progress

9.3 Fund, implement and promote effective and relevant strategies and programs to address specific issues experienced by people in Progress Indigenous communities such as lack of access to affordable, high stalled quality food.

10| Build the evidence base, monitor and evaluate the effectiveness of actions.

10.1 A national prevention agency to develop a national research agenda Progress for overweight and obesity with a strong focus on public health, stalled population and interventional research.

10.2 Expand the National Health Risk Survey Program to cover adults and Completed the indigenous population.

10.3 Ensure that the National Children’s Nutrition and Physical Activity Ongoing Survey is repeated on a regular basis to allow for the ongoing progress collection of national data on children.

10.4 Support ongoing research on effective strategies to address social Ongoing determinants of obesity in Indigenous communities. progress

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Scorecard

This table illustrates the level of progress on the Taskforce’s recommendations within each of the 10 key action areas and provides a total progress rating.

Ongoing Progress No Key Action Area Completed progress stalled progress

1| Drive environmental changes throughout the community to increase levels of physical 0 0 1 3 activity and reduce sedentary behaviour 2| Drive change within the food supply to promote healthy 0 2 1 2 diets 3| Embed physical activity and healthy eating in everyday 0 1 2 0 life 4| Encourage healthier eating and activity through 0 1 0 0 comprehensive and effective social marketing 5| Reduce peoples’ exposure to marketing of unhealthy 0 0 0 1 products 6| Support the health workforce to support people in making 0 0 1 0 healthy choices 7| Address maternal and child health, enhancing early life 0 2 0 0 and growth patterns 8| Develop effective community- based programs in low SES 0 0 3 0 communities 9| Develop effective interventions among 0 1 2 0 indigenous communities 10| Build the evidence base, monitor and evaluate the 1 2 1 0 effectiveness of actions

TOTALS 1 9 11 6

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DISCUSSION

The National Preventative Health Taskforce spent considerable time and effort to develop a suite of promising evidence-informed interventions to improve population and meet the goal of becoming the healthiest country by 2020. Ten years on, most of the Taskforce’s recommendations for policy reform to reduce overweight and obesity rates have not been developed or implemented.

Apart from the introduction of the Star Rating system (HSRS). Implementing Health Star Rating System, key policy an interpretive front-of-pack labelling and regulatory interventions to create a scheme, supported by public education to healthier environment, such as taxes and increase nutrition literacy for both adults pricing strategies to reduce consumption and children,8 is a key recommendation of of harmful products and measures to global reports such as the World Health reduce children’s exposure to marketing Organization’s recent Commission on have not been implemented. This is Ending . Australia has despite robust supporting evidence, been assessed as meeting best practice strong and documented public support on implementation of policies to improve and established international action population nutrition, due to implementation bringing such measures squarely into the of the HSRS.9 mainstream of policy options to reduce rates of chronic disease. The overarching objective of the HSRS to provide nutrition information on There has been an emphasis on actions food packages to assist consumers to which focus on individual behaviour make healthier choices is not being fully change, rather than on policies and realised however due to significant flaws regulation that would create an that impact on its public credibility. This environment supportive of healthy eating includes the current algorithm generating and active living. Measures that focus inappropriately high ratings for some foods on influencing the environment through with high levels of added sugar, sodium and systems change are more effective and saturated fat. It is also important to note less likely to widen inequities. The policy that the HSRS remains a voluntary system and regulatory initiatives to create a with variable uptake between product healthier environment are those that the categories, and even within them,10 thereby ultra-processed food industry, together limiting its benefits for consumers. with other vested interests, fight hardest against.7 There has been some progress to build the evidence base (Key Action Area 10);

in particular, there has been progress in The positive steps funding research on effective strategies the low-hanging fruit to address social determinants of obesity in Indigenous communities. In addition, Australia has made some progress to drive significant data has been collected through change within the food supply to promote the Australian Health Survey, but further healthy diets (Key Action Area 2) by data collection is required to better inform developing and implementing the Health

