letter of transmittal - rural health

20th July 2018

Committee Secretary Department of the Senate PO Box 6100 Parliament House Canberra ACT 2600 [email protected]

Letter of Transmittal Dear Committee Secretary and Committee Members, Please accept this submission in response to the inquiry into the Obesity epidemic in Australia from the National Rural Health Alliance. The submission features in depth analysis and an overview of the inequalities and challenges that children living in rural and remote Australia have in trying to prevent or reduce obesity. All terms of reference are addressed. The Alliance has also provided seven Alliance specific recommendations and also endorsed the eight policy actions proposed by the ‘Tipping the Scales’ campaign. We will gladly answer any questions you have regarding this submission. My regards

Mark Diamond Chief Executive Officer National Rural Health Alliance

mailto:[email protected]

Obesity Epidemic

Select Committee on Obesity Epidemic in

Australia

July 2018

National Rural Health Alliance

10 Campion St, Deakin, ACT, 2600

Table of Contents

Introduction ................................................................................................................................ 4

a. Prevalence of overweight and obesity among children ...................................................... 6

b. The causes of the rise in overweight and obesity ............................................................... 7

c. The short and long-term harm to health associated with obesity, particularly in children

11

d. The short and long-term economic burden of obesity, particularly related to obesity in

children .................................................................................................................................... 13

e. The effectiveness of existing policies and programs introduced by Australian

governments to improve diets and prevent childhood obesity................................................. 13

f. Evidence-based measures and interventions to prevent and reverse childhood obesity

including experiences from overseas jurisdictions .................................................................. 16

g. The role of the food industry in contributing to poor diets and childhood obesity in

Australia ................................................................................................................................... 17

h. Any other related matters ..................................................................................................... 19

Recommendations .................................................................................................................... 20

References ................................................................................................................................ 22

Attachment 1: Membership of the National Rural Health Alliance ........................................ 27

Attachment 2: Allied Health workforce by remoteness ........................................................... 28

Introduction The National Rural Health Alliance (the Alliance) welcomes the opportunity to provide this

submission to the Senate Select Committee into the Obesity Epidemic in Australia. Ensuring that

children in rural and remote Australia get the best start in life is a priority for the National Rural

Health Alliance.

The Alliance is Australia’s peak body for rural and remote health. It represents 35 national

organisations working to improve the health and wellbeing of 7 million people living in rural,

regional and remote Australia.1 Our members include consumer groups, the Aboriginal and Torres

Strait Islander health sector, health professional organisations, educators, and service providers. This

large and diverse membership gives the Alliance a comprehensive and authentic view of the health

interests across country Australia. For a full list of our members see Attachment 1.

Obesity is a growing global public health issue. Children in rural and remote areas of Australia are

more likely to be obese than those living in major cities, particularly for children who are Aboriginal

or Torres Strait Islanders or are socio-economically disadvantaged.

Programs aimed at preventing obesity are currently in place in many rural and remote areas. For

example in preschools, schools and communities. These programs focus on individual and family and

service level change to increase physical activity and promote healthy eating. Many of these

programs have good participation and community support and have been in place for some time,

some a decade or more. Yet, the rate of obesity in remote areas remains higher than those in major

cities. This is because the cause of obesity in rural and remote Australia is far more complex than

children's physical activity and eating behaviour.

For children living in rural and remote Australia, obesity is a “canary in a mineshaft” (Egger and

Dixon 2014). It is a signal to us that there are significant problems in Australia’s social, economic and

environment policies, that are broader than any single individual’s control and behaviour (Hruby and

Hu 2015). These policy areas include (but are not limited to) agriculture and the food system,

including processing, distribution and marketing of food and drinks; transport; urban planning; and

education (World Health Organization [WHO] 2018a). The ever emerging digital world and

introduction of new technologies has forever changed ways of living, machination of previous

manual tasks, motorised vehicles for travelling and screens of all sizes for work and recreation.

Despite many internet connection and mobile phone blackspots country people’s lifestyles have also

changed because of the digital transition. Technological change has led to sedentary lifestyles and

this has not been to our benefit.

The cause of obesity is also a direct reflection of other social, economic and environmental

inequalities children in rural and remote areas face on a daily basis. These inequalities include living

in communities that in comparison to those in major cities have lower incomes; lower education

attainment; less access to healthy, affordable, nutritious quality food (especially in the remote

areas); and a reduced physical activity levels due to sedentary lifestyles and geographical, climate

and other environmental barriers.

1 Throughout this submission references to remoteness areas are based on ASGC-RA, in which category 1 is Major cities, 2

is Inner regional areas, 3 Outer regional, 4 Remote and 5 Very remote. Because of small numbers, Remote and Very remote are often reported jointly. In the submission, references to 'regional areas' mean Inner plus Outer regional; and references to 'remote areas' mean Remote plus Very remote.

In this submission, the Alliance has provided responses to the Terms of Reference relating them to

the rural and remote Australian context, with a view to convincing the Select Committee that

addressing the causes of higher rates of obesity epidemic in rural and remote Australia should be a

national health priority.

The Alliance would like the Select Committee to consider the following recommendations:

1. Australia needs a National Obesity Prevention Strategy as a matter of urgency. The strategy

needs to focus on eradicating obesogenic environments in rural and remote Australia. It needs

to target inequalities and inequities in education, income and access to affordable quality fresh

fruit and vegetables and physical activity. Priority should be given to ending obesity inequalities

for children in lower socioeconomic groups, particularly Aboriginal and Torres Strait islander

children and children in remote Australia.

2. Government research programs need to prioritise research that will improve understanding of

food environments (particularly consumer nutrition environments) in rural and remote

Australia.

3. Increased funding for additional resources, infrastructure and workforce should be made

available to improve the access of rural and remote communities to appropriately trained early

childhood educators, teachers and multi-disciplinary health professional teams.

4. State-wide programs such as the Healthy Together, Tackling Childhood Obesity and OPAL

should continue to be funded and even enhanced to enable them to have a broader reach and

achieve what they have set out to do. However, given there is a greater need in rural and

remote places, particularly where there are higher proportion of Aboriginal or Torres Strait

Islander children, these programs should be prioritised for additional resources.

