Obesity

Here you’ll find a comprehensive research review, created specifically for The Well. Analysing the contemporary evidence base on obesity, with up-to-date and academically reviewed information. This research was authored by Bonnie Rosen – Symplan Consulting, and academically reviewed the World Health Organisation Collaborating Centre for Obesity Prevention, Population Health Strategic Research Centre, Faculty of Health, Deakin University

Last updated Oct 17, 2019

Obesity

Obesity in Australia has more than doubled in the past 20 years, and high body mass index (BMI) is the greatest contributor to the burden of the diseases that can ensue.

Impacts & Outcomes


Health outcomes of obesity

Serious health consequences can result from being overweight or obese. These include type 2 diabetes, hypertension, cardiovascular disease, stroke, certain cancers, risks to pregnant women, loss of mental health and wellbeing, quality of life and premature mortality. Health outcomes of obesity can include the development of non-communicable diseases (NCDs), poor mental health and wellbeing. Other health outcomes include poor oral health and sleep breathing problems (sleep apnoea).

High body mass index is the greatest contributor to the burden of disease, accounting for 55% of its burden (AIHW, 2012). Overweight and obesity contribute to four of the seven diseases included in the national health priority areas (diabetes, cancer, cardiovascular health, musculoskeletal disease) which together represent 64.2% of total expenditure on national health priority areas (AIHW, 2012).


Non-communicable diseases (NCDs)

Non-communicable diseases (NCDs) are chronic diseases of long duration and generally slow progression (WHO, 2013). There are four main types of NCDs: cardiovascular diseases (like heart attacks and stroke); cancers; chronic respiratory diseases (such as chronic obstructed pulmonary disease and asthma) and diabetes (WHO, 2013). These chronic diseases are caused by multiple factors in a person’s genetics, lifestyle and environment. The Australian Health Survey (2011-2012) highlighted that one million Australians suffered from diabetes mellitus (4.6% population, however only 3.9% with type 2 diabetes); 1.1 million from heart disease (5% population); 2.3 million from hypertensive disease (10.6% population) and 183,400 from kidney disease (0.9% population) (ABS, 2013).

Risk factors for NCDs include tobacco smoking, alcohol consumption, poor diet and not being physically active (WHO, 2013). As excess weight increases, so does the risk of chronic disease and mortality. Being overweight, and in particular, being obese increases the risk of developing a number of diseases and conditions such as coronary heart disease, increased blood pressure, increased blood cholesterol, type 2 diabetes, chronic kidney disease, certain cancers, musculoskeletal conditions, sleep apnoea and mental health problems and disorders (AIHW, 2012). Losing weight can reduce the incidence and severity of the majority of these conditions (AIHW, 2012).

People with chronic conditions such as heart disease, diabetes, arthritis, cancer and kidney disease, all of which are associated with obesity, are twice as likely to report that they experienced toothache, discomfort with their oral appearance or had avoided some foods due to oral problems often or very often. They are also more likely to experience oro-facial pain and have inadequate dentition. Similarly, people with chronic disease are less likely to report that their oral health was good, very good or excellent (74.7% compared to 86.9% respectively). Approximately 11% of people with a chronic condition expressed that oral health impacted on their general health. Oral conditions include toothache, discomfort with oral appearance, avoiding certain foods and oro-facial pain. They are also more likely to have inadequate dentition which makes it difficult to chew food. People with diabetes are less likely than people with any other chronic condition to visit the dentist (AIHW, 2012).

Obesity also poses significant risk to pregnant women. During pregnancy obesity can cause pre-eclampsia, gestational diabetes, abnormalities of the baby’s growth, development and general health and sleep apnoea. Furthermore, obesity can delay the progress of labour and delivery, because difficulties in monitoring the baby’s heart result in difficulties administering pain relief and increase the risks of complications with an emergency caesarean. After the birth, obesity can increase the risk of infection and blood clots and can cause postnatal depression (The Royal Women's Hospital, 2014).


Mental health and wellbeing

Overweight and obesity also impact mental health and wellbeing. People who are overweight or obese, particularly children, may experience discrimination and are prone to depression and problems with cognition. This may lead to productivity losses across a range of sectors. Evidence suggests diet quality contributes to some mental health issues (Jacka, Mykletun, & Berk, 2012) and poor diet is specifically implicated in increased risk of depression (Jacka & Berk, 2007). Greater fruit and vegetable consumption (a marker of diet quality) has been demonstrated to be associated with lower odds of depression, psychological distress, self-reported mood and anxiety disorders and poor perceived mental health in a study of Canadians (McMartin, FN, & Colman, 2013). Recent longitudinal studies in adults have supported cross-sectional studies that there is a bi-directional link between depression and obesity (Luppino, et al., 2010).

Individuals with obesity had a 55% increased risk of developing depression, and having depression increased the risk of developing obesity by 58% (Luppino, et al., 2010). This association is being researched further to understand the complex nature of the relationship. This information, along with the large impact on the length and quality of people’s lives, and exorbitant societal costs, prompted the Canadian Obesity Network, World Obesity (formerly the International Association for the Study of Obesity) and the Centre for Mental Health and Addiction to develop the Toronto Charter on Obesity and Mental Health to decrease the negative consequences of obesity and mental health using a range of strategies to focus on enabling change through policy, the role of health professionals, and expanding and disseminating knowledge (Canadian Obesity Network, 2012).


Other health conditions

Obesity is associated with compromised productivity in the workplace. Productivity losses amongst truck drivers who are overweight or obese are amongst the highest of any occupation. Loss of productivity in the transportation industry can have repercussions for productivity across the whole of the economy. In particular, sleep apnoea is associated with narcolepsy, i.e. falling asleep on the job, potentially causing serious injuries and fatalities in the broader community (Funder, 2011).

Obesity can result in sleep breathing abnormalities due to the increased mass (adipose tissue) loading the chest wall and abdomen which affects respiration rates (Kopelman, 2000). Irregular respiration and occasional apnoeic episodes disturb sleep patterns (Kopelman, 2000). In severe cases, these sleep breathing abnormalities can result in cardiac arrhythmias (Kopelman, 2000).

Recently, evidence has supported the notion that inadequate sleep (<7 hours) may be an independent risk factor for overweight and obesity (Jean-Louis, et al., 2014). A study using US National Health Interview Survey data (1977-2009) revealed the prevalence of overweight and obesity; and very short sleep (<5 hours) and short sleep (5-6 hours) to increase over time (Jean-Louis, et al., 2014). In comparison to 7-8 hour sleepers, the odds of being overweight increased with very short and short sleep, and the odds of being obese were increased with very short, short and long sleep (Jean-Louis, et al., 2014). The obesity-sleep relationship is not entirely understood however sleep duration should be considered in public health campaigns (Jean-Louis, et al., 2014).


Economic impacts

Overweight and obesity contribute to four of the seven diseases included in the national health priority areas, namely, diabetes, cancer, cardiovascular health, musculoskeletal disease which together represent 64.2% of total expenditure on national health priority areas (AIHW, 2012). Health problems related to excess weight impose substantial economic burdens on individuals, families and communities. High body mass index is the greatest contributor to the burden of disease, accounting for 55% of its burden (AIHW, 2012). The total direct cost for overweight and obesity in 2005 was $21 billion ($6.5 billion for overweight and $14.5 billion for obesity). The same study estimated indirect costs of $35.6 billion per year, resulting in an overall total annual cost of $56.6 billion (Colagiuri, et al., 2010). Obese people use on average ten more days of sick leave a year (Funder, 2011).

In 2004-05, expenditure on diabetes represented 4.3% of expenditure on all national health priority area conditions (AIHW, 2012). Given that diabetes is also a cause of other diseases such as cardiovascular and renal diseases, total allocated health expenditure attributable to diabetes is greater than the $1.0 billion in direct allocated expenditure (AIHW, 2012). Between 2000-01 and 2004-05, expenditure on endocrine, nutritional and metabolic diseases increased by 32%, and expenditure on diabetes increased by 26% (AIHW, 2012).