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policy and practice interventions for the physical activity across the population, with Indigenous population. Some progress has a focus on vulnerable communities. Work also been made to develop and run social on the National Nutrition Policy and the marketing initiatives and public education National Research Agenda for Overweight campaigns (Key Action Area 4). and Obesity was also discontinued. Since then, there has been a lack of federal Missed opportunities leadership to prevent overweight and The OPC believes that the termination obesity in Australia. A major failing has of the National Partnership Agreement been the failure to adopt obesity prevention on Preventive Health (NPAPH) and the goals across sectors (Key Action Area 1). Australian National Preventive Health There has been a lack of ongoing interest Agency (ANPHA) marked a backwards in ’s ‘Health in All Policies’ step for public health policy and programs, approach at a national level, and few efforts and public education on preventive health. to incorporate considerations of health into A key component of NPAPH was to other portfolios. Lack of national leadership establish enabling infrastructure to in this area may have contributed to the relatively poor uptake of a Health in All drive national preventive health policy Policies approach by Australian states in and programs. ANPHA was established influential policy areas such as planning, under NPAPH to provide evidence-based environment and transport. advice to Federal, State and Territory Health Ministers, support research on In several other policy areas, action preventive health in Australia, improve started strongly, but development and the effectiveness of health interventions, implementation of many initiatives has and implement national guidelines faltered. Funding for the the Healthy and standards to guide prevention Workers Initiative and the Healthy activities. ANPHA was mainly focused on Children’s Initiative was withdrawn with addressing risk factors of alcohol, tobacco the cancellation of the NPAPH in 2014 consumption and obesity (including diet and some programs were continued and physical activity), which contribute sporadically in jurisdictions that provided to approximately 40% of preventable funding. 11 hospitalisations and chronic conditions. In Key Action Area 9: prioritising the When NPAPH and ANPHA were implementation of preventative health terminated, ANPHA’s essential functions initiatives in Indigenous communities, were transferred to the Department of action faltered despite an encouraging Health. This increased the pressure on the start. Specifically, funding for the health budget and led to fewer programs Healthy Lifestyle Workers Initiative was and research on the key risk factors of discontinued when the government overweight, obesity and physical activity. reduced the Tackling Chronic Disease As a result, many of the programs that had Package prevention measure to Tackling started to address the recommendations in Indigenous Smoking alone. Since the expiry this report were discontinued due to lack of the National Aboriginal and Torres Strait of funding or only continued sporadically Islander Nutrition Strategy (2000–2010) in some jurisdictions with reduced state there has been no specific food and funding. Programs discontinued when nutrition policy targeting Indigenous diet, ANPHA and NPAPH were terminated nutrition and food security.12 included the Healthy Communities Initiative, which delivered community-based In the area of physical activity (Key Action interventions to improve nutrition and Area 1) there has been little action to

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change the environment. Planning and and more recently in 2017 introduced development provides an illustrative regulations in non-broadcast media.16 example of a potentially influential policy Chile has implemented the world’s most area that has not adequately incorporated comprehensive approach to marketing preventive health considerations. A lack restrictions to date, introducing regulations of leadership at the national level has that restrict advertising for TV programs or meant insufficient impetus for states websites targeting children younger than to amend planning, development and 14 years, or where children younger than 14 building policies, and laws to promote make up more than 20% of the audience. physical activity. Although some states In 2019, the advertising ban in Chile was have investigated the possibility,13 only extended to advertising on TV, radio and Queensland’s Sustainable Planning movie theatres between 6am and 10pm.17 Act 2009 has prioritised the physical The Australian Government’s approach health and sustainability of communities to the issue has also been at odds with through reform to planning legislation,14 international recommendations. In 2010, while Tasmania’s Land Use Planning and recognising the evidence of the effects Approvals Act (1993) objectives include on children of unhealthy food advertising, promoting sustainable development “which the World Health Assembly endorsed enables people and communities to provide recommendations by the World Health for their social, economic and cultural Organization for countries to develop policy well-being and for their health and safety.” mechanisms to reduce children’s exposure The opportunity for national leadership to unhealthy food advertising and to in increasing active transport through eliminate this advertising from all children’s planning and transport reforms has also settings.18 The World Health Organization’s been missed. Commission on Ending Childhood Obesity Failure to tackle recommendations also include reducing children’s exposure to marketing of key interventions unhealthy foods and beverages.19 Key interventions where there has been a complete lack of action have included In light of the international momentum investigating taxes and pricing strategies to that has amassed in support of this Key reduce consumption of harmful products, Action Area since the Taskforce’s report, and implementation of measures to reduce it is particularly disappointing that in children’s exposure to unhealthy food Australia, progress on the issue has not marketing. even extended to Government monitoring or evidence gathering to determine the Reducing exposure to advertising extent and nature of Australians’ exposure (Key Action Area 5) to different types of marketing. No The OPC believes that the lack of action to comprehensive independent evaluation of reduce Australians’ exposure to marketing the existing industry-based codes, which of unhealthy food and beverages has were developed around the same time as been particularly disappointing. Australia the Taskforce’s recommendations, has been has fallen further behind comparable undertaken, nor any evidence gathering jurisdictions such as the United Kingdom, to establish baseline measurements that started to implement broadcast of adults’ and children’s exposure to regulations to reduce children’s exposure marketing. Moreover, the media landscape to harmful food advertising in 2007,15 has undergone dramatic changes over

