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Rethinking how we live to stop the chronic diseases epidemic

We are in the midst of a global epidemic of chronic diseases – diabetes, heart disease, cancers and respiratory disease are on the rise across the world. Posing a real and increasing threat to health and…

Urban environments are increasingly bombarding us with unhealthy food choices. John Walker

We are in the midst of a global epidemic of chronic diseases – diabetes, heart disease, cancers and respiratory disease are on the rise across the world. Posing a real and increasing threat to health and prosperity, these diseases affect all populations, in particular, the world’s poorest and most marginalised.

Simultaneously, the world is rapidly urbanising – over half the world’s population now lives in urban settings. An acknowledged driver of chronic disease, urbanisation and urban living must become a stage for good health rather than its opposite.

Acknowledging the context

The way we live, access to education and employment, quality of housing and the environments in which we work and play all profoundly shape our health.

Industrialisation has seen social and economic innovation – finding ways to increase productivity in a range of sectors while reducing physical activity. Our diets have also changed drastically with this – we eat food that comes in larger portions, is increasingly processed, endlessly available and more energy-dense.

Put together, there’s now an energy imbalance between what we eat, and the energy we expend. This leads to obesity and related chronic diseases - but it’s not simply due to people making poor choices.

Many people see the current obesity epidemic as an issue of “calories in, calories out”. But a significant reason why people are increasingly overweight is because the default position for the modern, urban citizen is being overweight. Our cities are not designed to make healthy living easy - and this stands for many low-, middle- and high-income settings.

If we are to tackle chronic diseases, public policy must strive towards this key mantra – make healthy choices the easy choices. It’s pointless to continue struggling with attempts to coerce populations into making healthy choices while allowing the expansion of increasingly obesogenic urban environments. Urban settings must be fundamentally altered to make healthy behaviours the path of least resistance.

Making good health easier

But can healthy public policy really make a difference? Consider the case of Denmark, a high-income country with a similar GDP (gross domestic product) to Australia, the United Kingdom and the United States. Yet, with a record of intelligent social and planning policies, Denmark has an obesity rate around half that of Australia or the United States.

Denmark’s capital, Copenhagen, represents a blueprint urban environment with key social policies structured towards making good health easier. High-quality, ubiquitous bike lanes, efficient public transport and safe green spaces result in 40% of the population commuting to work by bicycle – simply because biking is the cheapest and easiest option for getting around, and it’s safe.

The city also mandates regularly spaced small, accessible supermarkets throughout suburban and central districts. Not only does this result in increased competition and reduced consumer prices, it also means that every citizen passes by fresh food options on their daily commute. This maximises the opportunity for incidental food shopping.

Town planning considerations, coupled with strict laws on frequency and signage of fast-food businesses, help to promote home cooking and create barriers to unhealthy eating.

Copenhagen represents a blueprint urban environment for making good health easier. Jim G/Flickr

Take-out food is also less accessible. Reflecting high commercial rents and taxation, a Big Mac meal, for example, costs around AU$15, approximately twice the price in Australia. It’s hardly a surprise then, that there’s just a handful of McDonalds restaurants in the city of 1.2 million. There are also stricter laws around advertising these foods.

Looking to a healthier future

Clearly, progress has been made in cities outside of Denmark, and the global expansion of bike-sharing programs, the “Copenhagenize” movement as well as increasing attention on food advertising are good reflections of this. But many efforts are thwarted by the simple fact that, for many, disease has become easier to achieve than health.

If making the healthy option the easy option is the goal, we need to take a hard look at our public environments as exemplars for healthy living. What then is the place for fast-food outlets in public hospitals? Should we follow New York Mayor Michael Bloomberg’s lead and consider bans on fast food and sugary drinks in these places, including soft-drink vending machines?

We need to rethink the way our societies are structured so that chronic disease prevention and healthy living become the default option for individuals. The current paradigm in which medical and public health communities promote healthy behaviours while societies continue to build social environments conducive to the opposite, is a waste of time and money.

The easy option, wherever possible, must become the healthy option and our society should strive to create built environments conducive to this.

We don’t want to force health on populations, or limit citizen choice – we simply want to create an even playing field. As a society, it’s time we acknowledge that it’s unrealistic to continue creating environments conducive to diabetes, heart-disease and cancers, and then blame individuals for getting ill.

