Chapter 1 Introduction

Australia is one of the most overweight developed nations, with overweight and obesity affecting about one in two Australian adults and up to one in four children.[1]

‘The big picture’

1.1                   The issue of a growing overweight and obese population is a pressing health concern for Australia. The 2007-08 National Health Survey (which measures the exact height and weight of adults and children using the Body Mass Index (BMI) approach) found that 68 percent of adult men and 55 percent of adult women are overweight or obese. This has increased from 64 percent of men and 49 percent of women found to be overweight or obese in the 1995 survey.[2]

1.2                   The increase supports data from the Bettering the Evaluation and Care of Health (BEACH) study (which collects information from general practitioners across Australia)[3] that indicates that the prevalence of adult overweight and obesity has risen significantly in the last decade, from 51.1 percent in 1998-99 to 58.5 percent in 2006-07.[4]

1.3                   It is not just the adult population that is becoming heavier. The growing rate of obesity amongst Australian children is equally concerning.

1.4                   In October 2008, the Department of Health and Ageing (DoHA) released the 2007 Australian National Children’s Nutrition and Physical Activity Survey. The survey stated that 17 percent of children in Australia are classified as overweight and six percent are classified as obese. While research from the University of South Australia’s School of Health Sciences indicates that the rate of obesity in children may have levelled off in the past 15 years,[5] the general consensus amongst obesity experts is that it is too early to say whether this is the case and that children are still growing up in an increasingly sedentary and calorie-rich environment.

1.5                   In addition to the costs of overweight and obesity incurred by individuals, families and communities, there are huge financial costs for the health system.  In 2008 Access Economics released its report, The Growing Cost of Obesity in 2008: three years on, which updated an earlier report of theirs titled The Economic Costs of Obesity, published in 2006. The latest report found that the total cost of obesity in 2008 was $58.2 billion which included the attributable cost of diseases such as diabetes, cardiovascular disease, various types of cancer and osteoarthritis. Of this total, the financial cost was estimated at $8.283 billion and the estimated cost of lost wellbeing $49.9 billion.[6]  This figure had risen from an earlier estimate of $21 billion for the total cost of obesity.[7] Access Economics informed the Committee that the earlier report had been ‘quite conservative in its projections of obesity prevalence.’[8] The higher figures strengthen calls for action to reverse the rates of obesity.

1.6                   Should nothing be done to address obesity, the outlook is likely to worsen. The 2008 Access Economics report predicts that population ageing alone will result in 4.6 million Australians being classified as obese by 2025. If the growth rates in obesity continue at the current rate over the next 20 years, an estimated 6.9 million Australians will become obese by 2025.[9]

Additional prevalence data

1.7                   In addition to the Access Economics report, other major studies support the notion of Australia’s growing weight problem.

1.8                   The AusDiab base-line study which was conducted under the auspices of the International Diabetes Institute in 1999/2000 (and the largest Australian longitudinal population-based study ever done into diabetes, heart disease and kidney disease)[10] unearthed high prevalence rates with 19.1 percent of men and 20.1 percent of women found to be obese and a further 60 percent of men and almost half of all adult females found to be overweight.[11]

1.9                   The Baker Heart Research Institute’s report Australia’s Future Fat Bomb contains more recent data that shows that, as of 2008, approximately four million adult Australians are obese and that seven in ten men and six in ten women are classed as being overweight or obese.[12] This data reveals that the prevalence of obesity may therefore be higher than currently thought.

1.10               International data adds further credence to the growing concerns about the level of obesity in Australia. The 2007 Organisation for Economic Cooperation and Development (OECD) report, Health at a Glance 2007: OECD indicators found that Australia had the fifth largest rate of adult obesity (21.7 percent) behind the United States (32.2 percent), Mexico (30.2 percent), United Kingdom (23 percent) and Greece (21.9 percent).[13]

1.11               It is crucial to note that there are a range of co-morbidities (that is the presence of two or more illnesses in the same person at the same time) associated with overweight and obesity. These include type 2 diabetes, cardiovascular disease, high blood pressure, some cancers, sleep apnoea, osteoarthritis and psychological disorders. These conditions can be caused or exacerbated by excess body weight.[14] According to the Access Economics report, these conditions also incur significant financial costs.[15]

What is overweight and obesity?

