Healthy weight 2008: still waiting on Australia to act?

    Obesity and its attendant problems have long been a matter of
    concern to both the medical community and the public ... obesity is
    a hazard to health and detriment to well-being. It is common enough
    to constitute one of the most important medical and public health
    problems of our time. Because of the epidemic proportions of
    obesity, the task force stressed the importance of proceeding with
    action (1).

Such statements are likely to sound familiar to those of us currently working in health and medicine. What is surprising is that these are not extracted from recent publications. They come from a report edited by George Bray published a quarter of a century ago. While obesity is currently a topical issue, it is by no means a new phenomenon. Researchers have been voicing concern about this epidemic, emphasising the need for research into its causes and prevention, and calling for action to halt increases in its prevalence, since the 1970s.

Given these longstanding concerns, one might ask what progress have we made in tackling this problem? It would appear that, on the whole, we have not progressed very far. Over the past 20 years, obesity has increased worldwide. Table 1 shows strong parallels between recommendations for reducing obesity made in the late 1990s (2,3), and in the recently released report of the National Obesity Taskforce (4), with those made 25 years earlier (1). The fact that the same recommendations are being made repeatedly over time, with no apparent impact on the incidence of obesity, suggests that they have not been implemented effectively, if at all. The most recent of these documents provides some novel recommendations, such as a stronger focus on 'upstream', environmental interventions, and the implementation of 'whole of community' approaches. However, while such strategies are intuitively appealing given their potential to be wide reaching, there is currently no evidence supporting the use of these approaches in combating obesity (5,6). After 25 years of lamenting the seriousness of this problem and the need for research, we continue to have a poor understanding of the underlying drivers of the obesity epidemic.

Why have we made such little progress? Australia provides a good case study. Despite being the first country to develop a national plan for obesity prevention in 1997 (2), the following six years have seen little by way of action in terms of obesity prevention programs on the ground. In fact, at the 2003 Scientific Meeting of the Australasian Society for the Study of Obesity, it was suggested that the 1997 National Health and Medical Research Council document 'Acting on Australia's Weight' would be more appropriately titled 'Waiting on Australia's Act'! Developing recommendations is only one step in addressing the obesity epidemic; it is imperative that action is taken to implement and evaluate them.

Is the apparent lack of progress in tackling the epidemic due to governments not caring about the issue? In Australia, obesity is recognised as a major contributor to the burden of disease (7) and the Federal government has invested significant resources in the development of its obesity prevention plan. State governments have also held numerous forums to consider how best to tackle obesity. It is clear that obesity is an issue of national concern.

Is the lack of progress due to a lack of expertise? The evidence suggests otherwise. The International Association for the Study of Obesity comprises over 7000 professionals in 32 national associations. National and international conferences focusing on obesity are well attended. There are also three major international journals that focus on the issue (International Journal of Obesity, Obesity Research, Obesity Reviews).

We argue that an important explanation for the lack of progress in tackling obesity is the lack of a research evidence base to underpin prevention efforts. This situation may be partly attributable to the fact that we operate in a climate that requires governments to be seen to be taking action, i.e. delivering obesity prevention programs. However, funding research to create the necessary evidence base is not considered as 'action'. It is therefore perhaps not surprising that, contrary to recommendations dating back to the 1970s, there has been little obesity prevention research conducted (8). We thus find ourselves in a catch-22 situation in which governments require evidence before they act, yet the provision of funds to create the evidence base is a low priority. This situation does not appear to have changed since the publication of Bray's report: 'Obesity is a chronic condition with adverse effects ... How is it possible that such a widespread condition, which is a product of our environment, has not received more recognition in our health research priorities?' (1).

Action is required on two fronts. Firstly, it is essential that governments invest in research now, in order to provide the evidence necessary upon which to base effective action. Secondly, there must be adequate resources to implement recommendations based on existing and emerging evidence.

Clearly considerable effort has been put into the latest Obesity Taskforce report. Let us hope that this effort is not wasted, and that adequate resources are devoted to building the evidence base and implementing and evaluating these recommendations. Without a significant ongoing investment in research and its translation into public health action, we may well be asking the same question as that posed in Bray's report, another 25 years from now.