The authors would like to acknowledge the valued contribution of Kyra-Bae Snell to this article.

Join the conversation

25 Comments sorted by

  1. Sue Ieraci

    Public hospital clinician

    There is no doubt that wealthy communities consume too many calories and are too immobile for optimal health.

    We also know, however, that longevity in our community continues to increase, and that the vast majority of chronic diseases - notably cancers and heart disease, increase with older age.

    It would benefit our understanding of chronic disease to have an outline of trends by AGE GROUP. Is there really more coronary disease, or cancer, at a younger age, or is the increase in incidence (if there is one) related to longevity?

    It's not enough to say "x" is the greatest killer, knowing that, at the end of our lifespan, some organ has to fail first.

    It would be great to be able to rationally target conditions that limit longevity rather than are secondary to it.

    My initial guess would be that not smoking and having a balanced diet would go a long way for overall community health - but, as we age, something will go wrong or wear out.

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  2. Geoff Taylor

    Consultant

    The model is interesting.
    But in Australia we face the current spread out urban design, very hot summer climate in many places, and lack of shower and change facilities in workplaces. Hard to shower as you move from one meeting to another during a day of hot weather.
    And how do the Danes cycle in wet weather without ending up at work in wet clothes (either from rain or sweat) and wet shoes?
    Still, I note those modular bike lockups/showers designed to go in carparks could help somewhat.

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    1. Fred Hersch

      Doctor, Global Health researcher at University of Sydney

      In reply to Geoff Taylor

      Providing basic facilities that would encourage active transport is an important step and one that should be strongly advocated for. There is lots of data on the productivity improvements from a "healthy" workforce and it is the private sector that is often far ahead in responding to the growing demand.

      In terms of exemplars, if we are serious about promoting active transport I would like to see the public sector taking a lead here.

      The Danes are notorious for being all weather riders and it is more about attitude than weather. There are lots of options for staying dry from light wet weather gear to bike mudguards.

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    2. Judith Olney

      Ms

      In reply to Fred Hersch

      Many people live a long way from where they work, and face long commutes, cycling is just not a viable option for them. The cost of housing, particularly in cities, is a big problem. There is no low cost housing close to CBD's, and businesses are reluctant to locate anywhere else. Many cities have very poor public transport, and there is no political will to change this in any significant way. In Perth, the nearest city to me, public transport is also not a safe option for anyone travelling at night…

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    3. Matt Stevens

      Senior Research Fellow/Statistician/PhD

      In reply to Judith Olney

      Precisely what the article was about. Making public transport or cycling the easier and cheaper option. Spend money improving the facilities, run education campaigns, teach the little ones in school and in 10 to 15 years there should be some change in the social norms. Especially like the idea of putting higher tax on junk food, making healthy food the best option for people.

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    4. Judith Olney

      Ms

      In reply to Matt Stevens

      I agree with you about education, as a child I attended a weekly bike riding lesson in primary school. We were taught the road rules, and a lot about how to ride safely. I carry those lessons with me today when I'm cycling.

      I agree with the article in many areas, we need to totally rethink the way we build our cities, towns and suburbs. We will be a healthier and wealthier nations if we do.

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  3. James Jenkin

    EFL Teacher Trainer

    Is there a causal relationship between town planning in Copenhagen and Denmark's low obesity rate?

    The obesity rates throughout Scandinavia and much of Western Europe (France, Italy, Switzerland) - and not to mention Japan and Korea - are also half that of Australia's (http://www.oecd.org/health/49716427.pdf).

    Therefore there must be many other factors the article has not considered. We need pretty good evidence before we turn town planning on its head, and use the law to shape where people shop, what they eat and how they move around.

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    1. Joe Gartner

      Tilter

      In reply to James Jenkin

      Taxing those things that produce the greatest chronic disease (and hence increase morbidity and health costs) seems like a sensible option. Public health controls on water, air quality immunisation etc have historically enacted great gains in public health.
      We have to start seeing junk food as a form of pre-morbid corporeal pollution and we have to see our town planning as a similar pre-morbid state. There is no issue with exacting a toll via taxation or other enforced stricture upon those things that reduce our population health.
      As for evidence... What more do you need? Walked around our cities lately?

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    2. Judith Olney

      Ms

      In reply to Joe Gartner

      I agree with your idea for taxing unhealthy foods at a higher rate, but on the flip side we need to make sure that healthy food is made cheaper.

