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Keywords:

  • Food industry;
  • government action;
  • policies;
  • programmes

Summary

  1. Top of page
  2. Summary
  3. Historical overview
  4. Australia highlights and lessons
  5. New Zealand highlights and lessons
  6. Conclusions
  7. Acknowledgements
  8. Conflicts of interest
  9. References

The lessons learned from over 20 years of obesity prevention efforts in Australia and New Zealand are presented. The obesity epidemic started in the 1980s but poor monitoring systems meant the rise in obesity prevalence initially went undetected. In the 1990s, experts started advocating for government action; however, it was the rapid increase in media reports on obesity in the early 2000s which created the pressure for action. Several, comprehensive reports produced some programme investment but no regulatory policies were implemented. The powerful food industry lobby ensured this lack of policies on front-of-pack food labelling, restrictions on unhealthy food marketing to children, or taxes on unhealthy foods. The New Zealand government even backpedalled by rescinding healthy school food guidelines and withdrawing funding for the comprehensive national obesity strategy. In 2007, Australian Governments started a major long term-investment in preventive health in order to improve economic productivity. Other positive initiatives, especially in Australia, were: the establishment of several advocacy organizations; successful, long-term, whole-of-community projects reducing childhood obesity; a national knowledge exchange system for practitioners; and some innovative programmes and social marketing. However, despite multiple reports and strong advocacy, key recommended regulatory policies remain unimplemented, largely due to the private sector interests dominating public policy development.


Abbreviations
AFGC

Australian Food and Grocery Council

ANA

Agencies for Nutrition Action

ANZOS

Australian and New Zealand Obesity Society

BMI

body mass index

CO-OPS

Collaboration, Collaboration of Community Obesity Prevention Sites

COAG

Council of Australian Governments

HEHA

Healthy Eating Healthy Action

HPA

Health Promotion Agency

LMIC

low- and middle-income countries

NGO

non-government organization

OPAL

Obesity Prevention and Lifestyle

PHC

Public Health Commission; VicHealth, Victorian Health Promotion Foundation

WHO

World Health Organization

Historical overview

  1. Top of page
  2. Summary
  3. Historical overview
  4. Australia highlights and lessons
  5. New Zealand highlights and lessons
  6. Conclusions
  7. Acknowledgements
  8. Conflicts of interest
  9. References

Australia and New Zealand are high-income countries with a strong public health tradition and with over 20 years' experience in their efforts to address obesity. It is instructive to reflect on these efforts and examine their history and why they have failed to reduce the prevalence of overweight and obesity in adults and children. The Stages of Change framework for behaviour change [1, 2] provides some general descriptors for the stages that both countries have gone through since the obesity epidemic probably began its upswing in the late 1970s and early 1980s.

The 1980s

The 1980s could be characterized as the first stage of change which is pre-contemplation – a lack of appreciation that there is even a problem. Since neither country had a regular monitoring system in place, they did not detect the early changes in population obesity prevalence. This meant that at least a decade passed before researchers could document the growing epidemic. Even now, with high body mass index (BMI) being the preventable risk factor creating the highest population health burden [3], there is no comprehensive, regular monitoring system for measuring BMI in adults and children in either country.

The 1990s

The 1990s roughly correspond to the stage of contemplation where researchers and professionals established the Australasian Society for the Study of Obesity (now the Australian and New Zealand Obesity Society, ANZOS) [4] and started agitating to get the issue on the agenda. National surveys in the 1990s [5, 6] which showed dramatic increases in obesity were seminal in mobilizing a call to action and ANZOS published a policy advocacy document in 1995 [7]. This converted remarkably quickly into an authoritative report (Acting on Australia's Weight) by the National Health and Medical Council in 1997 [8]. This was one of the first comprehensive reports for action on obesity in the world but because it came from the government's research agency and was not embedded in government policy or bureaucracy, most of its important recommendations remained unimplemented. In New Zealand, an advocacy group, Agencies for Nutrition Action [9, 10], was established by key non-government organizations (NGOs) to stimulate action on obesity prevention.