Prevalence

The prevalence of obesity in Australia has more than doubled in the past 20 years. The direct costs associated with overweight and obesity in Australia exceed $21 billion per annum (Colagiuri, et al., 2010). If weight gains continue at current levels, by 2025 close to 80% of all Australian adults and a third of all children will be overweight or obese (Department of Human Services, 2008).

Global estimates from 2010 suggested that approximately one billion adults were overweight (BMI 25-29.9kg/m2) and a further 475 million were obese (IOTF, 2014). Additionally, in 2011 it was estimated that 40 million children under five years old were overweight (WHO, 2013). The prevalence of overweight and obesity among Australians has been steadily increasing for the past 30 years (AIHW, 2012). Australia currently has the third highest rate of obesity overall in the Organisation for Economic Co-operation and Development (OECD) countries, behind Mexico and the United States of America (OECD, 2013). In 2011–12, 62.8% of Australian adults were classified as overweight or obese (35.3% overweight, 27.5% obese); and 25.1% of children aged 2–17 were overweight or obese (18.2% overweight, 6.9% obese) (ABS, 2013)).

Categorisation of individuals into overweight or obese categories is conducted using body mass index (BMI), which is defined as weight in kilograms divided by the square of the height in meters (kg/m2) (WHO, 2013). Individuals with a BMI over 25kg/m2 are categorised as overweight and those with a BMI of over 30kg/m2 are categorised as obese (WHO, 2013).


Overweight and obesity in the Australian context

The continuing rise of overweight and obesity, resulting from poor diet, excessive energy intakes and low levels of physical activity, is one of the greatest public health challenges facing Australia. Due to the burden of disease that obesity places on individuals, their families and the community, halting and reversing the increase in obesity in both adults and children has become one of Australia’s key health priorities (AIHW, 2012).

In 2011–12, 62.8% of Australian adults were classified as overweight or obese (35.3% overweight, 27.5% obese) and 25.1% of children aged two–17 were overweight or obese (18.2% overweight, 6.9% obese) (ABS, 2013). It is predicted that there will be continued increases in overweight and obesity levels across all age groups during the next decade in Australia, increasing to 66% (NHMRC, 2013).

In 2012–13, two-thirds (65.6%) of Aboriginal and Torres Strait Islander people aged 15 years and over were categorised by BMI with 28.6% overweight and 37.0% obese (ABS, 2013). Furthermore, almost one-third (30.4%) of Aboriginal and Torres Strait Islander children aged two–14 years were overweight or obese (ABS, 2013). When compared to non- Aboriginal and Torres Strait Islander people, in almost every age group obesity rates for Aboriginal and Torres Strait Islander females and males were significantly higher (ABS, 2013).

In 2011-12, data from the Australian Health Survey identified that adults living in inner regional, outer regional and remote areas of Australia were more likely to be overweight or obese compared to adults living in major cities, regardless of gender (ABS, 2013). In Australia, basic nutritious foods in rural and remote areas can cost up to 30% more than in capital cities and be less available. South Australia has the highest proportion of overweight and obesity in Australia, and Victoria the lowest proportion (ABS, 2013).


Overweight and obesity in the Victorian context

In 2010, 62.6% of Victorians were overweight or obese with 38.1% being classified as overweight and 24.5% classified as obese. This equates to approximately 2.4 million people aged 18-75 (Department of Health, 2012). Results of a 2012-2013 survey of Aboriginal and Torres Strait Islander people over the age of 15 years estimated that 14,700 Victorian Aboriginal and Torres Strait Islander people were overweight or obese (7,100 overweight, 7,600 obese) (ABS, 2013).

According to the 2011 Census, the Victorian Aboriginal and Torres Strait Islander population was 37,988 persons, therefore the proportion of overweight and obese is high. The prevalence of overweight and obesity and diabetes is higher in Victorians living in rural areas than it is amongst Victorians living in urban areas (Department of Health, 2012). Additionally, in 2009, perinatal BMI was collected from 63,394 Victorian women revealing 24% women to be overweight, and 18% obese (Consultative Council on Obstetric and Paediatric Mortality and Morbidity, 2012).

Determinants

Frameworks can be useful in describing the various factors which influence the development of obesity. There are various frameworks and models available, such as the social determinants of health (WHO, 2003); within a local government context (Victoria, Australia) using the Municipal Public Health Plan (Department of Health, 2001); or within a global systems approach using the Foresight Model (Government Office for Science, 2007). The social determinants of health approach examines upstream and downstream influencing factors on health (Braveman, Egerter, & Williams, 2011). The Municipal Public Health Plan (MPHP) aims to provide a framework to systematically address individual, organisational, community, social, political, economic and environmental factors involved in health; particularly through personal, social and environmental action (Department of Health, 2001).

Four key environmental dimensions are focused on – built/physical environment (e.g. urban planning, transport); social environment (e.g. demographics, ethnicity); economic environment (e.g policy, industrial development) and natural environment (e.g. climate, geography) (Department of Health, 2001). Given the strong international recognition of the Foresight Model, and its consideration of the social determinants of health (SDoH) and MPHP domains, this will be the framework focussed upon in this report. The following matrix outlines the relevant links between these three models.


The Foresight Model

The Foresight Model was designed within the Government Office for Science in conjunction with over 300 experts and stakeholders to determine how best society might tackle obesity in the UK over the next 40 years in a sustainable manner (Government Office for Science, 2007). A systems mapping approach allowed an understanding of the biological and social complexity of obesity. The map produced was highly complex, revealing that it will not be simple to tackle the issue of obesity. Overall, four key determinants driving energy balance were established.

These key determinants were physiological factors (e.g. appetite control in the brain), eating habits, activity levels (e.g. physical activity) and psychosocial influences (which influence lifestyle choice). The creators suggested that a positive feedback cycle locks individuals into a pattern of positive energy balance (energy intake exceeds energy expenditure) and combined with the four determinants the result is excess weight gain (Government Office for Science, 2007).

The map’s core was energy balance which was surrounded by 108 variables which might influence energy balance. These variables are clustered into seven themes: biology/physiology; individual activity; physical activity environment; food consumption; food production; individual psychology; social psychology (Government Office for Science, 2007). There are >300 solid or dashed lines representing relationships between variables (positive and negative influences) and some connections cause a feedback look between variables (Finegood, Merth, & Rutter, 2010).

The Foresight Model of obesity is extremely complex, with many factors contributing to the development of obesity. However, this map allows for the identification of many potential pathways which result in obesity and therefore helps to identify points at which it might be best to intervene.


Thematic clusters within the Foresight obesity map

Biology/physiology

This Foresight Model theme includes biologic variables such as genetic predisposition to obesity, satiety levels, resting metabolic rate and maintenance of appropriate body composition (Government Office for Science, 2007). Additionally, genetic/inheritable factors can affect gastrointestinal physiology, stomach capacity and emptying and inherited feelings of hunger which subsequently may affect meal size (de Castro, 2004).

Susceptibility genes which are inherited can determine who will become obese in any environmental circumstance (Kopelman, 2000). Twin studies (monozygotic (identical) versus dizygotic (non-identical) and adoption and family studies have provided evidence of the important roles genes play in the development of body composition. Differences in racial/ethnic groups also supports evidence for a genetic component of obesity (Xia & Grant, 2013).

Evidence is also emerging regarding the importance of intrauterine exposures such as maternal obesity, maternal diet and excess gestational weight gain may lead to increased risk of developing obesity in offspring (Poston, 2012). Additionally, foetal under nutrition during intrauterine development may influence the development of obesity, hypertension and type 2 diabetes later in life, regardless of inherited genetic factors (Kopelman, 2000).

In a very small proportion of individuals, endocrine and hypothalamic disorders may contribute to obesity (Jebb, 1997). Candidate genes associated with the development of obesity (e.g. leptin) have been identified to be involved in regulation of appetite and thermogenesis (Kopelman, 2000), however these genetic defects cannot be responsible for the epidemic proportions of obesity observed today.