      For someone on a low or fixed income in Australia this is indeed a big problem, fresh healthy food is often the most expensive, and processed, high fat, high sugar content food, is the cheapest.

      In my town, I can easily cycle to my local IGA, a small supermarket. However, the prices are much higher in this small supermarket, than in the larger supermarket…

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    3. James Jenkin

      EFL Teacher Trainer

      In reply to Judith Olney

      I couldn't agree more, Judith, your school needs more bike racks!

      However, is there a larger town planning issue?

      The truly disadvantaged parts of Melbourne - Footscray, Sunshine, St Albans, Dandenong for example - have markets, and grocers on the street, and a great range of cheap fresh food options. Copenhagen already exists in these suburbs.

      So why aren't people healthy?

      Public health advocates might suggest the disadvantaged aren't aware of healthy diet and exercise. I really find it hard to believe that your average Footscray resident does not yet realise vegetables are good for you, fat makes you fat, and exercise is a good thing.

      Could it be that nice middle-class health experts actually get up people's noses, and buying junk food is a kind of 'up yours'? When advocates say 'you should eat quinoa and ride a bike' perhaps what people hear is 'you should copy my admirable lifestyle'.

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    4. Matt Stevens

      Senior Research Fellow/Statistician/PhD

      In reply to James Jenkin

      I think you will find levels of education significantly higher in the population as a whole. Teach people to empower themselves and have control over their lives.

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    5. Judith Olney

      Ms

      In reply to James Jenkin

      You make a good point James, I know the type of middle class health experts you are talking about, and they really get up my nose too.

      Its no good telling people with a low income that they should be eating healthy food, when they simply don't have the money for all the expensive organic produce, and cheap takeaway is filling and affordable, if not particularly nutritious. No good advocating for a tax on junk food, when the alternative is just if not more expensive. No good telling them they…

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    6. Julia Abbott

      logged in via email @gmail.com

      In reply to Judith Olney

      Judith, good points, but we do have a tax on junk food - the GST. It applies to all processed, take away and restaurant food. It does not apply to fresh food - like fruit and vegetables. And if a 10% price differential isn't sufficient to change people's habits, how much more would be needed? 50%? 100%?

      And Joe, you say "There is no issue with exacting a toll via taxation or other enforced stricture upon those things that reduce our population health". Mate, I think there is an issue. Alot of people are struggling with the cost of food now. Making it even more expensive will, for sure, make people poorer - but there's no evidence that it will make them healthier. In fact, poverty is probably better predictor of poor health than a person's weight.

      And James, I agree with you too. Our public health responses to obesity should be guided by evidence, and by a clear understanding of how translatable international experiences might be to the Australian environment.

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    7. Alessandro R Demaio

      Australian Medical Doctor; Postdoctoral Fellow in Global Health & NCDs at Harvard University

      In reply to James Jenkin

      Thanks James, but I think you have missed the point of the article.

      We are not suggesting that bike lanes alone will result in a halving of the obesity rate for nations like Australia - keeping in mind that it would be near impossible to run an RCT on this to prove causality anyway. But that we increasingly blame the ill for their chronic illness and the obese for "poor choices", while continuing to build urban environments which fail to make health the path of least resistance.

      And let's…

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    8. Joe Gartner

      Tilter

      In reply to Julia Abbott

      Julia,
      What leads you to think that it is only the poor who buy junk food, do not exercise or are subject to chronic disease?
      Urban design, taxation and education will just as likely improve the public health of citizens from other demographics.
      Of course further research is required in some respects and of course direct causal relationships are impossible to state, but as the status quo is so dire why is it problematic to act in those areas we know contribute to chronic disease?

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    9. Judith Olney

      Ms

      In reply to Julia Abbott

      Julie, I live in a remote town, and fresh fruit and vege is extremely expensive here, so even without the GST it is not the cheaper option for people at all. Processed and packaged food is cheaper because the transport costs are lower, and the shelf life is a lot longer.

      For many people on a low income, simple carbohydrates form the basis of their diet, things like rice, pasta and cheap bread. This is what is making people fat in my opinion. Most people I know on a low income eat very little…

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    10. James Jenkin

      EFL Teacher Trainer

      In reply to Alessandro R Demaio

      Hi Alessandro - thanks very much for your response.

      You say you don't want to 'shape' people.