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the last 10 years with the advent of digital level and to curb the global rise of life-style marketing, and the codes have failed related non-communicable diseases.23 Taxes dismally to keep pace. on sugary drinks have been introduced in more than 45 countries and smaller Investigation of economic, pricing jurisdictions.24 Evaluation data from Mexico and tax mechanisms to promote demonstrates that the tax was generally health (Key Action Areas 1 and 2) passed on through the prices and that Another notable disappointment to the consumers have reduced their purchases OPC has as been the lack of willingness of taxed beverages. Purchases of taxed from successive Australian Governments beverages decreased 5.5% in 2014 and 9.7% to consider economic strategies, including in 2015, yielding an average reduction of tax and pricing measures, to improve health 7.6% over two years.25 through active living and healthy eating. Australia’s lack of engagement with the Research has shown that in relation to issue is also contrary to global health sugary drinks, implementation of a tax to imperatives. The WHO’s Global Action reduce rates of overweight and obesity in Plan for the Prevention and Control of Australians is cost-effective and acceptable Noncommunicable Diseases 2013–2020 to most consumers.20 21 The Government recommends governments consider response to the roadmap advised that economic policies, including taxes and the ANPHA would play a critical role subsidies, to improve the affordability of in the development of any economic healthier food products and discourage interventions. However, the ANPHA was the consumption of less healthy options, to terminated prior to the development of help achieve goals for improved health and any economic strategies. contained obesity rates by 2020.26 No other strategies to use economic The WHO has also recently recommended policies, subsidies or pricing mechanisms that governments tax sugary drinks to to shape behaviour to improve health have address type 2 diabetes, overweight and been announced, trialled or implemented. obesity and tooth decay. This measure is A 2015 Federal Government discussion also acknowledged for its role in cutting paper, calling for submissions on tax reform, healthcare costs and increasing revenues merely referred to a levy on sugary drinks to invest in health services.27 The WHO’s as an example of a corrective tax used Commission on Ending Childhood Obesity in other parts of the world.22 The current Report, released in 2016, also recommends refusal by the two major Australian political an effective tax on sugary drinks to parties to give proper consideration to increase the price by at least 20%. The such policies puts Australia out of step with Commission clearly states that there is growing international implementation of sufficient rationale to implement a tax on policies using food and beverage taxes to sugary drinks.28 reduce consumption of specific products and/or nutrients. The Australian Senate Inquiry into the Obesity Epidemic in Australia also There is increasing impetus in international recommended consideration of the law and policy discourse for countries to introduction of a tax on sugary drinks.29 adopt economic measures such as taxes to change behaviours at the population

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CONCLUSION

Overall, our analysis found a general At this point in time, when the present lethargy and lack of progress on Government is considering introducing a the part of successive Australian national obesity strategy, it is instructive governments to implement the elements to review the failure of successive of a comprehensive strategy to address governments to deliver outcomes obesity. This has been characterised by against the National Preventative an obvious reluctance by government to Health Taskforce’s obesity policy support obesity prevention and general recommendations. A comprehensive preventive health organisations, and approach, crossing sectors and including to engage in regulatory and legislative regulatory and legislative reforms, is reforms to address environmental needed to make progress towards factors. This includes a failure to consider reducing the prevalence of overweight regulation of advertising to children, or to and obesity in Australia. implement tax and pricing measures to improve health through active living and healthy eating.

In addition, many of the positive efforts made by the Government since 2009, including significant funding for community, school and workplace-based programs, and research, have been discontinued with the termination of NPAPH and ANPHA.

...Lack of progress has been characterised by an obvious reluctance by government to support obesity prevention and general preventive health organisations...

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REFERENCES

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