Table 1. Recommendations for obesity prevention: 1970s, 1990s and 2003

                                Recommendations
                                 Food industry

Bray,      Encourage manufacturers to    Encourage accurate labelling
1970s(1)   develop food products low in  on food products, showing all
           saturated fat, high in        ingredients and nutritional
           polyunsaturated fat, and low  information
           in cholesterol
NHMRC,     Food industry continue to     Develop a food labelling
1997(2)    increase the proportion of    system that clearly informs
           foods on the market with low  about the total amount of fat
           or reduced fat levels         in foods
WHO,       The food industry is          Improved labelling of food
1998(3)    responsible for developing    products
           and promoting affordable
           healthy food products;
           subsidies for producers of
           low energy-dense food
National   Support food manufacturing    Improve consumer
Obesity    industry to develop less      understanding of food labels
Taskforce  energy-dense products
Report,
2003(4)

                               Recommendations
                    Schools                       Work sites

Bray,      Encourage school personnel    Encourage employers to provide
1970s(1)   to eliminate 'empty calorie'  better choices of nutritious
           food in vending machines and  foods on their menus. Provide
           replace with nutritious       employees with wise
           alternatives                  lunch/snacks options in vending
                                         machines, snack bars, employee
                                         cafeterias
NHMRC,     Encourage school councils to  Encourage workplace food
1997(2)    develop school canteen        services to offer a variety of
           policies consistent with      food choices consistent with
           dietary guidelines            dietary guidelines
WHO,       Schools should encourage      Workplaces should promote
1998(3)    healthy eating through        healthy eating by adopting
           adopting healthy nutrition    healthy nutrition catering
           standards for school meals    standards
National   Introduce standards           Encourage workplaces to
Obesity    consistent with dietary       provide supportive healthy
Taskforce  guidelines for school         eating workplace environments
Report,    canteens, vending machines,
2003(4)    etc

                                Recommendations
               Health care sector             Research

Bray,      Ensure that nutrition         Support research and
1970s(1)   education is incorporated     demonstration efforts aimed
           into the curricula of all     at determining the most
           health care professionals     effective educational and
                                         behavioural strategies for
                                         assisting individuals to adopt
                                         and maintain healthy weight
                                         levels
NHMRC,     Update the knowledge and      Research/develop population-
1997(2)    practices of health           based interventions to alter
           professionals                 fat-energy intake and/or
                                         physical activity
WHO,       Improved training of all      Research and evaluate
1998(3)    health care workers           different management
           involved in the management    strategies aimed at both
           of obese patients is          prevention and treatment of
           urgently required             excess weight gain
National   Promote NHMRC                 Recommend research to
Obesity    guidelines on prevention,     increase understanding of the
Taskforce  treatment and management of   effectiveness of potential
Report,    overweight/obesity to all     obesity interventions
2003(4)    primary health care
           professional groups

Acknowledgments 

Kylie Ball and David Crawford are each supported by a Career Development Award funded by the National Health and Medical Research Council and National Heart Foundation of Australia.

References

1. Bray GA, editor. Obesity in America: A conference. NIH Publication No. 80-359. Bethesda, Md: US Department of Health, Education, and Welfare, Public Health Service. National Institutes of Health; 1979.

2. National Health and Medical Research Council (NHMRC). Acting on Australia's Weight: A strategic plan for the prevention of over-weight and obesity. Canberra: Australian Government Publishing Service; 1997.

3. World Health Organization. Obesity, preventing and managing the global epidemic: Report of the WHO consultation on obesity. Geneva: WHO; 1997.

4. Australian National Obesity Taskforce. Healthy Weight 2008: Australia's future. http://www.healthyandactive.health.gov.au. Accessed 18 December 2003.

5. Jeffery RW, Utter J. The changing environment and population obesity in the United States. Obes Res 2003;11:12S-22S.

6. Ball K, Crawford D. The obesity epidemic: Contextual influences on physical activity and body weight [editorial]. J Sci Med Sport 2003;6:377-8.

7. Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: Australian Institute of Health and Welfare; 1999.

8. Kumanyika SK, Obarzanek E. Pathways to obesity prevention: report of a National Institutes of Health workshop. Obes Res 2003;11:1263-74.

Kylie Ball and David Crawford

Centre for Physical Activity and Nutrition Research, Deakin University