      But you do want to have control over their homes, transport and shopping. That does seem a bit like 'shaping' to me.

      You also mention you want an 'even playing field'. With whom? Rich people in trendy suburbs? Are you saying working class people should aspire to the lifestyle of the middle class? They should ride retro bikes and eat organic?

      That sounds awfully snobby to me.

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    11. Alessandro R Demaio

      Australian Medical Doctor; Postdoctoral Fellow in Global Health & NCDs at Harvard University

      In reply to James Jenkin

      Thanks James. Again, I think you might have missed the point of the article.

      The even playing field we refer to is between healthy and less-healthy choices - not between suburbs.

      We are also not suggesting controlling anything more than we currently "control" urban environments - this is called urban design and policy.

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    12. Judith Olney

      Ms

      In reply to Alessandro R Demaio

      I think that redesigning our urban areas would help make it easier to make healthier choices, but I think the problems with chronic diseases, and growing obesity, have a much wider reach.

      We are constantly told that we need to increase productivity, we already work some of the longest hours in the world, and for most families this means both parents working long hours.

      We also have a problem with the unwillingness of governments to provide enough welfare for those that are ill, disabled…

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  4. Neville Mattick

    Grazier: ALP Member at A 4th Generation Grazing Station

    We do need to get back to what we were designed to eat - I reckon.

    Advertising bombarding easily influenced minds from an early age does not help.

    Fructose is modern causal agent in my opinion, present in modern processed food by stealth.

    Absolutely agree in taxing where the food choices that are expensive will be disadvantaged in the market place.

    For my own management, I regularly try to get very hungry, have a physical life, making fences and shearing sheep all the time, eat very…

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  5. Gary Cassidy

    Great article. The obesogenic environment that we have created and continue to create is something that needs to be discussed, debated, and bought to the attention of us general public. Changing to a less obesogenic environment will take a lot of effort, hard decisions, brave decisions and may have a higher short term cost. To me it seems like madness that as our environment becomes more obesogenic we continue to solely blame individuals for betting obese? For most people living in this environment, doing what is the normal thing to do, they will get fat!

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  6. Matt Stevens

    Senior Research Fellow/Statistician/PhD

    Denmark is scrapping its fat tax
    http://www.abc.net.au/news/2012-11-11/denmark-to-scrap-world27s-first-fat-tax/4365176

    "Denmark says it will scrap a fat tax it introduced a little over a year ago in a world first, saying the measure was costly and failed to change Danes' eating habits.

    "The fat tax and the extension of the chocolate tax - the so-called sugar tax - has been criticised for increasing prices for consumers, increasing companies' administrative costs and putting Danish jobs at…

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    1. Alessandro R Demaio

      Australian Medical Doctor; Postdoctoral Fellow in Global Health & NCDs at Harvard University

      In reply to Matt Stevens

      Thanks Matt, indeed this is a sad development, but not totally unexpected. We had seen this coming from shortly after its implementation in Denmark.

      As you can probably deduce though this is not a decision made on science, but politics.

      The reason I say this, in addition to it being cited by the government themselves as a decision to protect economic interests, is that we cannot have expected any changes in health (chronic disease) in one year. Many would argue this is not even sufficient…

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  7. Margo Saunders

    Public Health Policy Researcher

    Maybe I've missed it, but I haven't seen anyone acknowledge one of the main reasons that many people don't make 'healthy choices': they don't want to. It is simply not at the top of their list of values. 'You've got to enjoy life!,' is what I hear constantly from -- yes -- non-tertiary educated male blue-collar and female pink-collar workers who suffer disproportionately from many chronic 'lifestyle' diseases and conditions.
    According to their balance sheets, the value they derive from smoking…

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  8. aligatorhardt

    logged in via Twitter

    As a person who was previously used to daily heavy labor, then developed breathing problems, I can attest to the fact that diet is as important as exercise. I cannot maintain a high level of activity due to O2 shortages, but have reduced to a favorable weight by eating mostly vegetarian, fresh fruits, vegetables, nuts, grains, ect. Exercise like bicycle riding is no longer an option.
    The processed, sugar and fat heavy foods in modern diets are not only promoting obesity, but chemical contaminants, including hormone disruptors and growth hormones are contributing to the problem. Cancer rates are also much higher than several decades ago. It is not only the food, but the food additives that must be evaluated.

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