5. Planning systems across critical areas such as the location and density of convenience

restaurants and the design of areas for physical activity for recreation, leisure and exercise

should explicitly incorporate health as a core component to protect and promote the

population’s health and wellbeing.

6. Agricultural policies need to incorporate health outcomes. At a time of increasing change to

meet the multifaceted challenges of climate change, the modernisation of production methods

and the market concentration of supply chains, sustainable nutritious food is the foundation of

health and wellbeing.

The Alliance also supports the eight policy actions recommended by Obesity Prevention Coalition ‘Tipping the Scales’ campaign. However, the Alliance also recommends that the ‘Tipping the Scales’ policy actions are adapted to the rural and remote context, particularly policy action number 4. (See the list in the Recommendations section).

NRHA Response to the Inquiry Terms of Reference

a. Prevalence of overweight and obesity among children Results from the 2014-15 Australian National Health Survey shows that 65% of the population are

either overweight or obese (ABS 2015a). This is an increase from 56% in 1995, 60% in 2007-08, and

63% in 2011-12. The National Health Survey also shows that 74% of males and 62% of females in

rural/regional areas were overweight or obese compared with 70% of males and 54% of females in

Major cities (PHIDU n.d.) (See Figure 1).

The prevalence of overweight is lower for males outside major cities, and similar for females inside

and outside major cities. But the prevalence of obesity increases with remoteness for both males

and females, with those in regional/rural areas being 30% more likely to be obese than those in

major cities (with males in outer regional areas being 50% more likely to be obese) (PHIDU n.d.).

Over one-quarter (27%) of children aged 2-17 years are overweight or obese (ABS 2015a). Of note,

children aged between 2 and 4 and 5 and 7 years have higher rates of obesity compared to older

children, 8.7% and 10% respectively.

Figure 1 Age standardised proportion of overweight or obese adults by remoteness 2014-15

Source: http://phidu.torrens.edu.au/social-health-atlases/data#social-health-atlas-of-australia-remoteness-areas

To some extent, the pattern for children 2-17 years is similar to adults, with 25%, 22% and 36% being

overweight or obese in Major cities, Inner regional and Outer regional/remote areas respectively in

2014-15 (ABS 2015a) (see Table1).

However, of concern to the Alliance is that the statistics show that children in Outer regional areas

are more likely to be overweight or obese than those in major cities, especially children who are

Aboriginal or Torres Strait Islander descent.

2633 38

2532 34

4441 34

2928 30

30 26 27

4639 36

0

10

20

30

40

50

60

70

80

90

100

MC IR OR/remote MC IR OR/remote

Age

sta

nd

ard

ised

per

cen

tage

Males Females

Obese Overweight Normal/underweight

http://phidu.torrens.edu.au/social-health-atlases/data#social-health-atlas-of-australia-remoteness-areas

Table 1 Proportion of overweight and obese children and adolescents aged 2–17, by remoteness area 2014–1523

Boys Girls All children

% 95% CI % 95% CI % 95% CI

Remoteness area

Major cities 27.0 23.9–30.1 23.5 21.2–25.8 25.3 23.4–27.2

Inner regional 21.3 16.2–26.4 23.1 16.2–30.1 22.2 17.6–26.9

Outer regional/Remote 35.3 24.8–45.8 36.0 28.3–43.8 35.7 28.3–43.0

Source: adapted from AIHW 2017 A picture of overweight and obesity in Australia, Table S5: Proportion of overweight and obese children and adolescents aged 2–17, by remoteness area and socioeconomic group, 2014–15

Sixty-seven per cent of the Aboriginal and Torres Strait Islander population live outside of major

cities, (approximately 436700 people) (AIHW 2018). With regards to obesity, Indigenous girls aged

2–14 were 1.6 times as likely to be obese (9.8% versus 6.1%) as non-Indigenous girls of the same

age, with a similar pattern for boys (AIHW 2018). Aboriginal and Torres Strait Islander children are

more likely to be obese than non-Indigenous children regardless of where they live, but more so in

remote Australia.

b. The causes of the rise in overweight and obesity

“Overweight and obesity are critical indicators of the environment in which children are

conceived, born, and raised” (WHO 2016a).

Causes of obesity are complex interaction of genetics, individual behaviour and lifestyle and social-

economic or environmental factors (WHO 2016; Hruby and Hu 2015). However, as with any health

issue, the determinants of health, often referred to as the ‘causes of the causes’ (CSDH 2008) play a

significant role in shaping conditions that promote an obesogenic environment.

Obesity arises as the result of an energy imbalance between calories consumed and the calories

expended, but this energy imbalance is a result of social and economic conditions many of which are

out of any single individual’s control (Hruby and Hu 2015). These social and economic conditions

include “economic growth, growing availability of abundant, inexpensive, and often nutrient-poor

food, industrialization {sic}, mechanised transportation, urbanisation” create an “obesogenic”

environment (Hruby and Hu 2015). Other determinants of health can be added to this list such as

parental education level and income as these determinants strongly influence the risk of children

becoming obese.

It is an inadequate behavioural and biological response to the obesogenic environment that creates

the energy imbalance and surplus body weight (WHO 2016). In Australia, people are more likely to

be obese if they are an Indigenous Australian, are socially disadvantaged and live in remote

Australia. This is because they live in an environment that is obesogenic, i.e. it is an environment

that facilitates unhealthy diets and lifestyles (Swinburn et al 2011).

For children living in these rural and remote obesogenic environments being able to enjoy a healthy

diet has a number of challenges such as lower household incomes, lower education attainment, and

barriers to accessing food and physical activity.

2 Overweight and obesity classification is based on measured height and weight 3 95% CI = 95% confidence interval. We can be 95% confident that the true value is within this confidence interval

Incomes in rural and remote Australia

Lower socioeconomic status is a risk factor for obesity. People who live in rural and remote areas

tend to have lower incomes and are more likely to have incomes in the lower income quintiles.

Household incomes are on average 18% lower outside capital cities (ABS 2017a), and the 100 Local

Government Area with the lowest household incomes are almost exclusively rural, regional or

remote (ABS 2017b).

In 2015-16, the household income of people outside metropolitan areas was 18 percent lower and

household worth was 29 per cent less than their metropolitan counterparts (NRHA 2017).

In rural and remote Australia there are:

• More people living in single parent families.

• More families on welfare support.