1.12               It is important to define overweight and obesity for the purposes of this report. Traditionally, overweight and obesity are measured using the Body Mass Index (BMI). The BMI measures a person’s weight in relation to their height.[16] Adults with a BMI between 25 and 30 are classified as overweight, while those with a BMI greater than 30 are characterised as obese. However, the BMI is not always a suitable measurement tool for all body types, ethnic groups and growing children.[17] For instance, overweight and obesity in growing children should be measured using a combination of the BMI, growth charts and other measures of fat.[18]

1.13               Notwithstanding criticism of the BMI as an imperfect measuring tool for obesity (especially its ability to provide a nuanced result specific to an individual), it remains a useful tool to assess obesity at the population level. As the senior statistician from the Telethon Institute for Child Health Research told the Committee:

I think the BMI is a crude tool. It can work reasonably well at the population level with some assumptions, because sometimes when you are collecting data … the easiest thing to do is height and weight and out you go … You would not tend to use it at the individual level … but as a broad population measure, sometimes it is all you have got.[19]

1.14               BMI is not the only tool that can be used to determine whether an individual is in a healthy weight range. Another common measurement is a person’s waist circumference. This measures intra-abdominal fat, which is associated with increased risk of chronic disease. Men with a waist circumference larger than 94 centimetres and women with a measurement greater than 80 centimetres are at an increased risk of chronic disease. The risk of chronic disease is significantly increased when men’s waist circumference is greater than 102 centimetres and women’s greater than 88 centimetres. Recently the Federal Government launched the How do you measure up? campaign as part of the Australian Better Health Initiative (ABHI), which is a joint Australian, State and Territory Government initiative. The campaign encourages Australians to measure their waist circumference and change their lifestyles to reduce the risk of chronic diseases including cancers, cardiovascular disease and type 2 diabetes.[20]

Subject of increased attention and reason for inquiry

1.15               Obesity has garnered a significant amount of attention over the last few years, and this has gathered pace and momentum throughout the duration of the inquiry. Barely a day has gone by without a piece appearing in the media, newspapers or television, about some aspect of the issue, in Australia or overseas. It is a reality of modern society and governments, industry, communities and individuals all have a stake.

1.16               In December 2007 the then new Minister for Health, the Hon Nicola Roxon MP, attended a summit aimed at tackling childhood obesity in Australia. Here she stated the new government’s commitment to making obesity prevention a National Health Priority Area.[21]

1.17               In addition to the Minister for Health identifying obesity prevention as a national health priority, in early 2008 the Prime Minister announced that the Government would convene a 2020 summit at Parliament House in Canberra in April 2008. One of the policy areas debated at the summit was a long-term health strategy for Australia, including the prevention of chronic and acute health problems such as overweight and obesity.[22] At the summit, overweight and obesity were identified as key health issues.[23]

1.18               Subsequent to the emerging data about the scale of overweight and obesity in Australia, the Minister for Health requested that the House of Representatives Standing Committee on Health and Ageing (the Committee) investigate the issue of overweight and obesity in Australia.

1.19               Therefore, on 19 March 2008, the Committee adopted the following self referred terms of reference for the inquiry into obesity in Australia:

The House of Representatives Standing Committee on Health and Ageing has reviewed the 2006-07 annual report of the Department of Health and Ageing and, pursuant to Standing Order 215 (c), resolved to conduct an inquiry into obesity in Australia.

“The Committee will inquire into and report on the increasing prevalence of obesity in the Australian population, focusing on future implications for Australia’s health system.

The Committee will recommend what governments, industry, individuals and the broader community can do to prevent and manage the obesity epidemic in children, youth and adults.”[24]

1.20               At around the same time that the Committee’s inquiry was established, the Prime Minister announced the formation of the National Preventative Health Taskforce (the Taskforce) whose objective is to provide a framework to government to address the burden of disease caused by alcohol, tobacco and obesity.[25] The Taskforce is comprised of a panel of experts who will develop a blueprint for tackling the burden of disease caused by excessive alcohol consumption, smoking and obesity. Their focus is on primary prevention and their recommendations will cover both health and non-health sectors.[26]

1.21               Also in 2008, the Council of Australian Governments (COAG) committed to a Health Prevention National Partnership, with the goal of improving the health of all Australians, at their meeting of 29 November.[27] The focus on prevention is central to the debates surrounding overweight and obesity and the impact on the health system given that obesity is such a major risk factor for chronic disease and its effects can be felt throughout the entire health system.[28]

1.22               While the increased attention on obesity – through near constant media coverage - has done much to raise people’s awareness of the extent of the problem, the Committee believes that much of the reporting has been overly negative, alarmist and almost defeatest in nature. Popular weight loss television shows are somewhat extreme. No one discounts the powerful personal journeys and incredible transformations that the contestants on these shows clearly undergo. However, they do perhaps mislead people to believe that everyone can, or indeed should, lose vast amounts of weight in a very short amount of time. This sort of dramatic weight loss and increased physical activity is a severe approach to adopting a healthier lifestyle. Rather than people feeling either overwhelmed and that there is no way forward, or that they must take extreme measures to change their lives, this report seeks to show that obesity is an opportunity, as much as it is a challenge for the Australian populace to embrace healthier ways of living and that there are many different paths toward this goal. Incremental and even-handed steps can lead to more sustainable changes.

