Queensland appears intent on dismantling its public and preventive health services. Health Minister Lawrence Springborg last week outlined the rationale for getting rid of more than 150 jobs in nutrition, health promotion and Indigenous health, arguing previous “campaigns” and “messaging” around obesity were “piecemeal” and had “grossly failed”.
The plan now, the minister argued, is to focus on a new centrally-driven and high-profile approach.
On the surface that doesn’t sound so bad. But even a cursory glance at the details suggests something else is going on.
Of particular concern is the Queensland government’s call for the Commonwealth to invest more in preventive health through the Australia-wide Medicare Local network. This may be a bold attempt to shift costs, or a fundamental misunderstanding of what preventive health is all about – or both.
Although it’s good to see Minister Springborg confirming a commitment to “health prevention campaigns” and “evidence-based medicine”, questions remain as to what this really means for public health in Queensland.
One challenge working in the area of obesity is that most people, including decision makers, eat and move, and so are self-informed experts. If this was brain surgery, expert briefings on the evidence would be sought before decisions were made. But addressing obesity is more complex.
To inform decisions about obesity intervention, the scientific evidence needs to be assessed at three levels. Firstly to identify whether something should be done, then to investigate what should be done, and finally to inform how something should be done.
At the first level, there is little disagreement about the magnitude of the problem; something definitely needs to be done about obesity – and urgently. The epidemic of overweight and obesity is sweeping most developed economies. In Australia, the prevalence has doubled over the past 30 years – it’s now above 60% in adults and around 25% in children.
Obesity is bad news for the health system. In Queensland, excess body weight has now overtaken cigarette smoking as the single greatest risk factor contributing to the burden of disease. In 2008, the health system cost of obesity was A$391 million, with an additional cost of about A$9.96bn in lost well-being across all sectors throughout the state.
But the good news is that most obesity-related conditions are preventable. That such an enormous expense and burden is avoidable, must surely be of interest to any government concerned about its economic outlook, and the well-being and health of its people.
What should be done about it?
To answer, it’s necessary to look at both causes and treatment outcomes.
A surprisingly small daily excess in energy intake is sufficient to account for the weight gain seen in Australians over time.
It’s now clear that changes to our socioeconomic environment are responsible for the current epidemic. These changes actually make it easier for all of us (but particularly those who have limited resources and opportunities) to consume more energy-dense and nutrient-poor foods and drinks, to eat too much, to sit longer and move less.
Being overweight is a normal physiological response to an abnormal “obesogenic” environment. And this is exactly why losing weight is so hard – and keeping it off is harder still.
Studies showconsistently that just telling people to change their behaviour is bound to fail. Generally, mass media advertising increases awareness, but only leads to behaviour change when supported by complementary policies, programs and services provided within the community.
How can we achieve healthy weight at a population level?
Strategically, the best approach to obesity prevention involves regulatory reform. This has been demonstrated repeatedly in other public health areas such as infectious disease, traffic safety and tobacco control. However, there is little evidence that any governments in Australia currently want to go down this path to combat obesity.
So at a more pragmatic, operational level, the evidence points to two main areas:
Counteract the gross misinformation about food, dieting and exercise so rampant in our society and, at the same time,
Influence sectors beyond health to improve the social and physical environment to make it easier for people to make healthier choices.
And that is exactly what the dismissed nutrition, Indigenous and health promotion workforce was doing in Queensland.
Among many projects, they worked to improve the food supply in child care centres, schools, workplaces, health facilities and remote communities, and encouraged greater physical activity through urban planning. They ran effective, group-based behaviour modification programs to support adoption of healthy habits.
In areas such as mental health and infant feeding, they developed evidence-based training materials and resources to help lighten the workload of clinicians. And their efforts were having traction and providing cost- effective health outcomes for the state.
In 2007, the rate of measured (rather than self-reported) healthy weight among children in Queensland was 2% to 3% higher than in other states where comparable data was available. This equates to 3,000 less children becoming overweight per year, and 1,200 fewer future cases of Type 2 Diabetes per year by 2015.
At its peak, the multi-strategy Go for 2 and 5 fruit and vegetable promotion program exceeded targets, resulting in an additional turnover of A$9.8 million of fresh produce per month in Brisbane alone, and a technical saving of A$55 million per year to the ill-health system state-wide.
Since 2004, adult physical activity participation rates had increased by over 34%.
And since 2003, rates of exclusive breastfeeding for the first six months of life had quadrupled, and the proportion of infants breastfed at one and six months had increased substantially.
These results demonstrate that preventive health services provided the front line, indeed the vanguard, of medical ill-health services – helping to reduce waiting lists and increase the likely effectiveness of clinical treatment.
What happens next?
Within the health sector, preventive health interventions to address obesity must be applied across the whole continuum – not only in primary care settings like Medicare Locals. But most importantly, concerted, sustained effort is needed beyond the health sector, with non-government organisations, industry and all members of the community.
So, fingers crossed that the promised new “campaigns” will provide more than expensive advertising telling us all to lose weight. And fingers crossed that Medicare Locals will have the resources and abilities to foster partnerships to improve the toxic “obesogenic” environments that continually undermine health messages.
Because, if not, we will definitely lose the war against obesity and growing rates of chronic disease in Queensland. All available evidence tells us that more investment is needed in preventive health – not cuts.