• More families that are jobless.

• Higher rates of unemployment, particularly youth unemployment. In some regions the rate

of youth unemployment is over double (~20%) that of major cities (12.2%) (Brotherhood of

St. Laurence 2018).

• Of those that are employed, there are higher numbers of people who occupy lower income

jobs e.g. machinery operators, drivers, and labourers.

Australian with higher levels of education, income and living in areas of greater socioeconomic

advantage have higher diet quality (Backholer et al. 2016). Australians living in areas of

socioeconomic disadvantage are more likely to consume sugar-sweetened beverages than those

living in less disadvantaged areas (ABS 2015b).

Lower incomes is also related to housing stress and poverty. In some Aboriginal households, children

do not have access to basic needs, even if their family could afford to buy the healthy food. For

example they may not have access to functioning hardware to store, prepare and cook food, such as

cupboards, bench space, refrigeration and a functioning stove and sink, live in houses that are

overcrowded, and may have difficulty accessing to water for drinking and washing (Lee & Ride 2018).

Lower incomes make it difficult to afford nutritious foods. A number of Healthy Basket Food Surveys

all show greater cost of health food in rural and remote areas4.A study looking at Healthy Food

Baskets in rural South Australia also found that the inability to buy healthy food created 'food stress'

in low socioeconomic groups in rural settings (Ward et al 2012). For example, for some rural and

remote households to afford healthy food requires them to spend half of their income to purchase

it. This places a huge food cost burden on these families (Le et al 2013).

In a recent Australian scoping study looking at consumer nutrition environments such as food retail

outlets, and the products, price, promotion and placement of food, the authors noted that a

consistent theme in the literature is that people in rural and remote Australia are more likely to be

obese or have other non-communicable disease. However, authors also noted that despite the

health disparities reported in the studies, there were few papers describing consumer nutrition

environments in rural and remote Australia highlighting a research gap (Pulker et al 2017).

4 WA Regional Price Index http://www.drd.wa.gov.au/publications/Documents/Regional_Price_Index_2013.pdf . Queensland

Healthy Food Access Basket survey 2010. http://www.health.qld.gov.au/ph/documents/hpu/hafb-2010.pdf. SA Healthy Food Prices 2012 http://www.rrh.org.au/publishedarticles/article_print_1938.pdf.

http://www.drd.wa.gov.au/publications/Documents/Regional_Price_Index_2013.pdf

http://www.health.qld.gov.au/ph/documents/hpu/hafb-2010.pdf

http://www.rrh.org.au/publishedarticles/article_print_1938.pdf

Education attainment and health/food literacy

Children in rural and remote Australia face challenges in accessing quality education which is

strongly associated with healthy behaviours (Friel et al 2015) and good health literacy.

Health literacy is fundamental for understanding the daily requirements for eating healthy food and

how to acquire and apply the ‘knowledge, skills and behaviours required to plan, manage, select,

prepare and eat food to meet needs and determine intake’ (Vidgen & Gallegos 2014). Compared

with those in Major Cities, people in regional and remote areas are slightly more likely to have lower

levels of health literacy (ABS 2006).

Education level is attributed to healthier choices and parental perception and lifestyle behaviours

have an influence on childhood obesity (Patrick et al 2005). Parental educational levels have also

been found to be an important factor in preventing childhood obesity, perhaps more so than income

(Ogden et al 2018). There is evidence that more work needs to be done in educating and supporting

rural families in recognising and understanding childhood obesity.

One rural community study discovered a major discrepancy between the child’s measured BMI and

their parent’s perception of their child’s weight (Spargo & Mellis 2013) and another study (also in

rural Australia) showed that 31% of parents and carers in rural communities underestimate the

weight of their children (Fisher et al 2006). Authors reported that in cases where the child was

overweight, this proportion almost doubled to 56%, particularly for boys, and that a focus on

increasing caregiver’s ability to correctly estimate the weight of their (overweight) child is

recommended (Fisher et al 2006)

There are lower levels of education attainment in rural and remote areas, a reflection of the lower

number of children completing high school and attaining non-school qualifications (ABS 2013). Rural

and remote students who are at or near the stage of making the transition from school to

employment, training, further study or combinations of them, are also often confronted with issues

and costs which their counterparts in urban areas do not encounter (Halsey 2018).

Access and costs of fresh fruit and vegetables are higher

In 2014–15, 50% of adults and 68% of children ate sufficient serves of fruit, and 7% of adults and 5%

of children ate sufficient serves of vegetables (AIHW 2018). Investigations in regional and remote

Australia have found that children are consuming suboptimal amounts of both fresh fruit and

vegetables (Godrich et al 2017) and consume less nutrients required for healthy development

(Gwynn et al 2012). This is magnified in Aboriginal and Torres Strait Islander children.

There are reports that while there appears to be reasonable access (in terms of cost, variety and

quality) to healthy food in the larger regional centres, the availability and quality of grocery items

declines very rapidly as town size declines lower than 5,000 people (Young, Dixon & Hogan 2011).

Factors contributing to the higher costs of foods in remote areas are related to increased freight

costs; higher store overheads; greater wastage of food stock; store management practices; and the

reduced economies of scale for purchasing and retailing in small remote communities (Lee & Ride

2018). As a result over-processed cheaply priced energy dense food often becomes the only option.

Unhealthy, energy dense foods tend to be cheaper than healthy foods particularly in the Northern

Territory (Brimblecombe & O’Dea 2009) and people with limited finances are more likely to buy

cheaper, energy dense food over healthier more nutritious foods (Drewnowski & Specter 2004).

Getting to basic amenities and services (e.g. to access healthy food) for many people in remote

Australia is a challenge often requiring driving long distances, with expensive fuel costs and

dependent on road and other environmental conditions. The lack of private transport or public

transport available in remote areas further restricts access. In one survey in rural Tasmania 15% of

respondents reported being unable to afford to buy food, and the need to travel some distance to

access food shops (Le et al 2013).

Physical Activity

In 2014/2015, 64% of children aged 5-8 years of age did not meet physical activity

recommendations, and 80% of children 5- 17 also did not meet the recommendations (AIHW 2016).

Modern lifestyles promote sedentary leisure activities, more screen-based time and less time on

physical activity for transport, work or play (AIHW 2018).