The 2000s

In the early 2000s, there was a remarkable rise in media stories on obesity globally, rising about 10-fold in a period of a few years [11]. This was the trigger to garner public and political interest and, in Australia, several states held ‘summits’ to advise governments on priority courses of action [12, 13]. In New South Wales, in particular, this led to a number of actions around school food, research and evidence infrastructure and pressure for national policies on marketing to children [12, 13]. Several other major government investigations into obesity also took place in this decade: in Australia, the Howard Government, under pressure from the states, established the National Obesity Taskforce for children and adults [14] and then implemented as its centrepiece, a very expensive (>$200 m) ‘Active After School’ programme (which, incidentally, was not even recommended by the Taskforce and turned out to be a very cost-ineffective programme for reducing childhood obesity [15]). In Australia, a Parliamentary Inquiry into Obesity in 2008 [16] and a National Preventative Health Taskforce health strategy in 2009 [17] added to the pile of authoritative government reports which recommended a comprehensive set of strategies, of which only the ‘softer’ education and health promotion have been implemented. In New Zealand, a major consultative process led to the comprehensive strategic plan of action called Healthy Eating Healthy Action (HEHA) launched in 2003 [18], a Parliamentary Inquiry into Obesity and Diabetes in 2006–2007 [19] and a joint ministers' programme of action called ‘Mission On’ in 2006 [20]. HEHA received significant funding (NZ$328 million between 2005 and 2010 for direct HEHA funding, as well as HEHA-related initiatives) [21], including for an evaluation, but the funding was largely withdrawn in 2011. Two new national advocacy groups emerged with a focus on obesity, Fight the Obesity Epidemic and the Obesity Action Coalition.

Victoria was the centre of activities in obesity prevention in Australia in the 2000s. Several advocacy groups were formed by NGOs, academia and professional organizations in Victoria with core funding from the Victorian Health Promotion Foundation (VicHealth), including Parents Jury, Obesity Policy Coalition and the Food Alliance. In addition, several whole-of-community demonstration projects were implemented in Victoria, most noticeably in the Barwon-South West Region [22] and these established the proof of principle that obesity in children could be reversed which then spawned a national knowledge exchange organization, the Collaboration of Community Obesity Prevention Sites (CO-OPS Collaboration) [23, 24].

The 2010s

The Council of Australian Governments (COAG) comprises the heads of the federal and state/territory governments and it determines the high-level policy directions needed for the country to maintain economic productivity and growth. After the first wave of actions to reduce the regulatory burden for businesses [25], COAG decided in 2006 that the second wave would be to improve the health of the workforce and the community [26]. This led to a series of initiatives aimed at promoting healthy lifestyles including increasing healthy eating and physical activity. These all targeted community-level actions and took a long-term view with significant funding commitment (AUD932 m over 9 years), allowing 2–3 years of development and planning before implementation began from about 2010. Unfortunately, this investment at the community level was not matched with a commitment to implement supportive policies and regulations. Major national policies on reducing unhealthy food marketing to children, front-of-pack labelling, national or state healthy food service policies across the government sector and fiscal policies were part of the recommendations from many of the Australian reports mentioned earlier, but remain largely unimplemented. In New Zealand, there has been a similar lack of policies to improve food environments and, in what was a triumph of current government ideology over public health advice and evidence, one of the early actions of the centre-right Key Government was to rescind the guidelines for healthy food canteens in schools, citing personal responsibility arguments [27].

Australia highlights and lessons

  1. Top of page
  2. Summary
  3. Historical overview
  4. Australia highlights and lessons
  5. New Zealand highlights and lessons
  6. Conclusions
  7. Acknowledgements
  8. Conflicts of interest
  9. References

The Australian experience carries some examples of excellent initiatives but other areas of stalled action, both of which provide valuable lessons for other countries, including low- and middle-income countries (LMICs).

