Is it political? Should political parties even have a stand and, if so, would carrots or sticks improve outcomes?
Is there an epidemic?
There is no doubt that as a society we are getting heavier, but we’re not alone. Figure (1) shows the number of Australians with overweight or obesity by age, and graph (1) shows how the risk of overweight and obesity measured as body mass index (BMI: weight in kg/height in m2). Based. On BMI, 25-29 is overweight and 30 or more is obese. The graph shows how these weight categories are tracking overtime in 200 countries
The next graph (2) shows how our rate of change compares with some other developed countries and graph (3) illustrates how we are punching above our weight at 8th heaviest in the world; sandwiched comfortably between Finland and Turkiye. That’s not to say that you can’t be overweight and healthy (so-called metabolically healthy obesity, discussed here. And yes, using BMI as a tool for the definition is also controversial but, in general, higher weight or BMI correlates with increased health risk.
Graph 1: Percentage increase in overweight and obesity over time, based on data from 200 countries.
Graph 2: Percentage change over time in the prevalence of overweight or obesity in Australia and comparable developed countries
Graph 3: Percentage of population who are overweight or obese in Australia and other countries
Interestingly, it has little to do with per capita health expenditure. The USA is way out in front in that league but has higher weight and lower life expectancy than countries with lower per capita health care costs, as shown by graph (4) based on OECD data below.
Graph 4. Longevity versus health expenditure; Retrieved from https://ourworldindata.org [open access online resource]
Individual risks and community costs
So, what risks emanate from this expanding trend, and what might be the role of government policy?
The first risk is to people’s quality of life and longevity. Overweight and obesity are prime causes of illness, particularly type 2 diabetes mellitus, heart and vascular disease, and worsening arthritic and back pain. Thus, they contribute directly to stroke, heart attack, kidney failure and reduced mobility. There are huge health costs associated with these illnesses, which particularly target indigenous and socially disadvantages groups in the community. Aboriginal and Torres Strait Islander Australians are almost three times more likely to have type 2 diabetes than non-indigenous Australians (Australian Bureau of Statistics, 2019), and Aboriginal and Torres Strait Islander children younger than age 17 are 6 to 20 times more likely to develop type 2 diabetes (traditionally considered an adult condition) than non-Indigenous children.
Mortality rates are correspondingly high, and Aboriginal and Torres Strait Islander people are four times more likely to die from diabetes than other Australians (Australian Institute of Health and Welfare, 2020c). Factors that increase the risk of developing type 2 diabetes include high blood pressure, smoking, low levels of physical activity, diets high in sodium, sugar and saturated fats, and being overweight or obese. Aboriginal and Torres Strait Islander people are more likely to have these risks because of poor economic and educational opportunity, unemployment and low income, in many cases poor physical infrastructure such as housing, and access to services, clean water and healthy food supplies.
Disadvantage also relates to loss of connection to land, racism and incarceration. For type 2 diabetes, the age-standardised hospitalisation rate for Aboriginal and Torres Strait Islander adults in 2017-18 was almost five times higher than for non-Indigenous adults .
In addition to these directly related illnesses, there are many others to which overweight and obesity increases risk indirectly – possibly through increased ‘inflammation’. Cancer risk increases as illustrated in Figure (2) below. In Australian data from 2019, it was estimated that 4,000 cancer cases each year were caused by overweight and obesity, and 7% of total health costs were due to overweight and obesity (Dr John Dixon, researcher at Baker Heart and Diabetes Institute).
Figure 2: Cancers for which risk is associated with overweight or obesity.
Health costs related to overweight, obesity and type 2 diabetes
In 2018 it was estimated that obesity cost the Australian community $11.8 billion and if nothing were done, the cost was estimated at $87.7 billion by 2032.
This underestimate did not include all associated health and social impacts. There are clear reasons for investing more in obesity prevention to improve health and well-being, and there are clear fiscal imperatives for developing policy in this area.
What works?
There is no need to reinvent the wheel. There are proven ways to improve this dilemma abd most have been been proposed by 2 Australian Government inquiries and many other leading organisations such as the George Institute for Global Health.
A sugar tax
Over 50 countries have now introduced such taxes. The UK introduced the Soft Drinks Industry
Levy in 2018, which led to reformulation of products equivalent to removing 45 million kg of sugar from soft drinks each year.