Active travel such as walking or cycling to school or work increases physical activity. However, for

children in rural and remote Australia many places offer less street connectivity or the distances

between destinations are too far for active transportation or recreation to be feasible (Eley et al

2014, Thornton et al 2012).

Barriers to physical activity in rural and remote Australia include the climate, heat, natural disaster

risk and road conditions. Cost, lack of opportunities for participation and transport problems were

also barriers most often reported, particularly by low income parents in rural areas (Smith et al

2010).

Other barriers cited by mothers of children who are overweight or obese in rural areas include the

child’s preference for sedentary behaviours, low self-esteem, poor motivation, social phobia because

of lack of fitness, difficulties in controlling the children’s eating habits in particular during periods of

stress (Druon et al 2008).

Local attitudes towards physical activity and community leadership (or lack thereof) also have a

unique role to play in the rural and remote context (Eley et al 2014). The local context (distance to

facilities or activities, the climate, cost and community attitudes and leadership) need to be taken

into consideration when designing systems and services aimed at addressing physical activity

barriers in rural and remote Australian communities.

Access to appropriately multidisciplinary health professional team that can undertake assessment,

treatment, and prevention for of childhood obesity is limited in rural and remote areas. Access to

appropriately qualified staff early childhood educators and teachers to support preschools, child

care and school settings is also a challenge. In addition to this, rural and remote doctors and their

practices bear the brunt of prevention and management of overweight and obesity health harms in

rural and remote communities. Additional support and resources should be allocated to support the

work of rural and remote primary health care practitioners. Additional support and resources is

needed in the form of training and additional allied health professionals who can provide case

management and behaviour counselling, group visits, and telehealth services to prevent and manage

childhood obesity (Findholt et al 2013).

Ideally, treatment of the diseases linked to childhood and adult obesity would be undertaken by a

multidisciplinary team that may include a general practitioner, nurse, diabetes educator, podiatrist,

optometrist, dietitian/nutritionist, oral health worker, exercise physiologist, pharmacist and

psychologist, depending on the needs of the individual. While data is not available for all allied

health professions, the data included in Attachment 2 indicates that access to this range of allied

health professionals is limited in rural communities, and in remote and very remote communities

may be difficult to simply unavailable.

In summary, healthy food is more expensive outside of major cities, particularly in remote Australia,

and people have less money to pay for it. To prevent food deserts5 and facilitate food security6 in

remote Australia a monitoring food system that measures the equitable distribution, affordability

and quality of food including price variability and identification of areas where the cost of food is

disproportionately high (Chapman et al 2014) and incentives to provide variety of fresh fruit,

vegetable and other perishable foods should be implemented to support grocers and transport

operators serving these areas (RIRDC 2016).

There needs to be a greater investment to address and end remote Australians’ inequalities

particularly for inequalities in education, income and access to affordable quality fresh fruit and

vegetables and physical activity. There also needs to be greater investment in appropriately trained

health professionals, early childhood educators and teachers to work with rural and remote

communities to prevent and reduce childhood obesity.

c. The short and long-term harm to health associated with obesity, particularly in children

Overweight and obesity among adults increases the likelihood of developing many chronic

conditions, including some cancers, cardiovascular disease, asthma, back pain and problems, chronic

kidney disease, dementia, diabetes, gallbladder disease, gout, and osteoarthritis (AIHW 2017a).

Seven percent of the total health burden is attributable to overweight and obesity7, similar to the

burden due to smoking (AIHW 2017b).

Childhood obesity increases the chance of developing the same conditions at a younger age or, with

premature onset, or greater likelihood in adulthood of premature death and disability (Reilly & Kelly

2011, WHO 2018).

Other childhood obesity health issues have also been identified such as severe obstructive sleep

apnoea, social and emotional problems and chronic school absenteeism (Cheng 2012), greater risk of

asthma, cognitive impairment and reproductive disorders later in life (WHO 2016a).

Young children in remote areas are already more likely to be developmentally vulnerable particularly

in language and cognitive domain, and 42% of young children in very remote areas are vulnerable on

one or more domains (see Table 2). In an Australian study Pearce et al (2016) report that obese

children were more likely to be vulnerable on the physical health and wellbeing and social

competence domains, and to be vulnerable on one or more domains. The authors also reported

that children who are obese in the first year of school may already be exhibiting developmental

vulnerabilities (Pearce et al 2016).

Another Australian study examined childhood obesity and its physical and psychological co-

morbidities in rural children (Sanders et al 2015). The authors reported that overweight/obese

Australian children and adolescents, compared to normal-weight peers, had more cardio-metabolic

risk factors and higher risk factors of non-alcohol fatty liver disease and were experiencing more

5 Food desert- healthy nutritious food is rare or even absent in a region or community 6 Food security- refers to the availability of healthy, affordable foods and the capacity of individuals and communities to access them (AIHW 2006) 7 https://www.aihw.gov.au/getmedia/f8618e51-c1c4-4dfb-85e0-54ea19500c91/20700.pdf.aspx?inline=true

negative psychological outcomes (depression, low self-esteem and lower scores of health-related

quality of life) (Sanders et al 2015).

Table 2 Vulnerability and risk during early childhood development8, 2015

Percentage of children developmentally: MC IR OR R VR

vulnerable on one or more domains 21 22 25 28 42

vulnerable on two or more domains 10 12 13 16 28

vulnerable in physical domain 9 11 12 14 22

at risk in physical domain 13 13 14 12 13

on track in physical domain 78 76 74 74 59

vulnerable in social domain 9 10 12 12 22

at risk in social domain 15 15 16 17 19

on track in social domain 76 74 72 70 54

vulnerable in emotional domain 8 9 10 11 19

at risk in emotional domain 15 15 17 18 20

on track in emotional domain 77 75 74 71 55

vulnerable in language and cognitive domain 6 7 9 12 23

at risk in language and cognitive domain 8 10 10 13 16

on track in language and cognitive domain 86 83 81 75 55

vulnerable in communication domain 8 8 9 11 19

at risk in communication domain 15 15 16 15 19

on track in communication domain 77 77 75 74 56

For children aged 5–14, the top three causes of total disease burden were asthma, anxiety disorders

and depressive disorders (AIHW 2018). Children with higher BMI (over the 85th percentile) are at

higher risk of developing asthma (Mohanan et al 2014). Children in rural and remote Australia higher

hospitalisation rates for both asthma in inland Australia and rural areas (AIHW 2013). There is also a

higher prevalence of mental health disorders for 4-17-year-old compared to those in major cities,

see Table 3 (Lawrence et al 2015).