Individual activity

This theme includes the types and level of physical activity (e.g. recreational, domestic, occupational, transport activity), parental modelling of physical activity and learned activity patterns (Government Office for Science, 2007). Over the last 50 years, daily energy expenditure has decreased due to fewer jobs requiring manual work; increased labour-saving technology (at home, work and retail environments), changes in work and shopping patterns which have resulted in higher dependency on motorised transport, increased self-sufficiency at home (entertainment, food storage and preparation, climate control) and reductions in active transport such as walking and cycling (Fox & Hillsdon, 2007). Of concern is the greater time spent in sedentary pursuits, particularly sitting, due to higher disposable income for consumer goods such as TVs, stereos, computers, game stations (Fox & Hillsdon, 2007).

A recent systematic review examining physical activity interventions suggested that overall exercise has a positive effect on body weight in overweight and obese individuals, particularly when the intervention included a diet component. The exercise also improved cardiovascular risk factors such as blood lipid profiles and blood pressure even when no weight loss occurred (Shaw, Gennat, O'Rourke, & Del Mar, 2009). Physical activity can also improve quality of life, particularly for older people who benefit from social interaction and engagement with the community whilst undertaking the activity (Fox & Hillsdon, 2007).

Of high importance is embedding physical activity early in life. Physical inactivity in adolescence has been found to strongly and independently predict overall and abdominal obesity in young adulthood, resulting in the development of a vicious circle of further obesity, physical inactivity and low energy expenditure in life (Pietilainen, et al., 2008).


Physical activity environment

This theme includes variables which may be enablers or barriers to conducting physical activity. These may include the influence of the environment on an individual’s behaviour, costs, perceived safety involved and cultural values (Government Office for Science, 2007). Environmental influences are important as they can increase energy intake and/or decrease energy expenditure (Jebb, 1997).

Our current environment discourages physical activity with advances in technology and transportation reducing the need to be active daily. Adults and children spend an increased about of time in appealing sedentary pursuits such as television, electronic games and computers. Creative ways will need to be designed to oppose attractive sedentary pursuits. The participation of parents for children can increase the likelihood of children participating and the activity being fun.

Environments need to be more conducive to physical activity, and schools should encourage children to engage in daily physical activity given the tracking of health behaviours over the lifespan (Hill & Peters, 1998). Creating active transport policies in conjunction with a supportive built environment have been suggested to not only be beneficial for health (e.g. mortality, obesity, chronic disease, mental health), but also advantageous to the environment in the long term (e.g. decrease air pollution, greenhouse gases, noise, traffic hazards) (de Nazelle, et al., 2011). Evidence suggests that environments that encourage walking are associated with more active transport and less driving (de Nazelle, et al., 2011).

The family home environment is important in developing children’s health behaviours and consequently is important in influencing their likelihood of developing obesity (Hendrie, Coveney, & Cox, 2011). Children can learn through behaviour imitation, parental support, reinforcement of favourable behaviours and from family rules and restrictions (Hendrie, Coveney, & Cox, 2011). In children, the family activity home environment has been found to be positively associated with physical activity (e.g. a more supportive home had higher levels of physical activity); and negatively associated with screen time (e.g. less screen time in a supportive home) (Hendrie, Coveney, & Cox, 2011).

Geographic location may be an important enabler for participation in physical activity (Veitch, Salmon, Ball, Crawford, & Timperio, 2013). An audit of Victorian parks (urban vs. rural) found that urban parks had better scores for access, lighting and safety, suitability of paths for walking and cycling and play equipment that was diverse. Rural parks were scored more aesthetically attractive (Veitch, Salmon, Ball, Crawford, & Timperio, 2013). The scores may help to explain why rural park users were less physically active than urban park users (Veitch, Salmon, Ball, Crawford, & Timperio, 2013). Furthermore, examining the association between ‘greenness’ (e.g. presence and condition of green vegetation) and weight status revealed higher levels and greater variation of neighbourhood greenness to be associated with lower odds of obesity in Australian adults (Pereira, et al., 2013). This could be due to higher levels of physical activity due to the protective effect of living in a leafy green neighbourhood (Pereira, et al., 2013). In an elderly population, the built environment (assessed by a neighbourhood walkability score) was associated with increased walking for exercise (Berke, Koepsell, Moudon, Hoskins, & Larson, 2007).


Food consumption

This includes variables such as the characteristics of food products (abundance, variety, nutritional quality, energy density, portion size) (Government Office for Science, 2007). The current environment promotes opportunities to consume large quantities of food by providing highly palatable, inexpensive foods in large portion sizes everywhere (Hill & Peters, 1998). In a meta-analysis analysing physical activity interventions, diet alone was significantly more effective at weight loss than exercise alone (Shaw, Gennat, O'Rourke, & Del Mar, 2009), indicating just how important diet modification is.


Food production

This includes the drivers of the food production industry (market price, ingredient cost, production efficiency, profitability, social and economic societal situation, societal pressure to consume) (Government Office for Science, 2007). Our current environment contains an unlimited supply of convenient, relatively inexpensive, highly palatable, energy-dense foods, which promotes high energy intake (Hill & Peters, 1998). The global food market is highly complex, and given the future pressures such as global population growth, economic growth in countries, climate change, a limited supply of natural resources and a rise in poor nutrition resulting in obesity and chronic disease; food industries have to develop plans to sustainable and resilient long-term (DAFF, 2011).


Individual Psychology

This includes psychological attributes and the drive for foods, such as self-esteem, stress, food literacy, parenting style (Government Office for Science, 2007). The degree in which humans can attempt to control their food intake differs amongst individuals, due to psychological factors. Physiological regulatory systems can be over-ridden by voluntary or cognitive factors (Jebb, 1997).

Hedonic pathways can drive the consumption of rewarding foods which seek pleasure. These foods are the palatable foods and often contain sugar, fat and salt which subsequently reinforce individuals to consume more to their taste. This can lead to an addictive-like cycle (Swencionis & Rendell, 2012).

Stress, and the individual’s capacity to control stress, can contribute to the development of obesity with suggestions that stress can influence the increased consumption of high fat foods (Jebb, 1997), high sugar foods and ingest more calories without having an increased appetite (Swencionis & Rendell, 2012).

There are suggestions that restrained eating can also contribute to the development of obesity whereby restrained eaters may have increased susceptibility to the availability of highly palatable foods, which then stimulates excess food consumption (Jebb, 1997).

A recent review highlights the potential negative psychological consequences of being overweight and obese in adolescents which include low self-esteem, depression, disordered eating behaviours (e.g. dieting, fasting, binging, laxatives, diuretics), body dissatisfaction, weight stigmatisation and weight-based teasing (Harriger & Thompson, 2012).


Social psychology

This includes variables whereby society can have an influence (media, education, social desirability/acceptability, culture, peer pressure) (Government Office for Science, 2007).

The human race is social and therefore affected by social influences. The social facilitation of food intake suggests that individuals will eat larger quantities of food if dining with other people present rather than alone (de Castro, 2004). Internal hunger cues are suggested to also be part mediated by external cues as the larger amounts and increased varieties of food also results in individuals eating more (Swencionis & Rendell, 2012)).

Media and advertising has a strong influence on society. The internet has changed the way companies market products and there is a trend to step away from television commercials as the most influential marketing vehicle (Jain, 2010). New marketing strategies include product placement within television and movies, viral marketing (e.g. chain email), guerrilla marketing (e.g. free giveaways), advertainment and advergaming (e.g. online games which include advertising)and neuromarketing research methods (which utilise brain imaging to draw upon emotions) (Jain, 2010). Mobile phones, music players, social networking sites and social connectivity allow continuous exposure to advertising in many different forms (Jain, 2010).

From a young age it is thought that individuals learn what constitutes an idea or attractive body size via sociocultural exposure. Different racial and ethnic groups perceive body size in different ways. In some Pacific Island communities, the church plays a central role in influencing attitudes to giving and eating food and places a high value on it since many individuals cannot afford monetary donations. The celebration of food is embedded into Fijian and Tongan culture, with communal gatherings with a wealth of traditional food and drink for religious, political, economic and social activities. Television, magazines and advertisements promote an ideal body image (Bonsergent, et al., 2012). This combined with the social stigma attached to obesity and a “fat phobia” has been suggested to influence individuals daily regarding their body image, with the suggestion that girls are more aware of their bodies compared to boys (Bonsergent, et al., 2012).