Check out this video on introduction of a sugar tax in Mexico, where a 10% tax on sugary drinks resulted in a 7.5% reduction in consumption that was particularly noticeable amongst lower socioeconomic groups.
The ‘Commonwealth Government report on the obesity epidemic in Australia 2018’ © Commonwealth of Australia 2018; ISBN 978-1-76010-870-0 (PDF 1.7MB) suggested that a tax on sugar-sweetened beverages (SSBs) ‘be considered’ because it ‘would drive food and drink companies to focus on marketing healthier products’.
Recommendation 10 called on the Australian Government to introduce the tax, but the inquiry was led by the Coalition, so Labor senators dissented, saying that the measure would impact lower-income households disproportionately because these households spent a greater proportion of their budget on sugary beverages. This is of course an illogical conclusion because that argument supports the tax, but it nicely fits with the food industry’s messaging. The tax would reduce the intake of SSBs by people most impacted, and reduced consumption would lead to improved health. It is a very simple formula, similar to a tax on cigarettes that has also proven effective.
The 2024 Report on The State of Diabetes Mellitus in Australia led by the Labor MP Dr Mike Freelander, also recommended a sugar tax graduated according to the sugar content. ’From reviewing the evidence, the Committee considers that a reconstitution levy on sugar-sweetened beverages (SSBs), comparable to fiscal measures pertaining to tobacco, can contribute towards a healthier Australia’.
Perversely, on this occasion, a dissenting report came from Coalition committee members, who quoted the 2018 dissenting Labor report; ‘This was the position of Labor senators when arguing against a SSB levy as part of the 2018 Senate Select Committee into the Obesity Epidemic in Australia inquiry…. an Australian SSB levy would … impact lower-income households disproportionately’. What goes around comes around! A sugar tax would be positive to the economy but calculations did not include the impact on reduced health expenditure over time, which would be huge if consumption decreased.
Reduce advertising of unhealthy foods
The Royal Australasian College of Physicians told the 2024 Committee that according to a 2024 report by Deakin University, food companies are marketing unhealthy products online in ways that target children as young as 8 years old. ‘Children in Australia see 168 junk food or sugary drink advertisements on the web or mobile devices per week, adding to the 800 promotions they see annually if they watch 80 minutes of television per day.
The Committee recommended that the Australian Government implement food labelling reforms targeting added sugar, to allow consumers to clearly identify the content of added sugar from front-of-pack labelling, and recommended that the Australian Government consider regulating the marketing and advertising of unhealthy food to children, and that this recommendation be applied to television, radio, gaming and online.
Improved access to healthy and affordable food
An inability to access healthy food is seen as a factor underpinning rising rates of Type 2 diabetes and gestational diabetes. As such, multiple submissions to the Committee called for a healthy food subsidy, or a subsidy specifically targeted at remote areas. The Central Australian Aboriginal Congress proposed a direct-to-consumer, point-of-sale subsidy. Miwatj Health suggested funding ‘transport subsidies for food supply to remote communities.’
Healthy foods cost more
A common argument is that ‘healthy food is more expensive’. In remote areas that is undoubtedly true. However, Dieticians Australia said that research on household family shopping from the University of Wollongong confirmed that ‘The average cost of eating a diet rich in seasonal fruit and vegetables is still the most affordable option in this country’. Professor Karen Charlton provides more data on this but the caveat is that it’s only cheaper if done smartly and carefully – pre-recorded radio grabs can be downloaded here.
And there’s the rub, because if you have poor health literacy and are time poor, or don’t have a kitchen and cooking utensils, then eating ‘super cheap processed food like ramen, boxed mac and cheese, canned processed meats, etc. that can create meals for 75 cents a serving’ is a cheaper option.
Reddit comments
food_is_too_expensivedifficult_is_a_myth/?rdt=65172
Public education campaigns to improve attitudes and behaviours around diet and physical activity.
Does this sound like nanny state politics? Perhaps it does, but for years food manufacturers have been driving public education in the opposite direction, and this is not unlike the debate around smoking.
Improve access to exercise by subsidised gym memberships.