For rural and remote children who live in environments where the prevalence of non-communicable

disease is already higher compared to those in major cities, obesity adds additional burdens to an

already disadvantaged population.

Table 3 12-month prevalence of mental disorder among 4-17-year-olds by remoteness area 2015

Remoteness area Prevalence (%)

Major Cities of Australia 12.9

Inner Regional Australia 14.8

Outer Regional Australia 19.0

Remote Australia or Very Remote Australia

14.0

Source: Lawrence et al 2015 The Mental Health of Children and Adolescents. Report on the second Australian Child and Adolescent Survey

of Mental Health and Wellbeing.

8 Measured across 5 domains - physical, social, emotional, language and cognitive, and communication. “Vulnerable” and “at risk” refer to different levels of hazard, with “at risk” indicating a higher perceived level of risk for the child than “vulnerable”.

d. The short and long-term economic burden of obesity, particularly related to obesity in children

Obesity cost the Australian economy $8.6 billion in 2011-12 and is predicted to cost the Australian

economy almost $90 billion in the decade to 2025 (Van Smeerdijk et al 2015).

The indirect costs are even greater. An earlier study estimated annual direct costs of obesity at $8

billion annually, with lost wellbeing estimated at $50 billion annually (Access Economics 2008).

In 2008/09 the estimated direct and indirect costs of obesity and obesity-related illnesses in

Australia was $37.7 billion, whereas the costs related to productivity loss due to absenteeism and

premature death was estimated to be $6.4 billion per year (Medicare Australia 2010). More recently

the Australian Institute of Health and Welfare reported that in 2011-12 overweight and obesity

contributed 7% of the total health burden and was estimated to have cost the Australian economy

$8.6 billion (AIHW 2017a).

There are few studies examining the cost of childhood obesity in Australia. One economic study

however looking at obese children in Sydney found that after adjusting for maternal and

sociodemographic characteristics, healthcare costs of children with obesity were 1.62 times those of

children with healthy weight (Hayes et al 2016). The authors concluded that prevention of obesity in

early childhood may have concurrent benefits in reducing healthcare expenditure. Economic benefit

of early obesity prevention programs has previously only acknowledged later savings in healthcare

costs resulting from reduced chronic disease in later life (Hayes et al 2016).

The Alliance was not able to locate research that focused on economic burdens for children in rural

and remote Australia. This remains a gap in the research that should be addressed as part of a

National Obesity Prevention Strategy.

e. The effectiveness of existing policies and programs introduced by Australian governments to improve diets and prevent childhood obesity

Preventing and reducing obesity will take a long-term investment and commitment with a whole of

government holistic system-wide approach, and funding that goes beyond a short political cycle.

There are a number of Australian government policies and programs that have been in place for

some time and they have continued to evolve. Some programs have resulted in positive change in

rural and remote Australian settings to improve diets, however to what extent they prevent

childhood obesity has not been verified.

Examples of policies and programs that are getting traction in rural and remote areas include

Healthy Together Victoria (in Victoria), Obesity Prevention and Lifestyle program or OPAL (South

Australia) and Tackling Childhood Obesity (New South Wales).

Healthy Together Victoria

Healthy Together Victoria is Victorian Government initiative that commenced in 2011/12, whose aim

is by taking a complex systems approach to prevention ‘To create a healthier Victoria by tackling the

rising rates of obesity and preventing obesity-related chronic disease’. The program is operating

across Victoria and has community-level trials in progress in twelve Healthy Together Communities

(Victorian Government 2018).

Healthy Together Communities are operating across the municipalities of Hume, Wyndham,

Whittlesea, Knox, Greater Dandenong, Cardinia Shire, Mildura, Greater Bendigo, Wodonga, Latrobe,

Greater Geelong, Ararat, Pyrenees and Central Goldfields and will reach approximately 1.3 million

Victorians, 520 schools, 938 early childhood services and 4,409 medium to large workplaces

(Victorian Government 2013).

The evaluation framework includes (but not limited to)evaluating changes to accessibility to

opportunities for physical exercise, temperature, costs, dominance of motorised transport,

opportunity for unmotorised transport, perceived danger in environment and safety (Strugnell et al

2016). All components that have been identified as barriers to rural and remote children’s

participation in physical activity.

The Alliance was unable to find evaluation reports that demonstrate health impact or outcomes for

these programs. However, the Alliance did source one evaluation report from Healthy Together

Mildura program (Mildura Rural City Council and Sunraysia Community Health Services 2016). This

evaluation paper reported on the implementation of a complex system approach and the experience

of the program staff in working in partnership with local government, non-government and health

agencies. The report demonstrates that this level of complex change takes considerable time to set

up, provide education on a new way thinking and working (e.g. on the complex systems

methodology) and build trust and a shared vision. However, the report provides optimistic insights

that a complex systems approach will being about positive health outcomes in this rural place.

Obesity Prevention and Lifestyle program (OPAL)

The OPAL program was established in South Australia in 2009. The program is coordinated through

local government to work with communities to create opportunities to eat well and be active. OPAL

is an adaption of France’s ‘Ensemble Prévenons l'Obésité Des Enfants’ (EPODE, Together Let's

Prevent Childhood Obesity).

The aim of OPAL is to improve the eating and activity patterns of children, through families and

communities in OPAL regions, thereby increasing the proportion of 0 to18 year olds in the healthy

weight range. OPAL draws on three complementary social and behavioural theoretical perspectives:

the social marketing theory of behaviour change; community development theory of action and

change; and ecological systems theory (Jones et al 2016).

There are six goals to bring about behavioural change across the community:

Eating well, which means:

healthy food choices available at food outlets

healthy meals produced in and from homes

local healthy food production, access and distribution.

Being active, which includes

active travel journeys

active leisure participation choices

use of parks, spaces and places.