Civil society creating pressure for action

There is a strong tradition in Australia of effective advocacy by professional associations, NGOs and academics for government action on health. The professional obesity association (ANZOS) and medical associations provided strong early advocacy, and ANZOS continues to run its annual ‘Couch Potato’ award where it rates Australian states and territories on their progress on obesity prevention and provides awards and feedback to ministers and premiers [28]. Advocacy got onto a more solid footing with the establishment of three Victoria-based organizations variously supported by NGOs (Cancer Council Victoria and Diabetes Australia Victoria), ANZOS and the World Health Organization (WHO) Collaborating Centre for Obesity Prevention at Deakin University. The Obesity Policy Coalition [29] has become the premier public voice for strong policies to reduce obesity. It has legal, policy and media expertise and creates the evidence-based position statements and policy briefs for its key regulatory priorities such as unhealthy food marketing to children [30] and front-of-pack labelling [31]. The Parents Jury [32] was modelled on a similar UK initiative, and it aims to be the voice for Australian parents calling for healthier food and physical activity environments for children. It is an online platform with over 4,000 members, and it runs high profile activities such as the Annual Fame and Shame Awards for advertising to children as well as providing the parents’ stories for many media commentaries. The Food Alliance [33] has a broader remit and its priority areas are food policies for fruit and vegetables (production to consumption), healthy food service policies for the public sector and joined up food policymaking across government [34].

The critical factor for all these groups has been the funding support from VicHealth, which is funded by the Victorian government and has supported public health research, programmes and advocacy for 25 years [35]. Such foundations are legal entities with funding either from hypothecated taxes from tobacco and/or alcohol or from government directly but with a degree of autonomy from the government. These have been established in several LMICs such as Thailand, Malaysia and Tonga, and they provide enormous potential for improving public health. Across LMICs, the variety of political and cultural contexts for civil advocacy means that strengthening the advocacy voice for action on preventing obesity will vary widely. Academics and NGOs are often at the forefront of calling for social change, and in the case of obesity where there is no public movement around the issue, their voices remain the most active [36]. Linking with other social movements (such as sustainability, social justice, food sovereignty and safe, liveable cities) is another way for the health voice to influence social change. Robinson [37] calls these ‘stealth interventions’ for obesity.

Community-level approaches to obesity prevention

Of the 11 large, whole-of-community based intervention projects for obesity prevention in children conducted in Australia, nine were in Victoria, with the three conducted in the Barwon-South West Region [22] being the most influential. These three projects were all of 3 years duration and took a community capacity-building approach to the intervention design [38]. They all showed positive effects on reducing unhealthy weight gain in preschool children [39], primary school children [40] and adolescents [41]. This provided the proof of principle that community-level action could make a difference. Indeed, again within Victoria, there is some evidence that prevalence of obesity is declining in preschool children [42] and that the actions and impacts of the demonstration projects is now ‘spilling over’ into the surrounding areas in the Barwon-South West Region [43]. For LMICs with little in the way of local evidence or health promotion capacity, well-evaluated, community-level intervention projects can be an excellent entre into obesity prevention. If these interventions take a capacity-building approach, they can readily be translated into wider-scale, systems-oriented approach because the building blocks are the same [44].

With the strategic COAG funding to states and communities (mentioned above), the Victorian government is now taking an explicitly systems-based approach with a state-wide initiative, Healthy Together Victoria [45]. This is quite unique and world-leading because it is putting into practice what many obesity prevention experts have been advocating [46, 47]. Activating and reorienting community organizations (such as local governments) and local systems (such as food supply chains) towards a wider health agenda presents greater challenges for health than delivering its own programmes in the community. It is essentially creating a health ‘prevention system’, analogous to the healthcare system but for prevention, but this system lies largely outside health's jurisdiction. A similar programme in South Australia, called OPAL (Obesity Prevention And Lifestyle), is also investing heavily in childhood obesity prevention through local governments [48].

This systems approach is a new and more complex way to reduce obesity, but ultimately it promises to be more sustainable and effective. It does, however, require a significant amount of capacity and expertise and, as such, it may not be directly applicable to many LMICs, although it does provide a picture of the directions that large-scale community actions are heading. It should be noted that the total investment in this Australian prevention effort over a period of 9 years is $923 m for 23 million people. While this has provided a real boost to prevention, for the healthcare system, it is small change. For Australia, this represents 0.2% of the annual health budget (∼AU$61 billion) [49] and is roughly the equivalent to the annual cost of subsidizing the top two cholesterol lowering drugs [50].