Risk & Protective Factors

There are many risk factors associated with the development of overweight and obesity. Main risk factors include low fruit and vegetable intake, low levels of physical activity, increased levels of sedentary behaviour and low breastfeeding rates.


Fruit and vegetable consumption

The food we eat plays a significant role in our health and wellbeing. It contributes to the healthy development of infants and children and the reduction of chronic disease and premature death amongst adults. Poor diet is a risk factor associated with chronic diseases such as cardiovascular disease, diabetes and some cancers, all of which are major causes of death and disability in Australia (AIHW, 2012). Inadequate vegetable and fruit intake is responsible for 30% of coronary heart disease, 20% of gastrointestinal cancer and 14% of stroke (VicHealth, 2012)).

Eating a balanced and varied diet is essential for good health. This involves eating fruits and vegetables and reduced fat products to provide the body with sufficient fibre, minerals and vitamins (VicHealth, 2012)). Poor diet involves the consumption of large intakes of energy-dense foods with high saturated fat, sugar and/or salt content and low intakes of nutrient-dense foods such as vegetables, fruit and wholegrain cereals (AIHW, 2012). Diets high in fat are associated with increased risk of obesity (AIHW, 2012). A substantial amount of evidence has suggested a link between sugar-sweetened beverages and an increased weight gain and risk of obesity (Hu, 2013)). Sugar-sweetened beverages include soft drinks, fruit drinks, energy and vitamin water drinks containing sugar (Hu, 2013)); and in the Australian context, cordial. Sugar-sweetened beverages can be referred to as offering ‘empty calories’ as whilst they provide energy, they provide almost no nutritional value (Hu, 2013)). There is a suggestion that decreasing sugar-sweetened beverages will reduce obesity risk and the risk of developing other obesity-related consequences such as type 2 diabetes (Hu, 2013)). The World Health Organisation is currently updating its guidelines on sugar intake for adults and children. The Australian Dietary Guideline 3c states to limit intake of foods and drinks containing added sugars which include confectionary, sugar-sweetened beverages (soft drink, cordial, fruit drinks, vitamin waters, energy drinks and sports drinks) with supporting evidence of an association between these items and type 2 diabetes, excess weight, dental caries and reduced bone strength (NHMRC, 2013)).

The Australian Dietary Guidelines for fruit and vegetable consumption are presented in Table 2. Examples of a serve of vegetables are: half a cup of cooked green or orange vegetables, beans, peas or lentils, one cup of green leafy or raw salad vegetables, half of a medium potato. Examples of a serve of fruit include one medium apple/banana/orange/pear, two small apricots/plums, one cup diced/canned fruit (NHMRC, 2013)).

Table 2- Minimum recommended serves of vegetable and fruit per day, by age and gender (adapted) (NHMRC, 2013))

Vegetables

Fruit

2-3yrs

4-8yrs

9-11yrs

12-18yrs

19-50yrs

51-70yrs

70+yrs

2-3yrs

4-8yrs

9-70+yrs

Males

5

6

5

1

2

Females

5

5

5

5

5

1

2


Family meal times

Additionally, family meal times appears to be a protective factor for the development of overweight, unhealthy and disordered eating (Hammons & Fiese, 2011)). A meta-analysis of studies examining shared family meals and their frequency in relation to the nutritional status of children and adolescents revealed that children and adolescents who shared three or more family meals a week were more likely to be in the normal weight range, with healthier diets and eating patterns, and less likely to adopt disordered eating habits (Hammons & Fiese, 2011)).


Sedentary behaviour

Physical activity is defined as any bodily movement produced by skeletal muscles that requires energy expenditure (WHO, n.d.). Physical activity time is calculated as the sum of the time spent walking or performing moderate physical activity per week, plus double the time spent in vigorous physical activity. In 2010, the proportion of Victorians undertaking sufficient physical activity to meet national guidelines was 69% (Department of Health, 2012).

Inadequate physical activity may result from sedentary lifestyles associated with prolonged and uninterrupted periods of sitting or reclining. Sedentary behaviour is the overall sitting time which is eight or more hours per day (Department of Health, 2012). Sedentary lifestyles are associated with time spent sitting e.g. while watching TV or at the computer. Most people spend between three and six hours a day sitting during their leisure time, over and above sitting during their working day (AIHW, 2012). At present, over a quarter of Australians (26%) report sitting for eight or more hours during a typical day (Australian Government, 2009). Prolonged sitting, which differs from inadequate physical activity, can lead to a number of health issues such as musculoskeletal disorders, cardiovascular disease, diabetes and eye strain (Healy, et al., 2012). Workplace sitting has been associated with an increased risk of mental disorders and depression including job stress, depression and fatigue (Healy, et al., 2012). In addition, the use of email and internal telephone systems are likely to have reduced the amount of time employees have in face-to-face contact with each other, potentially affecting social wellbeing (Healy, et al., 2012).

Physical inactivity is associated with an increased risk of ill health and death, particularly for diseases such as cardiovascular disease, type 2 diabetes and chronic kidney disease. In addition, it is associated with other risk factors such as overweight or obesity, increased blood pressure and increased blood cholesterol (AIHW, 2012). Physical inactivity has been identified as the fourth leading risk factor for global mortality causing an estimated 3.2 million deaths globally (WHO, n.d.), and estimated to cost Australia more than $719 million a year, contributing to 6.6% per the burden of disease and injury in Australia, rating second after tobacco smoking, 22% of heart disease, 11% of stroke, 14% of diabetes and 10% of breast cancer, in addition to 16,178 premature deaths (VicHealth, 2012). Individually, physical inactivity accounted for approximately 7% of the overall burden of disease and injury in Australia in 2003, placing it fourth out of the 14 risk factors analysed. For diabetes, physical inactivity was the second highest contributor to the burden of disease, accounting for 24% of its burden (AIHW, 2012).

Adequate physical activity supports optimum health and wellbeing by preventing and managing chronic disease and maintaining a healthy body weight (AIHW, 2012). Regular physical activity has a protective effect, reducing the risk of developing diseases such as cardiovascular disease, chronic kidney disease and type 2 diabetes (AIHW, 2012). Furthermore, increasing participation in physical activity and reducing time spent sitting in a day is associated with a number of health benefits including promoting health and prevention of disease, improving individual self-confidence and social connectedness, improving the wellbeing of the local workforce and productivity, reducing local traffic congestion and contributing to safer (VicHealth, 2012). The benefits of physical activity have prompted the development of Healthy by Design, a practical guideline to help local governments in Victoria develop supportive environments and opportunities for individuals to be physically active where they live, work and visit (National Heart Foundation of Australia, 2012).

The idea is to incorporate health into planning and design for walking and cycling routes, streets, local destinations (which are walkable/rideable), open space, public transport, supporting infrastructure (e.g. seating, signage, lighting, fencing and walls) and fostering community spirit (National Heart Foundation of Australia, 2012). This initiative was internationally recognised in the WHO “Closing the gap in generations” report (CSDH, 2008). In further support of the importance of creating supportive environments for health such as increasing open park space and ensuring maintenance of these parks; a recent study conducted in New York City demonstrated that greater access to park spaces and park cleanliness was associated with lower BMI in adults (Stark, et al., 2014).


Breastfeeding rates

Breastfeeding has many health benefits for both infant and mother. For infants, breastfeeding helps protect against infection, some chronic diseases (e.g. type 1 and type 2 diabetes), coeliac disease, inflammatory bowel disease, lowers cardiovascular disease risk factors (high blood pressure, cholesterol and obesity) and enhances cognitive development. Mothers can benefit from reduced risk of ovarian and breast cancer and type 2 diabetes in women who have experienced gestational diabetes. Current National Health and Medical Research Council Infant Feeding Guidelines (2013) recommend sole breastfeeding until approximately six months old when solids are then introduced and to continue breastfeeding until 12 months of age and beyond as mother and child choose (NHMRC, 2013).