The OPAL website provides a list of case studies that demonstrate successful outcomes of locally

based programs in rural South Australia. For example, in the rural town of Wallaroo, some outcomes

of the program included changes in the environment including the installation of water fountains in

playgrounds and 13 bike racks, redevelopment of other playgrounds to provide outdoor fitness

equipment (see Opal case studies, SA Health, for more examples9). However, the rate of childhood

obesity is over 7% (PHIDU 2018) in the Council of the Copper Coast, indicating, there is still much

work to be done.

Tackling Childhood Obesity

The Tackling Childhood obesity program is an NSW Government initiative that aims to reduce

overweight and obesity rates of children by five percentage points by 2025. The NSW Government

report that the tackling Childhood Obesity program has helped stabilise overweight and obesity

rates in children in NSW to 21.4 per cent (247,000 children) in 201610.

This program is an interdepartmental project that falls primarily under the responsibility of the

Ministry of Health but working in close partnership with the education sector. Strategies are being

implemented in schools (Live Life Well @School), early childhood and child care centres (Munch &

Move) and community-based programs (Go 4 Fun). The program is supported by state-wide social

marketing strategies (Make Healthy Normal), health coaching (Get Healthy Coach line, Get Healthy

Pregnancy), and a strategy to have routine height and weight measurements in clinical settings

(NSW Government 2016).

The Live Life Well @ School evaluation reports that in 2015 73.7% of schools in remote communities

have now adopted the Live Life Well @ School program principles, an increase from 9.5% in 2012. In

2015, the majority of Live Life Well @ School program practices were achieved by over 70% of

schools, and in many instances by over 75% of schools (Bravo et al 2016).

The Munch & Move program commenced in 2008. The evaluation report showed that there has

been a significant increase in the proportion of early childhood services that have implemented 70%

or more of the Munch & Move practices. In 2012 the total for NSW was 36% and in 2015 this had

increased to 78%. The increase has been observed in early childhood services with a high proportion

of Aboriginal children attending, services in disadvantaged communities and services in remote

communities. However, in relation to practice achievements associated with healthy eating and

physical activity and the provision of health information to families, services in remote communities

achieved less of the practices when compared to all other services (Lockeridge et al 2015).

Key points about these projects:

1. The programs were initially part of a National Prevention Health Partnership Agreement and built

on previous work that was already underway within each state (e.g. the Eat Well Be Active

Strategy in South Australia or the Be Active Eat well in Victoria). As such the programs were

national and state health priorities at the time they began and had a lot of political will/ drive

from the outset.

2. Although the programs were state-wide initiatives, operationally they were designed to fit the

local context. This required in-depth planning at the local level. The OPAL program for example

undertook a six month needs assessment to consult with a range of stakeholder and undertake

community audits of infrastructure and services available.

9 http://www.sahealth.sa.gov.au/wps/wcm/connect/6a145f80446c5107aebbae76d172935c/G337+OPAL+Case+Studies_Mid+Murray_Under5%27s_INTERNAL.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-6a145f80446c5107aebbae76d172935c-lG58edi 10 https://www.nsw.gov.au/improving-nsw/premiers-priorities/tackling-childhood-obesity/

https://www.nsw.gov.au/improving-nsw/premiers-priorities/tackling-childhood-obesity/

3. Each program has employed a dedicated project team.

4. Evaluation processes and research are ongoing components of the program.

5. Intersectoral partnerships and strategies are core components of the program strategies.

6. These programs are not a quick fix. They have taken time to establish and it may take a decade or

more to begin to see results.

The Alliance would like to see that these state-wide programs continue to be funded and even

enhanced to enable them to achieve what they have set out to do. However, given there is a greater

need in rural and remote places, particularly where there are higher proportion of Aboriginal or

Torres Strait Islander children, these programs should be targeted for additional resources and

support to reduce and prevent childhood obesity.

f. Evidence-based measures and interventions to prevent and reverse childhood obesity including experiences from overseas jurisdictions

“Unlike other major causes of preventable death and disability, such as tobacco use, injuries,

and infectious diseases, there are no exemplar populations in which the obesity epidemic has

been reversed by public health measures. This absence increases the urgency for evidence-

creating policy action, with a priority on reduction of the supply-side drivers”. (Swinburn et al

2011)

To date, no country has reversed its obesity epidemic (Roberto et al 2015) however there are some

interventions that have been described as “promising” policies and programs (Waters et al 2011). In

the review of Interventions for preventing obesity in children, the authors found strong evidence to

support interventions that improved BMI, particularly for programs targeting children aged six to 12

years. Authors found that there was such a broad range of program components in the studies that

it was not possible for the authors to distinguish which components provided the most benefits.

However, the authors surmised that promising policies and strategies are those that:

are included in the school curriculum and includes healthy eating, physical activity and body

image

increased sessions for physical activity and the development of fundamental movement

skills throughout the school week

improved nutritional quality of the food supply in schools

had environments and cultural practices that support children eating healthier foods and

being active throughout each day

support for teachers and other staff to implement health promotion strategies and activities

(e.g. professional development, capacity building activities)

provide parent support and home activities that encourage children to be more active, eat

more nutritious foods and spend less time in screen-based activities.

More recently an Australian rapid review of evidence for chronic disease prevention interventions in

children and young adults (Pikora et al 2016) found that there is a lack of intervention research

targeting poor nutrition, physical inactivity in children and young adults.

However, authors reported there is “strong evidence that the greatest impact on reducing risk

factors for chronic disease is likely to come from a multi-level, multi-strategy, multi-sector approach

across the life course”. For example:

School-based interventions that address physical inactivity.

Classroom-based physical activity interventions positively influence blood cholesterol,

cardiorespiratory fitness and skinfold thickness among children and adolescents

Interventions conducted in multiple settings (e.g. schools, family and community) that target

multiple health risk factors (e.g. nutrition education, physical activity promotion and

discourage sedentary behaviours)

Nutrition interventions delivered across multiple settings (i.e. home and school)

Home- and family-based interventions for alcohol

Higher prices and alcohol taxes to reduce excessive alcohol consumption.

As noted, there is a critical need for research to underpin evidence based policy to address service

access needs to appropriately trained early childhood educators, teachers and multi-disciplinary

health professional teams who can implement these promising strategies.

g. The role of the food industry in contributing to poor diets and childhood obesity in Australia

The food industry (greatly influenced by globalization and multination corporations) has a significant

role to play in reducing obesity and contributing to healthy diets overall.