Policies and regulations

As with many countries, Australia has multiple reports, recommendations and national strategic plans [14, 16, 17, 51-55], the contents of which are in line with WHO's Action Plan for the Prevention and Control of Non-Communicable Diseases, 2013–2020 [56]. These documents contain all the ‘what to do’, including for regulatory policies. The real challenge is the ‘how to do it’ and this is especially true for regulatory and fiscal policies which target unhealthy foods. A short summary of the implementation progress (and lack of progress) of some major specific policy areas and the barriers they have faced is below:

  1. Restrictions on the foods which can carry claims: 
    There is an enormous push from the food industry to allow claims about its products. The government did not want food claims, especially related to health conditions, to be made indiscriminately or applied to foods which were otherwise unhealthy. Thus, it had to make definitions of what level of evidence would be accepted for a high-level health claim and what constituted an ‘unhealthy food’. For the latter, they used a modified version of the UK Food Standards Authority's nutrient profile modelling [57]. The political dynamics for this issue are that the pressure was from the industry so the government had to act by creating the necessary definitions and regulations. The final regulations, which cover Australia and New Zealand, are tight and provide good protection for the public against misleading claims. Importantly, they have legally defined what is considered an unhealthy food thus codifying the ‘good food/bad food’ dichotomy that the food industry has been arguing against for years.
  2. Front-of-pack labelling. 
    In Australia, as elsewhere, there has been a proliferation of front-of-pack nutrition signposts on processed foods to communicate to the consumer something about nutrient content, and there have been calls from public health and consumer groups to have a single, government-sanctioned, interpretive label. The government commissioned a report led by a former health minister to make recommendations on multiple aspects of food labelling [53]. The report assessed that the traffic light system had the most evidence and consumer support and that the government should introduce this as a voluntary scheme, moving to a regulated system if there was not widespread uptake. The processed food industry, led by the Australian Food and Grocery Council (AFGC), immediately launched such a severe assault on these recommendations that the government, in its response to the report, supported the industry's position over the public health and consumers' position (and the evidence) by removing the traffic light system from consideration. This left them in political confusion in this highly contested area, so in both Australia and New Zealand (which are virtually a single food market governed by common regulations) the governments ran negotiated processes between the food industry and public health experts to reach a political compromise. A proposed voluntary ‘star system’, which had no evidence behind it, was unveiled just ahead of the UK launching its voluntary traffic lights scheme which was backed by industries covering 60% of the food products sold in the UK [58]. The food industry across the world has ferociously opposed regulations for traffic light front-of-pack labels, according to one estimate committing over a €1 billion over many years in that fight within the European Union [59]. This new UK scheme will probably set the benchmark for other countries, and the Australasian scheme may already be behind the benchmark before it is even implemented.
  3. Unhealthy food marketing to children: 
    In many ways this has become the ‘litmus test’ in the battle between the public interests to protect children and the commercial interests to make profits. In Australia, in response to pressure from government during the period of the Preventative Health Taskforce, the AFCG developed further voluntary, self-regulatory codes for unhealthy food marketing to children. This has not been shown to be effective in reducing children's exposure to unhealthy food marketing. Furthermore, the regulatory body (Australian Communications and Media Authority) is discontinuing its monitoring of the effectiveness of these initiatives, thus adding to the weakening and increasingly piecemeal approach to protecting children from the marketing of unhealthy foods. The support from the evidence reviews, the rights of the child convention, ethical arguments, public health expert recommendations and public opinion are insufficient to counter balance the lobby pressure from the vested private interests, especially from the processed food industry and the broadcast media.

The issue of further aligning fiscal policies with health policies has not been seriously assessed by Treasury – Australia has a broad goods and services tax which already exempts healthy foods and there is a great reluctance to change the taxation regime further. The poor management of conflicts of interest in policy development has damaged the credibility of some of the government decision-making processes. For example, the AFGC, which is the processed food industry's peak lobby group, has been a full member of the government's Preventative Health Taskforce [60] and dietary guidelines committee [61].