Interventions


Obesity prevention background

Current evidence regarding effective strategies to prevent obesity is lacking (de Silva-Sanigorski, et al., 2010), with insufficient information to draw strong conclusions about which approaches are most effective (Lemmens, Oenema, Klepp, Henriksen, & Brug, 2008). More understanding of the characteristics of obesity prevention interventions such as the impact, the extent to which they work equitably and how safe they are to implement is required (Waters, et al., 2011). The most promising equitable, sustainable and cost-effective community-based obesity prevention approaches appear to be multi-sector, multi-strategy approaches in children (de Silva-Sanigorski, et al., 2010).

Settings such as schools, preschools and child care facilities have an important role of promoting healthy eating and physical activity, and the majority of obesity prevention interventions have been conducted in schools (de Silva-Sanigorski, et al., 2010). Schools have the advantage of being able to reach large populations of children, with varying socioeconomic circumstances, and provide an opportunity to subsequently implement the programs into surrounding communities (Manios, et al., 2012). However, given the multifactorial nature of obesity, and the many potential factors which influence its development, it is important to implement a holistic multifactorial approach, of which, can be guided by a socio-ecological framework (Manios, et al., 2012). The socio-ecological framework incorporates multi-level influences on individual behaviours with other important factors such as culture, organisational policies, practices and regulations, and engagement with the wider community such as engaging relevant stakeholders to be involved in the design, implementation and evaluation of the proposed program (de Silva-Sanigorski, et al., 2010) (Manios, et al., 2012). This model will be discussed in detail below.


The Socio-Ecological Framework

The socio-ecological framework considers interactions between individual behaviours and the role of the environment. With regards to obesity, it suggests that not only is weight status influenced by energy intake and expenditure, but it is also influenced by interrelationships between an individual’s personal dimensions (e.g. biomedical, attitudinal, behavioural factors) and other multiple components of the individual’s life context (e.g. social, organisational, community, public policy, physical environment) (Willows, Hanley, & Delormier, 201). This framework is a variation of Bronfenbrenner’s Ecological Systems Theory (Center for Disease Control and Prevention, 2013) (McLeroy, Bibeau, Steckler, & Glanz, 1988).

The socio-ecological framework (Center for Disease Control and Prevention, 2013)


Individual

Individual factors include characteristics of the actual individual such as knowledge, attitudes, behaviour, attributions, beliefs and the developmental history of the individual. Strategies focused at the individual level aim to facilitate behaviour change through enhancing the individual’s knowledge, skills, life experience, attitudes and beliefs through the provision of information and education. An example of a strategy which would target this component includes a social media campaign to educate adolescents and young adults regarding the benefits of physical activity in order to increase knowledge and influence the development of a positive attitude to physical activity (WHO, 1986).


Interpersonal

This component represents interpersonal processes and primary groups, individual’s interactions with one another, including social network and social support systems (families, peer groups, friendship networks) (Center for Disease Control and Prevention, 2013) (McLeroy, Bibeau, Steckler, & Glanz, 1988). Strategies focused at the interpersonal level aim to facilitate behaviour change by affecting social and cultural norms and overcoming individual-level barriers via networks and relationships with friends, family, health care providers, community health workers, etc. to enhance self-help, social support and greater participation. A strategy which would target this component would be the creation of a walking group which allows peers to support the individual and influence change.


Institutions and organisations

This component includes social institutions with organisational characteristics and rules for operation (e.g. commercial organisations, social institutions, associations and clubs, workplaces, schools, health services). Strategies focused at the organisational level aim to facilitate behaviour change by influencing organisational systems and policies, structure, organisational culture, rules and regulations enabling them to influence the physical and social environments maintained within their organisation. The replacement of fast food and soft drinks in a workplace would be one strategy which would target this component and subsequently encourage employees to replace unhealthy food with healthier options (McLeroy, Bibeau, Steckler, & Glanz, 1988) (WHO, 1986).


Community/Built Environment

Communities can be defined as a larger societal construct comprised of the three previous components of the model with geographical, political, structural and cultural characteristics (Center for Disease Control and Prevention, 2013). Strategies focused at the community level aim to facilitate behaviour change by influencing the structural and functional components of the community to create supportive, healthy places and spaces where people live and play – and leveraging resources and participation of community-level institutions and coalitions, community advocacy groups and the media. A strategy which covers this component includes creating a food co-operative and farmers market for a community which may have poor access to fresh fruit and vegetables.


Structures, policies and systems

The outermost component includes local, state and national laws and policies (McLeroy, Bibeau, Steckler, & Glanz, 1988) and represent the structures and systems that affect the built environment surrounding the communities and subsequently the individual (Center for Disease Control and Prevention, 2013). Strategies focused at the policy and system level aim to facilitate behaviour change by influencing and building healthy public policy by putting health on the agenda of policy makers in all sectors and at all levels, and promoting a coordinated action that leads to health, income and social policies that foster greater equity. The development of safe parks and recreational areas, and ensuring footpaths are present to increase walkability, as part of local government planning processes, is an example of a structural change embedded into policy to facilitate increased activity (Center for Disease Control and Prevention, 2013).


Obesity Prevention Strategies

There is no definite path for the prevention of obesity as yet and debate continues on what the most appropriate set of actions and outcomes should be (Swinburn, Gill, & Kumanyika, 2005)). When designing strategies for obesity prevention interventions thought should be given to factors such as gender, age, culture so that strategies and key messages can be appropriately tailored. With an understanding of the socio-ecological framework and the complex determinants of obesity as portrayed by the Foresight model, the next section will present obesity prevention strategies for each component of the socio-ecological framework.

The methodology for evidence-based medicine, which relies on making clinical decisions utilising an evidence base which primarily involves rigorous randomised control trials, is not appropriate for the public health field given that this methodology is too artificial or unrealistic for the complex systems affecting population health (Swinburn, Gill, & Kumanyika, 2005)). Therefore, it is suggested that obesity prevention strategies should still be evidence based however, this means using the best evidence available, not always the best evidence possible (Swinburn, Gill, & Kumanyika, 2005)). To maximise the interactions between sites and promote rapid dissemination of findings into policy and practice, the CO-OPS Collaboration plays a vital role in capturing and synthesising this information to accelerate the translation of what has been learned on the ground, and put it into practice and policy (Swinburn, et al., 2007)).

Quick reference guide to strategies across the socio-ecological model

Quick reference guide to strategies across the socio-ecological model

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Individual strategies

Issue - Reduced breastfeeding rates

  • Recommended strategy - Access to information and professional support to promote breastfeeding.
  • Example - Australian Breastfeeding Association provides the following services: classes; pump hire; email counselling, helpline, access to local support groups, online forums; many breastfeeding information resources.
  • Useful resources - Australian Breastfeeding Association website

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among children

  • Recommended strategy - Communication to parents – about healthy lunchboxes, reducing screen time, promoting physical activity (walking, strength-based and other), active transport, reducing intakes of energy-dense nutrient poor foods/drinks at and away from home, promoting family meal times (without TV on).
  • Example - Nutrition Australia website also has a diverse range of resources and services available regarding healthy eating, physical activity. Examples include Reclaim the lunchbox workshop for parents and newsletters.
  • The National Health and Medical Research Council (2013) Australian Dietary Guidelines use the best available scientific evidence to provide information on the types and amounts of foods, food groups and dietary patterns that aim to promote health and wellbeing, reduce the risk of diet-related conditions, and reduce the risk of chronic disease, across all age groupings.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among adults

  • Recommended strategy - Telephone and web-based lifestyle behaviour change programs.
  • Example - NSW Get Healthy Information and Coaching Service. This is a free service for six months and includes support (ten free coaching calls), information (booklet, progress journal, online modules and resources), tools and calculators to track progress and success stories from other participants. Key themes include health eating, physical activity and achieving and maintaining a healthy weight.
  • The Life! program is an alternative health coaching program to reduce the risk of type 2 diabetes, heart disease and stroke.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among adults

  • Recommended strategy - Brief advice/guidelines for nutrition, physical activity and weight management.
  • Example - The Australian Government's Department of Health Healthy Weight Guide contains guidelines to nutrition and physical activity (even over the different life stages), calculators (e.g. BMI, calorie/kilojoule calculator), and tip sheets.