One of the explanations as to why there has been “patchy progress’ on reducing obesity is the strong

lobbying from the food industry and poor policy implementation and accountability from

governments (Roberto et al 2015).

However, as is advocated in the literature, a multisectoral response and greater accountability is

needed, as for example it is not the food industries’ role to design urban environments that promote

active travel or to change societies’ addiction to screen time activities. Never the less, there is a lot

more that the food industry can do to promote healthy food environments and systems particularly

for rural and remote Australia.

To help guide food policy, the World Cancer Research Fund International has developed the

NOURISHING framework that provides an evidence informed guide to food policy interventions

within three domains, the food environment, food system and behaviour change and

communication (World Cancer Research Find International 2014), see Figure 2.

The majority of strategies employed by the food industry to date have been focused on voluntary

marketing codes, product reformulation, and sponsorship for physical activity or community

activities (Alexander et al 2011).

However, ‘Big Food’ have been criticised for using corporate social responsibility activities to

promote their brands, target parents and children through community activities and align

themselves with respected philanthropic organisations (Richards et al 2015). The food industry has

also been criticised for its shameless exploitation of children through advertising, exacerbating food

deserts and increasing food insecurity (Loo & Skipper 2017).

Figure 2 World Cancer Research Fund International NOURISHING Framework. https://www.wcrf.org/int/policy/nourishing/our-policy-framework-promote-healthy-diets-reduce-obesity#large

The World Health Organization (2010) provided a set of recommendations on the marketing of foods

and non-alcoholic beverages to children. WHO recommend that policies should aim to reduce the

impact on children of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt

and the exposure of children to, and power of, marketing of foods high in saturated fats, trans-fatty

acids, free sugars, or salt.

A number of countries have introduced statutory regulations on advertising to children. Australia has

opted for a self-regulated approach. A systematic review examining levels of exposure of children to

food advertising since the introduction of the statutory and voluntary codes in the UK found that

voluntary codes may not sufficiently reduce the advertising of foods and undermine healthy diets, or

reduce children’s exposure to this advertising (Galbraith et al 2013).

A more recent Australian study found that there has been no change in the rate of unhealthy food

advertising since the Australian food industry introduced initiatives to reduce the marketing of

unhealthy food to in 2009. The authors conclude that the current food industry initiatives on

reducing children’s exposure to unhealthy food advertising is having minimal impact (Watson et al

2017). The food industry, by advertising to children influences taste preferences and brand loyalty in

childhood years and this continues into adulthood (Lobstein et al 2015). Food companies pay to

advertise their products so as to sell more and make greater profits and targeting children is no

exception. The effect of ‘pester power’ advertising on children and parents shopping preferences are

strong and effective, which is why companies pay to advertise (Baker 2014). Advertising for

unhealthy foods substantially exceeds advertising for healthy foods.

Another Australian study looking at health and nutrition content claims on Australian fast-food

websites found that half of the products that had health claims on them did not meet the

requirements of the Food Standards Australia and New Zealand Nutrient Profiling Scoring Criteria

(Wellard et al 2017).

These examples alone demonstrate there is much room for improvement in strengthening current

food regulation and monitoring systems in Australia and promoting in demanding ethical behaviour

from multinational food companies.

Recently in Australia the question has been raised around a sugar tax and front of packaging

nutrition labelling. Sugar sweetened beverages are linked to diabetes, heart disease and oral health

problems (Brownell et al 2009) and poor cognition (Cohen et al 2018). Therefore by decreasing

children’s sugar consumption should reduce the risks of heart disease, diabetes, lessens tooth decay

and improves cognition. Some countries have already implemented some form of taxation on

sweetened beverages (France, Belgium, Barbados, Mexico, UK). A systematic literature review of

healthy food subsidies and unhealthy food taxation showed that there is consistent evidence that

taxation and subsidy interventions influence dietary behaviours (Niebylski et al 2015). The authors

recommended that to maximise success and effect, food taxes and subsidies should be a minimum

of 10 to 15% and used in tandem (Niebylski et al 2015).

Front of package labelling is also a recommended strategy aimed at reducing sugar sweetened

beverage consumption. An Australian study found that front of package labels, especially those with

graphic warnings, have the potential to reduce sweetened beverage purchases (Billich et al 2018).

The Alliance concurs that effective food-policy actions targeted at the food industry can lead to

positive changes to food environments particularly if strategies are tailored to the targeted

community (e.g. rural and remote communities) and are implemented as part of a combination of

‘mutually reinforcing actions’ (Hawkes et al 2015) such as those outlined in the NOURISHING

framework.

h. Any other related matters

There are three final matters that Alliance would like to highlight that urban design and the planning

system and agricultural policy have role to play in improving obesity rates in rural and remote

Australia.

Urban design, development and creation of healthy communities often falls within the purview of

local governments. However, current planning systems in Australia often limit the extent to which

local governments can control the location and density of convenience restaurants (Taylor 2015,

Thornton et al 2016). Local governments also have significant role to play in enhancing and designing

infrastructure that will promote physical activity for recreation, leisure and exercise (Obesity

Prevention Coalition 2017.) Planning systems should explicitly incorporate health as a core

component to protect and promote the population’s health and wellbeing.

Agricultural policies need to incorporate health outcomes. Farmers have a role to play in providing

ecologically sustainably grown nutritious food. Farmers markets as one example, deliver community

health and wellbeing benefits, provide access to locally grown food and provide a social hub (RIRDC

2014). However, the dominance of large food chains and supermarkets puts pressure on farmers for

pricing of produce, size of their production, the type of farming method used to meet production

demand (e.g. industrialised mono-crop farming) and experience significant economic pressures. All

this at a time of changes to the climate, increasing natural disasters, prolonged drought, and

changes to water, soil and biodiversity generally, land use policy and increased population

consumption demand. These pressures are having fatal consequences, for example farmers are

three times more likely to suicide than any other Australian profession (Australian Environmental

Grantmakers Network 2015).

Recommendations

The Alliance recommends that:

1. Australia needs a national obesity prevention strategy as a matter of urgency. The strategy

needs to focus on eradicating obesogenic environments in rural and remote Australia. It needs

to target inequalities and inequities in education, income and access to affordable quality fresh

fruit and vegetables and physical activity. Priority should be given to ending obesity inequalities

for children in lower socioeconomic groups, particularly Aboriginal and Torres Strait islander

children and children in remote Australia.

