Filling the regulatory gap in chronic disease prevention

The first public health laws governed sanitation and led to clean piped drinking water. Darren Stueber

OBESE NATION: It’s time to admit it - Australia is becoming an obese nation. This series looks at how this has happened and more importantly, what we can do to stop the obesity epidemic.

Today, we look at whether we can regulate to curb the epidemic. Here Bebe Loff and Helen Walls argue there’s a “gap” in regulation waiting to be filled by the government while Fiona Haines considers what kind of measures are possible.

Britain first enacted public health laws during the 19th century. They governed sanitation – piped drinking water and disposal of human wastes. This “sanitary reform” had a significant public health effect. In fact, in 2007 readers of the British Medical Journal (BMJ) voted these reforms the most important medical milestone since 1840.

With its focus on populations rather than individuals, law is a central aspect of public health practice. The experience of many other areas of public health – from smoking to infectious disease control – has also shown that informed legislative reform measures can be potent, equitable, and cost-effective.

Obesity-related chronic diseases account for 60% of preventable deaths in developed countries, and by 2020, they will account for 70% of deaths in developing countries. Despite this, we currently lack laws relating to obesity and chronic diseases. Tobacco control is a notable exception and we will consider the lessons we can learn from it below.

Environmental or structural changes are needed because education and treatment strategies are ill-suited to control obesity, and generally benefit those in higher socioeconomic brackets. So it’s unsurprising that we are increasingly hearing calls for regulatory approaches to address obesity and its attendant chronic diseases.

Historically, food industry regulation has addressed acute safety concerns, such as food poisoning, rather than nutrition-related chronic disease, which has been characterised as amenable to individual choice. This has to change if we are to address today’s epidemic of obesity and chronic diseases.

Earthquakes precipitated changes to building codes. BBC World Service

Lessons from history

So how can governments start the process of instituting regulations for better health? A look at the historical context of enacting laws to protect public health may suggest what compels governments to legislate.

  • Crisis-driven law

Physical catastrophes have often catalysed regulation. Building codes, such as laws enacted following the Great Fire of London, for instance, have been reactive and designed to avoid future damage. Earthquakes have also precipitated changes to building codes.

Concern in the 1950s and 1960s about smog in from cars in Los Angeles was a “crisis” to which legislators had to respond. Similarly, cholera outbreaks in 19th century England catalysed the sanitation reform mentioned above.

  • Law to control dissent (and preserve capital)

Britain was in depression in the 19th century and revolution was feared. Historically, regulation has been most easily enacted when it protects the elite. Sanitary law was enacted to ensure that the poor were in sufficiently good health to provide their labour, rather than claim relief in workhouses. By addressing problems of the poor, it protected the interests of the wealthy.

The Sanitary Report preceding the reforms addressed problems related to living conditions only incidentally. Disease outbreaks, sewers and water were mentioned, but so too were morality and “character”.

The new laws forced improvements in public health, eventually making the state the ultimate guarantor of health and environmental quality standards.

Scientific evidence has led to regulations for vehicle emission control. Steven Buss
  • Scientifically-informed law

Scientific evidence was relatively unimportant in early public health regulation, but more recently, science has precipitated regulations such as with vehicle emission control. Scientists attributed air pollution to cars and Rachel Carson’s 1962 book Silent Spring awakened the informed public to the dangers of pollution, catalysing the environmental movement.

But science is only ever a partial explanation for public health regulation. And as scientific evidence becomes more credible, industry usually produces its own experts to support contrary views.

  • Political philosophies

Political philosophies shape law reform, be it a belief in free markets or in welfare governance. Many researchers have suggested ways in which the regulatory environment could support better nutrition and physical activity. So why is government so slow to regulate in this area?

The examples above illustrate the kind of circumstances that enable reform, as does the regulatory experience with tobacco. Let’s turn to that now.

Lessons from tobacco

Tobacco and junk food are similar in their addictiveness, health impact, costs to the community, and the powerful industries behind each. As a legislative target, tobacco, an addictive carcinogen, has advantages over obesity. Unsafe when used as intended, tobacco regulation has a simple goal – to prevent people from using it at all. In terms of addictiveness, junk foods and tobacco may be similar, but food is necessary for survival.

Diseases associated with nutrition are multi-causal, often tied to a balance of energy consumption and energy expenditure. While there’s compelling evidence of a direct cause-and-effect relationship between cigarette smoking and poor health, less evidence links particular foods to nutrition-related diseases.

But the key obstacle to enacting policy and legislation, as was formerly the case with the tobacco industry, is opposition from the food industry. Naturally, the latter has strongly opposed legislative and regulatory approaches, as these may restrict its profitability.

Tobacco is an easy legislative target because it’s an addictive carcinogen. durera_toujours/Flickr

The tobacco industry once fostered a debate about “sound science”. The food industry has tried to create similar confusion about links between nutrition, obesity and chronic diseases, by emphasising that physical inactivity increases obesity and minimising the role of food. Industry also supports health promotion measures that are likely to increase consumer confusion rather than promoting healthy eating.

For tobacco, a strong body of evidence effectively communicated to the public catalysed a crisis, leading to government action. Similarly, pressure on governments to respond to obesity and resulting chronic diseases will grow as scientific evidence links them to disability and premature mortality. But as long as obesity and the chronic diseases it causes are perceived as matters personal choice, legislative reform will not be forthcoming.

The growing body of evidence regarding the reasons for and impact of obesity among those least well-off may also create social concern, advancing regulatory reform. But as with climate change, legislating to prevent chronic diseases runs counter to the government’s usual priorities.

We face chronic health and environmental crises today – increasing epidemics of obesity and nutrition-related disease, and environmental challenges, such as climate change. Regulation can help us address them but it seems that these crises must become acute before governments will act.

This is part seven of our series Obese Nation. To read the other instalments, follow the links below:

Part one: Mapping Australia’s collective weight gain

Part two: Explainer: overweight, obese, BMI – what does it all mean?

Part three: Explainer: how does excess weight cause disease?

Part four: Recipe for disaster: creating a food supply to suit the appetite

Part five: What’s economic growth got to do with expanding waistlines?

Part six: Preventing weight gain: the dilemma of effective regulation

Part eight: Why a fat tax is not enough to tackle the obesity problem

Part nine: Education, wealth and the place you live can affect your weight

Part ten: Innovative strategies needed to address Indigenous obesity

Part eleven: Two books, one big issue: Why Calories Count and Weighing In

Part twelve: Putting health at the heart of sustainability policy

Part thirteen: Want to stop the obesity epidemic? Let’s get moving

Part fourteen: Fat of the land: how urban design can help curb obesity

Part fifteen: Industry-sponsored self-regulation: it’s just not cricket

Part sixteen: Regulation and legislation as tools in the battle against obesity