Issue - Increased levels of overweight and chronic disease risk

  • Recommended strategy - Health checks for individuals at high risk for chronic disease.
  • Example - The Chronic Conditions Manual 1st edition 2015 - Prevention and Management of Diagnosed Conditions in Australia (Queensland Government) are an essential resource for staff to use in planning or delivery of prevention, detection and management activities and programs for chronic disease, including child and adult check procedure manuals, diagnosed condition guidelines, and care plan and screening summaries, with a specific focus upon the Indigenous population.

Inter-personal strategies

Issue - Reduced breastfeeding rates and unhealthy feeding practices among infants

  • Recommended strategy - Community-based mother’s groups promoting breastfeeding and infant healthy eating practices.
  • Example - Deakin University's Infant Program. Researchers from Deakin University in conjunction with the Royal Children’s Hospital developed and trialled the program across Victoria with very encouraging results. The program aim is to influence parents’ knowledge and parenting confidence and improve lifestyle behaviours of parents and children, by promoting healthy eating and active play behaviours. The program consists of six sessions delivered to parents of young infants over the first 18 months of the child’s life.
  • The Growing Strong - Pregnancy, breastfeeding, food and drink for children (Queensland Government) resources were developed for Aboriginal and Torres Strait Islander families. Resources are available online; however health staff members are also able to talk to families about nutrition for mothers, babies (breastfeeding and the introduction of solids) and young children. Resources include brochures, information booklets, and flipcharts for health staff members.
  • Fun not Fuss with Food (Queensland Government) - a program for health staff to provide nutrition information for parents. Resources include a powerpoint presentation, DVD and parent resource kit (fact sheets), tips for child friendly meals, food activities and games, healthy nutrition ideas.

Issue - Increased levels of sedentary behaviour and physical inactivity

  • Recommended strategy - Group-based physical activity programs/classes.
  • Example - Heart Foundation Walking website - The Heart Foundation has created an easy system online where you can join up to a walking group in your area. Walking groups are made up of a variety of individuals with varying physical activity abilities, diverse cultures and age groups.
  • Heartmoves - The Heart Foundation has developed a low-to-moderate intensity exercise program for individuals who have health conditions. Individuals can search online for their closest local group.
  • BEAT IT - The BEAT IT physical activity program was accredited Australian Diabetes Council and is a program suitable for individuals with diabetes, obesity, high blood pressure. BEAT IT classes are run twice a week and include aerobic and resistance training. Individuals can look online for the closest class in their area.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among adults

  • Recommended strategy - Community-based lifestyle behaviour change programs.
  • Example - Lighten Up to a Healthy Lifestyle Program (Queensland Health) developed this program for adults who want to eat well, be active, manage stress and have a sustainable healthy lifestyle. The program is delivered over 9-10 weeks by health professionals, with a mix of workshops and individual appointments.

Issue - Increased levels of overweight and chronic disease risk

  • Recommended strategy - Community-based lifestyle behaviour change program for fathers and children.
  • Example - Healthy Dads, Healthy Kids - This program has been developed with a primary aim of decreasing weight in fathers, along with helping fathers become a role model for health promoting behaviours to their children. These behaviours include physical activity, healthy eating, and ways to have fun and get fit with children. The program consists of seven weekly sessions (three for fathers only, four for fathers and children) which are delivered by trained facilitators.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among children and adolescents

  • Recommended strategy - Culturally appropriate family-focused weight management programs.
  • Example - Parenting, Eating and Activity for Child Health (PEACH) The PEACH program was initially run as a research project (2004), funded by National Health and Medical Research Council. The aim of the program was to take a whole-of-family approach and support families to manage their child’s weight by upskilling in nutrition, parenting and problem solving. The website contains resources such as nutrition and activity guidelines, healthy lunch box ideas, recipes, ideas to be physically active at home. Success of the project was demonstrated by a reduction in degree of overweight at the end of the program (six months) which was maintained over the next 18 months. Children’s behaviours were improved (increased fruit and vegetable intake, decreased intake of sweetened beverages and high fat/sugar foods, decreased screen time), improvements in parenting skills, good attendance rates at program sessions and a high level of satisfaction (99% parents would recommend the program to others).
  • The Ethnic Communities Council of Queensland Living Well Multicultural Program. This program is designed for adults from culturally and linguistically diverse backgrounds (languages the program has been translated into include Arabic, Bosnian, Indian, Samoan, Sudanese, Vietnamese, Spanish). Sessions will help family and the community to make healthy lifestyle choices, manage any chronic disease and improve health. Sessions are chosen by the community and include presentations, food activities, discussions, DVDs, cooking demonstrations, games and quizzes.
  • Useful resource - Living Strong Program (Queensland Health)

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among families

  • Recommended strategy - Community-based lifestyle behaviour change programs.
  • Example – FOODcents. The Department of Health funds the Cancer Council WA and Diabetes WA to coordinate the program in WA. The aim of the program is to help educate families how to achieve a healthy diet which is good value for money. The website contains some great resources regarding how to eat smart, shop smart, cook smart and move smart.

Organisational strategies

Issue - Reduced breastfeeding rates

  • Recommended strategy - Support for breastfeeding at the workplace and child-care centres.
  • Example - The Australian Breastfeeding Association can provide a consultancy service for employers to examine how workplaces can be made more breastfeeding friendly, and receive a formal accreditation of being a Breastfeeding Friendly Workplace.
  • Useful resources - Australian Breastfeeding Association Breastfeeding and Work website.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks among infants and young children

  • Recommended strategy - Strategies to reduce energy-dense, nutrient-poor foods/drinks in lunchboxes in child-care and schools.
  • Example - The Australian Government Department of Health has developed Get Up & Grow resources for early childhood settings, families, staff and carers to provide a national consistent approach to childhood nutrition and physical activity. The Get up & Grow website with numerous resources including a director/coordinator book, a staff and carer book, a cooking for children book, a family book, posters, brochures and stickers. Resources have also been specifically developed for Aboriginal and Torres Strait Islander childcare educators, families and carers. The resources are also available in nine additional languages.
  • Useful resources- Get Up & Grow: Healthy Eating and Physical Activity for Early Childhood resources

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks

  • Recommended strategy - Professional development and capacity building of teachers, caterers, food service providers and other staff.
  • Example - Nutrition Australia can provide a diverse variety of workshops for any nutrition topic of interest; can conduct menu assessments, parent workshops, nutrition and food handling courses.

Issue - Low levels of food literacy among children

  • Recommended strategy - Nutrition, cooking and food preparation skills in education curriculum.
  • Example -The Stephanie Alexander Kitchen Garden Foundation includes regular kitchen and garden classes with eight-twelve year old school children. The aim of the program is to establish positive eating habits that will last for life. Teachers are provided comprehensive training and resources to deliver the program, as well as the requirement of setting good examples and engaging children’s curiosity, energy and taste buds. It is hoped the skills learnt during the classes will enable children to grow and cook their own seasonal fruits and vegetables.

Issue - Reduced intakes of fruit and vegetables among children

  • Recommended strategy - Subsidised fruit and vegetable programs in primary schools.
  • Example - Free Fruit Friday was an initiative run by the previous Victorian Brumby government where the schools received a grant to purchase fruit for students in prep-grade 2 (fund allocation 70c/child) over a period of 3 years. However this initiative has ceased to exist in its current form and Boost Juice is currently running a campaign to fund and deliver fresh fruit to 300 Victorian schools (prep-grade 2). A website allows fruit sponsors to sign up and sponsor this activity in a particular school and options to sustain the program are currently being developed.