This was recently proposed to government by the fitness lobby, and is being ‘considered in the next budget’. The shadow sports minister Anne Ruston says that the opposition is prepared to look at ‘any policy that helps people reduce avoidable interactions with the health care system.’
https://www.abc.net.au/news/2024-04-02/are-tax-deductible-gym-memberships-the-answer-to-our-health-woes/103646036. Interestingly, in a paper from the USA, no-cost gym memberships for adults with high blood pressure led to reduced weight and blood pressure over a 12 month period (Prev Med Rep. 2018 Feb 8:10:66-71), which is not surprising, because multiple studies have shown improvements in health with increased exercise.
Other sensible recommendations from Government reports:
Better urban planning to reduce an ‘obesogenic environment’ and support efforts to improve exercise and a healthy lifestyle.
Consider language and the stigma associated with the term obesity
In prevention and intervention programs and public information campaigns, move the focus from weight to health.
So they’re some thoughts on prevention; always the cheapest way to deal with a problem.
But once you have the problem, where do we go?
At this point everything gets very expensive!
Health care interventions
Targeting childhood obesity.
The 2018 Committee proposed a ‘National Childhood Obesity Strategy’, which as far as I can tell was not instituted. But improving the health of kids will certainly have most bang for buck.
A strategy of ‘intensive behavioural modification’ has been tested in the USA. It is extremely time-consuming and resource-intensive (Figure 3). One US study found that this ‘lifestyle modification therapy’, which includes dietary advice, physical activity and behavioural counselling, requires more than 26 contact hours over 1 year for a 3% BMI reduction (JAMA June 18, 2024 Interventions for Children and Adolescents With High Body Mass Index—Implementing the Recommendations in Clinical Practice). Quite impractical in most settings! The paper goes on to discuss pharmacotherapy and bariatric surgery, which are surely worse options than avoidance or amelioration by other means.
For adults
All the above measures are important, together with newer, effective weight loss drugs that remain in short supply. Of course, weight may be gained when these drugs are stopped so they need to be used together with lifestyle modification. Bariatric surgery can be life-changing and sometimes life-saving for some adults, and access needs to be improved.
Over the last decade, a growing body of evidence has shown that regular physical activity is effective in both primary and secondary cancer prevention. This has led to recommendations for aerobic and resistance training exercises to be embedded into standard cancer management in Australia to counteract the adverse effects of cancer treatments and improve clinical outcomes. Such programs should be encouraged and supported.
Conclusions
Ways to improve the obesity epidemic have been clearly described by Coalition and Labor-led committees over the last 6 years but there is reluctance to change. The stigma and shaming of obesity must be avoided and the emphasis needs to be on health and positive outcomes.
The Australian Democrats would support:
- a progressive tax on sugary products, particularly beverages
- prohibition of advertising of unhealthy products aimed at children and ban advertising of unhealthy products (defined in the latest 2024 report) during common children’s viewing times on all viewing platforms
- clear ‘front of packet’ labelling of the sugar content of all processed foods
- improving access to healthy fresh foods in remote communities, by providing a subsidy at point of sale
- education about healthy eating to the general public, and in primary and secondary schools
- access to management for children with obesity
- PBS listing of newer drugs that assist weight reduction but are not currently listed for that purpose, and support greater access to bariatric surgery
- planning regulations to promote exercise and a less obesogenic environment.
- subsidised or tax-deductible gym memberships, initially for people referred by a GP with conditions amenable to improvement with exercise, such as diabetes and hypertension
- exercise programs that have been shown to improve rehabilitation from cancer therapy.
- institution of the National Obesity Strategy 2022-2032 (Figure 4)
Figure 4: Framework for the proposed National Obesity Strategy 2022-23
So, is it carrots or sticks? A positive approach almost always wins, so it’s carrots of course!
And where is the DRILL going next?
Yes, immigration.
We’ve had the big Australia, the small Australia, children overboard and sending refugees to the USA and New Zealand. We’ve watched as a million refugees were taken in by Angela Merkel, followed by the rise of the extreme right in Germany, President Trump’s Mexico wall and Mr Dutton blaming migrants for the cost of housing. Can Australia develop an ethical yet pragmatic migrant and refugee policy, or is it just too hard? It’s coming next in the DRILL.