New Zealand highlights and lessons

  1. Top of page
  2. Summary
  3. Historical overview
  4. Australia highlights and lessons
  5. New Zealand highlights and lessons
  6. Conclusions
  7. Acknowledgements
  8. Conflicts of interest
  9. References

The New Zealand experience has several examples of promising initiatives, yet industry pressure and the dominant, market and business-oriented government philosophy remain major barriers to successful implementation of long-term, large-scale obesity prevention measures.

Creating demand for action

The coordinated advocacy efforts from public health NGOs in New Zealand helped to create the pressure for the development of the HEHA strategic plan, but in general, the pressure for action has been insufficient to ensure sustainable funding and policies. Agencies for Nutrition Action (ANA), which was established in 1992, is the largest network of nutrition and physical activity advocates in New Zealand [9]. This network operates differently from its Australian equivalents in a number of ways, because ANA relies on Ministry of Health funding to sustain many of its activities. This constrains the ANA's activities to those supported by the Ministry, such as supporting professional development and creating linkages between stakeholders. The production of strong position statements or the ‘fame and shame’ approach utilized by Australian advocates is not a viable option for such an advocacy group, although individual ANA members have taken stronger advocacy positions on certain policies (e.g. the National Heart Foundation's position statement on food marketing to children [62]. An Obesity Action Coalition was formed but it was also dependent on government funding and was relatively short-lived, whereas, the small, independent advocacy group, Fighting the Obesity Epidemic, has been a consistent and strong voice for government policies and a critic of the food industry undermining public health efforts.

Social marketing in New Zealand also suffers from not being able to create demand for change. The responsible agency, the Health Promotion Agency (HPA) [63], has only modest funding (about NZ$1 million for the Nutrition and Physical Activity programme) and sticks to low controversy issues such as promoting breakfast consumption among children [64]. Being a Crown entity places it very close to government and this hampers its ability to create strong campaigns with important cut-through messages like the LiveLighter campaign in Western Australia [65]. Having the chief executive officer of the main lobby group for processed food, the New Zealand Food and Grocery Council, on the HPA Board presents a major conflict of interest [66], and is a further example of the penetration of commercial interests into the machinery of public policymaking.

Community-level approaches to obesity prevention

Many community-based initiatives were established as part of the HEHA plan but ceased when funding was withdrawn even if the evaluations were showing some promise and success [67, 68]. Of particular importance in the HEHA programmes have been those which have supported Māori and Pacific Island communities in their efforts to encourage healthy lifestyles and reduce their high prevalence of type 2 diabetes. Many of these programmes involved local community centres, marae and churches and built the capacity of these communities to engage families in health promoting activities (e.g. [69]). The Green Prescription programme of general practitioners writing prescriptions for exercise has been another success story because of ongoing funding over 15 years, embedding it within primary care and community-based sports trust systems, and having the effectiveness and cost-effectiveness evidence from several randomized controlled trials [70, 71].

New Zealand's most promising and enduring community initiative has been Project Energize, which reaches over 240 schools and 44,000 students in the Waikato region where there is a high Māori population [72]. This initiative is funded by the Waikato District Health Board and utilizes a team of ‘Energizers’ to improve nutrition and increasing physical activity among primary school children involving schools, parents and the community [73] and early evaluations are showing some promising effects on blood pressure and body fat [74].

Policies and regulations

New Zealand has some pertinent experiences in the rise and demise of several attempts to lift public health efforts to reduce obesity and diabetes.