Issue - Increased levels of sedentary behaviour and physical inactivity among children

  • Recommended strategy - Multi-component physical activity programs in schools.
  • Example - Smart Moves - Physical Activity Programs in Queensland State Schools. From 2009 in all Queensland state schools, the Queensland Department of Education and Training implemented the Smart Moves initiative which had an aim of increasing physical activity participation, and the quality of activities delivered to all students.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among adults

  • Recommended strategy - Workplace nutrition and physical activity programs (large, blue-collar industries).
  • Example - The Australian Government's Healthy Workers initiative website. A comprehensive website which has resources for employees, and resources for employers with regarding to employee health and creating a healthier workplace. Topics include eating well, moving more, healthy weight, smoking e.g. being smoke free), alcohol, case studies with examples of what other workplaces have implemented, and resources for individual states and territories. There is also a calculator which will calculate the savings associated with a successful health program (including absenteeism and staff turnover).
  • Nutrition Australia Workplace Health services includes deliverance of presentations to employees on a wide range of topics, cooking demonstrations, smoothie/soup/salad demonstrations, healthy food cook offs between employees, health displays, canteen menu assessments and one-to-one consultations.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks, and reduced levels of physical activity among adults

  • Recommended strategy - Workplace awards/incentives for environmental/infrastructure changes to the workplace (e.g. healthy catering/vending machine guidelines; end of trip facilities).
  • Example - Healthy Choices Healthy Futures (HCHF) program, run by the Western Australian School Canteen Association (WASCA) provides support to workplaces in the area of nutrition. HCHF can provide advice, support and recommendations for any set up – whether it be the basic workplace kitchen or tea room, an on-site café or staff canteen, vending machines, fundraising gifts or the catering ordered for meetings and events.

Issue - Reduced levels of physical activity among adults

  • Recommended strategy - Active travel
  • Example - Warrnambool City Council Healthy Moves program. This is an initiative in Warrnambool, Victoria, which encourages primary school-aged children and their families to be active and healthy with a particular focus on encouraging children to use active transport (“use their feet and legs”) to get to school, and learn ways in which they can be more active, healthier and safe on streets and roads. Some of the strategies include walking groups to school, the Ride2School program (Bicycle Victoria), healthy food choices (pre-active travel to school), TravelSmart which raises active travel opportunities.

Community strategies

Issue - Increased levels of sedentary behaviour and physical inactivity

  • Recommended strategy - Playground and green open space; Land use zoning near schools and public playgrounds; Walkable active urban design.
  • Example - Heart Foundation's Healthy By Design. The goal of this initiative is to increase environmental support and opportunities for individuals to be physically active by integrating health into planning and designing spaces which encourage walking and cycling to local amenities, schools, parks and public transport. The website has resources such as a planner’s guide to developing an environment which promotes active living, and tools for assessment and design.

Issue - Reduced breastfeeding rates

  • Recommended strategy - Parenting (breastfeeding) facilities in public venues.
  • Example - Breastfeeding Welcome Here program. The Breastfeeding Welcome Here program was developed by the Australian Breastfeeding Association to improve community acceptability of breastfeeding in public by promoting breastfeeding friendly premises. Breastfeeding Welcome Here stickers can be displayed on the premises of these venues, upon the basis that three criteria are met: a) A welcoming attitude from staff and management of the venue, b) the venue is smoke free, and c) there is room to move a pram. Venues which display these stickers and fulfil the criteria can register themselves and subsequently mothers can find a list of venues which are breastfeeding friendly online.

Issue - Low levels of food literacy among adults

  • Recommended strategy - Specific food access and availability interventions in disadvantaged communities (e.g. community kitchens).
  • Example - Community Kitchens Australia. A national website has been developed for anyone interested in being involved in a Community Kitchen. Once registered as a member, individuals can access information on how to find a kitchen, how to set one up, how to volunteer in one, recipes and an online discussion forum. Community kitchens generally meet three times a month at a community venue (e.g. community centres, churches, welfare organisations, men’s sheds, clubs schools) with a session consisting of one facilitator and six participants. Two recipes are prepared (decided by a group vote) which are economical (approximately $2-$5/serve). Participants benefit from social skills, teamwork and leadership skills, how to budget, cook and shop, increased motivation to cook at home, how to access food, improved literacy and numeracy, and improved confidence and self-esteem.
  • Useful resources - Jamie’s Ministry of Food Australia. Communities can apply to have a Ministry of Food pop-up kitchen for 12 months which will provide hands-on cooking classes, information about food (e.g. where it comes from, how to cook it, how it affects their bodies) and give families the skills to cook tasty, exciting and nutritious food.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks

  • Recommended strategy - Incentives for stores in disadvantaged areas to create a healthy food retail environment (e.g. encouraging farmer markets in “food deserts areas”).
  • Example - Remote Indigenous Stores and Takeaways (RIST) Project. To improve access to healthy foods in Aboriginal and Torres Strait Islander People in remote communities, the Australian Government Health Departments (SA, WA, NT, QLD, NSW) designed a project to improve standards for healthy remote stores. The website for this project has an abundance of tools and resources such as:
    • Guidelines for stocking healthy food in community stores
    • How to maximise the shelf-life of fruit and vegetables
    • How to promote the sale of healthy food items (marketing ideas)
    • Healthy fast food manual – how to promote and support healthy eating with guidelines and recipes for takeaway venues
    • A healthy store checklist for store owners
    • A checklist to determine how healthy the takeaway venue is
    • A freight improvement toolkit to improve access to remote community stores
    • Heart Foundation buyer’s guide to help managers/owners of stores and takeaways decide which brands of foods and beverages are encouraged by the Heart Foundation
    • A practical tool to keep track of healthy food by retailers, store committees, health practitioners and researchers by entering sales data and providing data about the turnover of different foods.

Issue - Increased levels of sedentary behaviour and physical inactivity

  • Recommended strategy - Point-of-decision prompts to encourage stair usage.
  • Example - A systematic review of 16 studies revealed strong evidence to suggest that stairwell enhancements (e.g. painting the walls, adding carpet, artwork and playing music) combined with point of decision prompts were effective in increasing stair usage and may indirectly change attitudes towards using stairs.
  • Useful resources - Soler RE, Leeks KB, Buchanan LR, Brownson RC, Heath GW, Hopkins DH. Point-of-decision prompts to increase stair use: a systematic review update. Am J Prev Med 2010; 38 (S2): S292-300.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks

  • Recommended strategy - Pricing strategies, prompts and promotions at point-of-purchase, and store layout redesign in grocery stores, vending machines, cafeterias and restaurants to support healthier choices.
  • Example - Healthier Options for Vending - an Employer Resource (HOVER) by Eat Well Tasmania. HOVER takes a collaborative, cross sectoral approach to supporting healthy eating in Tasmanian workplaces by educating employers about the importance of supplying healthier food options and subsequently a healthier food environment to employees in the workplace. HOVER has resources for employers, vending machine suppliers and health professionals and helps support the establishment of mixed vending (i.e. dry pre-packaged products with fresh options such as dairy and fruit), or fresh vending (i.e. fresh sandwiches, sushi, ready to heat meals, dairy, fruit).

Issue - Increased levels of sedentary behaviour and physical inactivity

  • Recommended strategy - Mass media campaigns promoting physical activity, with community-based supportive activities, and associated policies to address barriers to participation.
  • Example - Swap It Don't Stop It. Through the Measure Up campaign, the Australian Government ran a mass media campaign which encouraged people to “become a swapper”. The campaign encouraged making every day small changes to have a healthier lifestyle. Examples of swapping: swap sitting for moving (e.g. ride your bike for short trips rather than driving the car), swap nutritional behaviours (e.g. swap takeaway for home-made). The website includes information and resources about healthy eating, physical activity, and tools to help promote a healthy lifestyle.
  • Let’s Move (USA) is a comprehensive initiative to help raise a generation of healthier kids, and was launched by the First Lady, Michelle Obama. This initiative includes a social marketing campaign.
  • Change for Life (UK) - An initiative run in England and Wales and you can register to become a member. The program includes lots of online information and resources about healthy eating, physical activity, alcohol, finding local activities, an App to help make smart swaps to your diet. With regards to physical activity, there are suggestions on how to be active (including active travel), how to plan an active holiday, the “fun generator” tool which lets you input environment (indoor/outdoor), number of kids participating, and will produce a list of suggested activities and ideas for hobbies and sports.