Carving out a niche for the Committee

1.23               As described in the previous section, there are a number of concurrent government processes which aim to find better solutions to chronic health problems, including obesity. The Committee does not seek to replicate these processes, but rather to complement them. The most important complementary process to our inquiry is that of the Taskforce. However, it is necessary to note upfront that the role of the Committee is very different to that of the Taskforce. The Taskforce is a panel of experts that have been asked to develop a technical national preventative health strategy. In addition, their focus is on three areas; alcohol, tobacco and obesity; and the burden of disease each cause.[29] This Committee has a less technical focus. Our public hearings have been a forum for members of the community - experts and citizens alike- to meet with Members of Parliament to discuss their knowledge and experiences in the context of taking the debate(s) forward where possible. These different approaches will result in different, yet complementary reports. Having consulted extensively with the Taskforce throughout the duration of our inquiry, the Committee expects that its report will broadly support and feed into the Taskforce’s national strategy, due out in the middle of 2009.

1.24               The Committee has been keen to foster national debate on the issues of overweight and obesity across the country. Throughout the inquiry, Committee members have taken the opportunity to travel across Australia, visiting urban and rural Australians, in the health system and out of it, to hear directly from the community how obesity impacts them. The Committee has seen first hand the complexity of the problem. And, the Committee has seen for itself many programs that are seeking to redress the many related problems.

Figure 1.1      The Committee meeting with members of the community in Wilcannia, NSW

1.25               Throughout the inquiry, the Committee has been impressed by the many individuals and organisations across Australia making positive changes, be it in their own lives, families, communities or workplaces. Many of these stories are yet to be shared at a national level, and this report seeks to showcase some of the excellent initiatives that already exist.

1.26               These initiatives are a counter to the negativity surrounding overweight and obesity and indicate that it is possible to reverse the numbers of overweight and obese Australians. Solutions include initiatives as diverse as fruit first policies at schools which encourage children to consume fruit at recess; community cookbooks in remote indigenous communities which feature simple ideas on how to prepare cost-effective healthy food; kitchen gardens in schools as well as community gardens that share the joy of food production with Australians of all ages; and an emerging focus on healthy urban environments where physical activity is embedded in urban design.

Parameters of the report

1.27               While there is a distinction between overweight and obesity as conditions, for a broad ranging inquiry such as this it is useful to consider the implications for the population across the spectrum from overweight through to morbidly obese. Therefore, throughout the report the term obesity will be used, and will generally refer to the excess body weight that is carried by individuals who are both overweight and obese. Some sections of the report will clearly be more relevant for people who are at one end of the spectrum. For example, the Committee is not advocating bariatric surgery[30] as the solution for everyone that is overweight.  However it is an option for the severely obese, in consultation with their clinician.

1.28               The report will not elaborate in detail on the various causes of obesity in Australia. Issues such as poor urban design, lifestyle, lack of time or lost art of cooking skills and affordability of fresh health food have been canvassed through many other forums. The United Kingdom (UK) Government’s 2007 report on obesity, Tackling Obesities: Future Choices (Foresight Report) expertly details a comprehensive causal relationship.[31] The Committee accepts that there are various factors, including the aforementioned ones, which contribute increasing levels of obesity within society. The Committee well understands how much more complex than a simple energy in – energy out equation the problem is and that it is a multifaceted issue. If anyone is in any doubt they should consult the obesity system map in the Foresight Report for an illustration of how tangled and interconnected the issues are. The UK Health Secretary has gone so far as to say that the phenomenon of obesity is as serious a threat to modern societies as climate change.[32]

1.29               The fact that obesity has so many contributing factors and impacts means that there will be no one or simple solution. The Committee is wary of recommending solutions of a ‘one size fits all’ nature. A balance must be struck between taking swift action, and ensuring that any major interventions are supported by evidence.

The inquiry process

1.30               As mentioned, the Committee adopted the terms of reference for the inquiry at a private meeting on 19 March 2008. The following day, the Chair issued a media release announcing the inquiry and calling for submissions from interested organisations and individuals. In order to publicise the inquiry more broadly, an advertisement was also placed in The Australian on 2 April 2008. Letters were sent to individuals, peak bodies and government agencies inviting them to make submissions to the inquiry.