2. Government research programs need to prioritise research that will improve understanding of

food environments (particularly consumer nutrition environments) in rural and remote

Australia.

3. Increased funding for additional resources, infrastructure and workforce should be made

available to improve the access of rural and remote communities to appropriately trained early

childhood educators, teachers and multi-disciplinary health professional teams.

4. State-wide programs such as the Healthy Together, Tackling Childhood Obesity and OPAL

should continue to be funded and even enhanced to enable them to have a broader reach and

achieve what they have set out to do. However, given there is a greater need in rural and

remote places, particularly where there are higher proportion of Aboriginal or Torres Strait

Islander children, these programs should be prioritised for additional resources.

5. Planning systems across critical areas such as the location and density of convenience

restaurants and the design of areas for physical activity for recreation, leisure and exercise

should explicitly incorporate health as a core component to protect and promote the

population’s health and wellbeing.

6. Agricultural policies need to incorporate health outcomes. At a time of increasing change to

meet the multifaceted challenges of climate change, the modernisation of production methods

and the market concentration of supply chains, sustainable nutritious food is the foundation of

health and wellbeing.

The Alliance also supports the eight policy actions recommended by Obesity Prevention Coalition ‘Tipping the Scales’ campaign.

1. Legislate to implement time-based restrictions on exposure of children (under 16 years of age)

to unhealthy food and drink marketing on free-to-air television until 9:30pm.

2. Set clear reformulation targets for food manufacturers, retailers and caterers with established

time periods and regulation to assist compliance if not met.

3. Make the Health Star Rating System mandatory by July 2019.

4. Develop and fund a comprehensive national active travel strategy to promote walking, cycling

and use of public transport.

5. Fund high-impact sustained public education campaigns to improve attitudes and behaviours

around diet, physical activity and sedentary behaviour.

6. Federal government to place a health levy on sugary drinks to increase the price by 20%.

7. Establish obesity prevention as a national priority, with a national taskforce, sustained

funding, regular and ongoing monitoring and evaluation of key measures and regular

reporting around targets.

8. Develop, support, update and monitor comprehensive and consistent diet, physical activity

and weight management national guidelines (Tipping the Scales 2017).

However, the Alliance also recommends that these policy actions are adapted to the rural and remote context, particularly policy action number 4 for active travel and public transport solutions.

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Attachment 1: Membership of the National Rural Health Alliance

National Rural Health Alliance - Member Body Organisations

Australasian College for Emergency Medicine (Rural, Regional and Remote Committee)

Australasian College of Health Service Management (rural members)

Australian College of Midwives (Rural and Remote Advisory Committee)

Australian College of Nursing - Rural Nursing and Midwifery Community of Interest

Australian College of Rural and Remote Medicine

Australian Healthcare and Hospitals Association

Allied Health Professions Australia Rural and Remote

Australian Indigenous Doctors’ Association

Australian Nursing and Midwifery Federation (rural nursing and midwifery members)

Australian Physiotherapy Association (Rural Members Network)

Australian Paediatric Society

Australian Psychological Society (Rural and Remote Psychology Interest Group)

Australian Rural Health Education Network

Council of Ambulance Authorities (Rural and Remote Group)

CRANAplus

Country Women’s Association of Australia

Exercise and Sports Science Australia (Rural and Remote Interest Group)

Federation of Rural Australian Medical Educators

Isolated Children’s Parents’ Association

National Aboriginal Community Controlled Health Organisation

National Rural Health Student Network

Paramedics Australasia (Rural and Remote Special Interest Group)

Rural Special Interest Group of Pharmaceutical Society of Australia

RACGP Rural: The Royal Australian College of General Practitioners

Rural Doctors Association of Australia

Rural Dentists’ Network of the Australian Dental Association

The Royal Australasian College of Surgeons – Rural Surgery Section

Royal Far West

Royal Flying Doctor Service

Rural Health Workforce Australia

Rural and Indigenous Health-interest Group of the Chiropractors’ Association of Australia

Rural Optometry Group of Optometry Australia

Rural Pharmacists Australia

Services for Australian Rural and Remote Allied Health

Speech Pathology Australia (Rural and Remote Member Community)

Attachment 2: Allied Health workforce by remoteness

Medical and Allied Health Workforce by remoteness 2016

Major

cities

Inner

regional

Outer

regional Remote

Very

remote

Allied Health Professions Total Full Time Equivalent (FTE) workforce

Medical Radiation

Practitioners 9521 1876 631 74 25

Oral health practitioners 14246 2623 1099 124 44

Occupational Therapists 10777 2059 950 112 46

Optometrists 3421 688 234 27 8

Osteopaths 1379 268 47 NP NP

Pharmacists 17219 3389 1593 220 93

Physiotherapists 17987 2878 1132 129 82

Podiatrists 3071 747 224 31 12

Psychologists 17881 2659 936 104 42

Other health

professionals

Medical practitioners 76411 13129 5814 975 446

Nurses and Midwives 200554 47994 22459 3833 2413

Major

cities

Inner

regional

Outer

regional Remote

Very

remote

Allied Health Professions No of FTE practitioners per 100,000 population

Medical Radiation

Practitioners 54.93 43.22 30.90 25.19 12.35

Oral health practitioners 82.20 60.42 53.82 42.21 21.74

Occupational Therapists 62.18 47.43 46.52 38.13 22.73

Optometrists 19.74 15.85 11.46 9.19 3.95

Osteopaths 7.96 6.17 2.30 NP NP

Pharmacists 99.35 78.07 78.01 74.89 45.95

Physiotherapists 103.78 66.30 55.44 43.91 40.51

Podiatrists 17.72 17.21 10.97 10.55 5.93

Psychologists 103.17 61.25 45.84 35.40 20.75

Other health

professionals

Medical practitioners 440.88 302.44 284.73 331.90 220.34

Nurses and Midwives 1157.15 1105.59 1099.88 1304.78 1192.12

Workforce data from http://hwd.health.gov.au/summary.html#part-3

ABS population data 3218.0 - remoteness area download

http://hwd.health.gov.au/summary.html#part-3