Policy-based strategies

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks

  • Recommended strategy - Government regulatory policies supporting a healthier composition of staple foods.
  • Example - The Australian Government's Food and Health Dialogue’s primary activity is action on food innovation, including a voluntary reformulation program across a range of commonly consumed foods. The reformulation program aims to reduce the saturated fat, added sugar, sodium and energy, and increase the fibre, wholegrain, fruit and vegetable content across nominated food categories.
  • Heart Foundation Tick program encourages food companies to improve and reformulate foods available to consumers. The Tick program has nutrition standards and particular criteria to which food must meet when independently tested. Once foods meet these standards and criteria, the company can pay a license fee for the Tick logo to appear on its package. The food needs to be a healthier choice when compared to similar foods. Tick products have reduced saturated fat, trans fat, salt and kilojoules, with more healthy nutrients such as fibre, vegetables and calcium. Portion size is also carefully monitored. Foods included in the Tick program include fresh foods (e.g. fruit, vegetables, eggs, plain nuts, seeds, lean meat); everyday foods (e.g. bread, low fat milk, pasta, rice, cereal) and occasional foods (e.g. pie).

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks

  • Recommended strategy - Front of pack interpretative food labelling.
  • Example - Health Star Rating system. The Institute of Medicine has concluded that front-of-package nutrition rating systems and symbols would be beneficial for consumers to promoting healthier choices in a user friendly way, rather than the potentially confusing nutritional panels. Systems such as the Traffic Light (UK) and proposed Health Star Rating (Australia) have been recommended as successful strategies.
  • Useful resources:
    • Front-of-Package Nutrition Rating Systems and Symbols: Promoting Healthier Choices, Institute of Medicine
    • Front of Pack nutrition labelling guidance, UK Government
    • Front-of-pack labelling updates, Australia and New Zealand Food Regulation

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks

  • Recommended strategy - Fast food menu and KJ labelling.
  • Example - The NSW Government introduced legislation in 2010 mandating the disclosure of nutrition information at standard menu restaurants in NSW. The Better Regulation Statement (BRS) considers three options to regulate against better regulation principles. The new rules, contained in the Food Act 2003 (NSW), and Food Regulation Act 2010 (NSW) establish a level playing field by applying to ‘standard food items’ across traditional fast food chains as well as café and coffee chains, bakery chains, snack food chains, juice bars, ice-cream chains, salad chains and supermarket chains.

Issue - Reduced breastfeeding rates

  • Recommended strategy - Institutional changes in maternity care practices and training of relevant staff to support breastfeeding.
  • Example - Baby Friendly Health Initiative was developed jointly by the World Health Organisation and UNICEF globally to improve infant health by supporting mothers to breastfeed. The aim of the initiative is to create environments where breastfeeding is normalised, in order to promote health and wellbeing of mothers and infants. To become accredited as a Baby Friendly, hospitals and community health facilities are assessed by a set of criteria each. Evidence of success regarding this initiative includes increased initiation and duration of exclusive breastfeeding rates, increased maternal satisfaction, reduced healthcare costs, reduced infant morbidity and mortality rates.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks

  • Recommended strategy - Targeted subsidies and health-related food taxes.
  • Example - Sacks G, Veerman JL, Moodie M, Swinburn B. 'Traffic-light' nutrition labelling and 'junk-food' tax: a modelled comparison of cost-effectiveness for obesity prevention. Int J Obes (Lond) 2011; 35 (7): 1001-9

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks among children

  • Recommended strategy - Restricted advertising to children that promotes unhealthy food and drinks in media, promotions and sponsorship.
  • Example - Coalition on food advertising to children (CFAC). CFAC was a collaboration of public health groups (such as the Cancer Council, Nutrition Australia, Public Health Association of Australia) with a common belief that television food advertising is a significant threat to the health of Australian children. CFAC disseminate information about television advertising through various campaigns, and advocate for improved regulations through grassroots, the media and policies. An example of a campaign they ran in 2007 was Pull the plug on food advertising to children.
  • Useful resources - Parents’ Voice is an online network of parents, grandparents and guardians with the common aim of improving the food and physical activity environments of children in Australia. Participants can register to become a member and join in the discussion to express opinions and advocate for change at a local, state and national level. Partners of Parents’ Voice include the Cancer Council Australia, Diabetes Australia, the Australian and New Zealand Obesity Society, VicHealth and YMCA Victoria. Parents’ Voice run advocacy campaigns around key issues such as healthy schools, physical activity, food marketing to kids, healthy checkouts, and healthy eating for kids. They lobby governments, food manufacturers and key decision makers for improvements in these areas. With regards to inappropriate food advertising, individuals can be directed to make an official complaint through suggested channels and can refer to a Fat Free TV guide.

Issue - Increased intakes of energy-dense and nutrient-poor foods/drinks among children

  • Recommended strategy - Restrictions on fast food outlet density in the vicinity of schools, parks or services for young people.
  • Example- Restriction of takeaway fast food outlets surrounding primary and secondary schools in the UK. Shires within the UK are currently putting together and implementing change to local planning policies regarding restricting the establishment of new hot food takeaway fast food outlets within 400m of primary and secondary schools.
  • Useful resources:
    • NHS Promoting healthy eating in Lambeth – Focusing on the impact on health of hot takeaway fast food outlets
    • Public Health England Healthy places

Issue - Increased levels of overweight and chronic disease risk

  • Recommended strategy - Using a framework to shape a response to the food environment, food system and how to communicate changing behaviours.
  • Example - World Cancer Research Fund International (WCRFI) NOURISHING database. An evidence based, interactive framework has been developed by WCRFI which focuses on three domains – the food environment, food systems and behaviour change communication. The website contains comprehensive resources regarding policy development to promote healthier eating and subsequently prevent obesity and non-communicable diseases. Examples of policies implemented globally can also be viewed.

Evaluation

There is concern that some obesity prevention programs are being planned and implemented without adequately considering the importance of evaluation and without allocating sufficient funds to allow a rigorous evaluation. Evaluation is a critical component of a program or intervention, as evidence of effectiveness is required given the limited evidence base on obesity prevention. Additionally, there is a responsibility to funders to provide high quality evaluations. If evaluations are not rigorous enough, they can waste precious resources and fail to improve the quality of a program.

Evaluation of community-based obesity prevention initiatives is challenging due to their complex nature and the fact that they often cannot be planned similarly to classic, well controlled trials. It has been suggested that 10-15% of a project budget should be allocated to evaluation so in-depth understanding of what worked, what did not work, and why is known. It has been suggested that program evaluation should include a comparison group, anthropometry measurements (height, weight, waist) and a deep understanding of process evaluation and contextual information (e.g. strategies, implementation factors, reach across groups) which will help interpret overall program results.

Best Practice Principles have been developed using published literature and professional experience to help others design and develop a clear decision making process for planning, implementing and evaluating community-based obesity prevention programs. A key best practice principle is evaluation, and includes guidance around the following areas:

  • evaluation framework and approach
  • planning
  • data collection, management, analysis
  • context
  • importance of dissemination and building the evidence-base

References

Obesity References

Obesity References

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National

Australia: The Healthiest Country By 2020

This paper discusses the value of engaging in health prevention and health promotion efforts.

Australia: The Healthiest Country By 2020
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Overweight and Obesity - Australia's Health 2018

Chapter from Australia's health 2018 identifying the demographics and burden of disease of overweight and obesity in Australia.

Overweight and Obesity - Australia's Health 2018
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National Obesity Summit

The National Obesity Summit was held to assist with the development of the National Obesity Strategy, which is currently underway.

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Victorian

Healthy Eating Strategy

The 2019-2023 strategy to address one of VicHealth's key priority areas.

Healthy Eating Strategy
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Physical Activity Strategy

The 2019-2023 strategy to support VicHealth's action area of encouraging regular physical activity.

Physical Activity Strategy
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Increasing Participation in Physical Activity and Reducing Sedentary Behaviour

A local government action guide to physical activity and sedentary behaviour.

Increasing Participation in Physical Activity and Reducing Sedentary Behaviour
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