1.31               A total of 158 submissions (listed at Appendix A) and 97 exhibits (listed at Appendix B) were accepted as evidence to the inquiry. The Committee was particularly pleased to receive submissions from a diverse range of stakeholders including; state and federal health departments; McDonalds Restaurants Australia; Woolworths Australia; the Australian and New Zealand Obesity Society; Weight Watchers Australasia; Weight Management Services at the Westmead Children’s Hospital; the Stephanie Alexander Kitchen Garden Project; the Obesity Policy Coalition; the National Rural Health Alliance; the Parents Jury; the Australian Association of National Advertisers; the Heart Foundation; the Planning Institute of Australia; and the Australian Local Government Association.

1.32               In order to further public involvement in the inquiry, the Committee travelled across Australia for a total of 13 public hearings. The hearings took place in most states and territories, capital cities, outer metropolitan areas and regional Australia. For instance, the Committee held hearings in Sydney, Perth, Adelaide, Lake Macquarie, Broken Hill and Dubbo.

1.33               At these public hearings the Committee heard from academics, public servants, dieticians, doctors, nurses, teachers, and people who had undergone treatment for obesity. The Committee was humbled to hear first hand from people who had undergone bariatric surgery and been on Weight Watchers, including the Slimmer of the year for 2008 and a Weight Watchers meeting leader. Their courage in coming before the Committee to share their personal struggles with weight gave the Committee a much greater understanding of the complexity of this health problem.

1.34               To complement the inquiry process the Committee also went on 16 inspections throughout the course of the inquiry. These inspections included visits to hospitals, to see the equipment challenges that obesity presents to hospital staff; schools, to see kitchen and community gardens instilling a love of food in our children; and a remote indigenous community, to learn more about the particular problems these communities face in terms of access to food, sporting facilities and medical care. In addition, members of the Committee were pleased to be able to participate in community sports events including the Active After-schools Program (AASC) and an Active Gold Coast Tai Chi class. Details of the hearing and inspection venues appear at Appendix C.

Figure 1.2      The Committee discussing the Premier’s ‘Be Active’ challenge with students at Adelaide High School, South Australia

1.35               The diverse evidence gathered by the Committee was complemented by seven private briefings to the Committee on the topic of obesity and the evidence received at four of these briefings was subsequently authorised for publication and placed on the website.[33] These included briefings from the Australian Sports Commission to learn more about the Active After-school Communities program; from Access Economics to hear about the financial implications of obesity; and from Stephanie Alexander to better understand the positive impact that growing and cooking food can have on a child. The Committee was also pleased to receive a briefing from and meet with the Taskforce in order to exchange ideas about policy solutions to this public health problem. The Chair of the Committee also met separately with the Chair of the Taskforce.

1.36               Media releases about the inquiry, copies of the submissions received, transcripts of the evidence from the public hearings, and a copy of the report are available on the inquiry’s web site.[34]

1.37               The Department of the House of Representatives About the House magazine featured three articles on the obesity inquiry, ‘Fighting Fat’ (September 2008), ‘Heart disease spreads with obesity’(December 2008) and ‘Fresh Harvest: Feeding our children’s health’ – on the Stephanie Alexander Kitchen Garden Programme (December 2008).[35]

1.38               The Committee’s inquiry was referred to repeatedly on the radio and in print media as we travelled around the country for hearings and also made national news on television several times.[36]

Structure of the report

1.39               The report is structured around the inquiry’s terms of reference and therefore the focus of the report is on the future implications of obesity for the long-term health of Australia and Australians and the role that governments, industry, the community and individuals can all play in its prevention and management.

1.40               Some key themes that the report will cover are:

n  the current and future costs of obesity;

n  the need for national leadership and a whole-of-society response;

n  the capacity of governments to create health enabling environments and the tools available to achieve this including;

§  regulation;

§  urban planning;

§  providing better treatment options; and

§  developing and driving a research agenda;

n  the role that industry must play;

n  the responsibility of individuals; and

n  the importance of community in any policy response to obesity.

1.41               Chapter 2 deals with the future implications of overweight and obesity for Australia’s health system. Chapter 3 focuses on the role that governments at all levels; federal, state and local, can play in addressing overweight and obesity. Chapter 4 deals with what more industry can do. Chapters 5 and 6 highlight the important role of individuals and communities within the obesity debate. Chapter 7 outlines the Committee’s concluding remarks.