  1. Repealed healthy food guidelines in schools: 
    One of the HEHA initiatives was the development of voluntary guidelines for healthy food to be sold in school canteens (most New Zealand children bring their lunches from home). The centre-right party in opposition at the time strongly disagreed with such guidelines on the grounds that they would ‘eliminate choice’ and ‘limit the sensible consumption of treat foods on an occasional basis’ [19]. One of the early actions of the new government, when this party won the election in 2008, was to repeal the healthy food guidelines for schools citing pressure from schools to decrease bureaucracy [27, 75, 76]. In this instance, the views of the food industry and the government coincided in strongly held beliefs in the primacy of personal choice and the inappropriateness or ineffectiveness of government policies and actions. This world view automatically favours interventions of education and personal skills and resists policies and regulations aimed at making healthy choices the easier or default choices. The weight of evidence and vocal public health advice that healthy food environments for children support them making healthy food choices were not sufficient to avoid the repeal of healthy food guidelines.
  2. The watering down of a Parliamentary Inquiry report: 
    In 2006–2007, a Parliamentary Inquiry into obesity and type 2 diabetes reviewed existing prevention approaches and heard many submissions, including highly polarized evidence from public health experts and the food industry [19]. The Inquiry report made 55 recommendations which mainly agreed with the public health arguments [75, 76]. The official government response, while mostly agreeing with the public health framing of the problem and claiming to support 47 of the recommendations, did not support some of the crucial regulatory recommendations (e.g. the development of a food labelling system or the establishment of independent commissioner to oversee progress and implementation of the proposed initiatives) [77]. Jenkin et al. carefully analysed this progressive shift towards the industry perspective as the policy development process unfolded [75, 76] and, indeed, revisiting original 55 recommendations in 2013, shows that only a handful of them were enacted and maintained. It is proposed that this effect of progressive dilution of public health approaches from the initial recommendations of reports from Inquiries or Taskforces through to enactment (Fig. 1) applies in many countries – as noted above, it certainly occurred with the various Taskforces and Inquiries in Australia.
  3. The short life of the independent Public Health Commission (PHC): 
    In 1993, the government established an independent PHC. Its aims were to monitor the health of New Zealanders, provide independent policy advice to the Minister, and purchase disease prevention and health promotion services. However, when it started to consider food polices for improving health, the food industry lobby groups (supported by tobacco and alcohol industry groups) pressured the government to disband the PHC, which it duly did in 1994 [78]. In its short life, the PHC had created great strides in coordinating and increasing public health action, but ‘speaking truth to power’ and putting the health of New Zealanders first proved to be fatal.
figure

Figure 1. Progression of policy development to action on obesity with a progressive shift from the public health perspective to the industry perspective.

Download figure to PowerPoint

There has been no move in New Zealand to align fiscal policies with health outcomes (such as removing the goods and services tax of 15% from fruit and vegetables or adding an excise tax on sugar-sweetened beverages) or to create healthy food service polices throughout the public sector as a sign of institutional leadership.

Conclusions

  1. Top of page
  2. Summary
  3. Historical overview
  4. Australia highlights and lessons
  5. New Zealand highlights and lessons
  6. Conclusions
  7. Acknowledgements
  8. Conflicts of interest
  9. References

Arguably, Australia and New Zealand should have provided more international leadership in obesity prevention than they have. There are some excellent examples of community-level actions, especially in Australia under COAG's high level policy direction for a greater preventive health effort to reduce obesity and its health consequences. In terms of specific policy actions, for example in marketing to children, front-of-pack labelling, fiscal policies and public sector healthy food service policies, both countries have remarkably little progress to show for over two decades of awareness of the escalating obesity crisis. In some cases, this inaction has been due to the government having a world view dominated by individual responsibility and choice but at the same time they have provided no policy support for people's healthy choices through policies for healthy food environments. This approach is perpetuating the current conditions that are driving obesity. However, mostly it seems that the food industry has become both heavily embedded in the policymaking process (despite the glaring conflicts of interest) and enormously successful at applying lobbying pressure to keep healthy food policies off the agenda. New ways will be needed to achieve gains in public policies to combat obesity.

Acknowledgements

  1. Top of page
  2. Summary
  3. Historical overview
  4. Australia highlights and lessons
  5. New Zealand highlights and lessons
  6. Conclusions
  7. Acknowledgements
  8. Conflicts of interest
  9. References

We thank the Rockefeller Foundation's Bellagio Center for support for this meeting. We also thank the University of North Carolina Nutrition Transition Program for administrative support, editing and funding of this publication and Bloomberg Philanthropies for supporting all phases of final paper preparation. Thanks to Jane Martin, Obesity Policy Coalition, Australia and Dr Gabrielle Jenkin, University of Otago, New Zealand for their review and feedback on the manuscript.

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  1. Top of page
  2. Summary
  3. Historical overview
  4. Australia highlights and lessons
  5. New Zealand highlights and lessons
  6. Conclusions
  7. Acknowledgements
  8. Conflicts of interest
  9. References
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