August 20th, 2006
The Unstoppable Australian Obesity and Diabetes Juggernaut. What Should Politicians Do?
By Paul Z. Zimmet and W. Philip T. James
The Medical Journal of Australia
Health professionals must create the climate to force politicians to act
Australia is in the throes of an unprecedented epidemic of diabetes and obesity. The Australian Diabetes, Obesity and Lifestyle (AusDiab) study found that a million Australians are affected by diabetes, and it provided vital data on Australia’s obesity epidemic.1 Obesity is a driving force behind type 2 diabetes, which has cardiovascular and other complications, such as renal failure and blindness.
The dominant effect of weight gain in precipitating glucose intolerance and its consequences suggests that reversal of the “diabesity” epidemic requires a public alert on the need to limit weight gain. The heightened risk of type 2 diabetes occurs at levels of abdominal or general obesity previously regarded as normal. For decades in affluent societies such as Australia, women have been obsessed with their shape and weight. They spend huge amounts of time and money desperately trying to slim, with little effect — men do no better. Meanwhile, the epidemic of both obesity and diabetes shows no sign of slowing.
There is a biological component to persistence of the epidemic. The adaptation in hypothalamic control of appetite to reinforce higher food intakes and the endocrine and metabolic thermogenic adjustments with slow weight gain counteract attempts to lose weight.2 Coupled with the modern commercial drive to market unhealthy foods everywhere and seduce us into ever more sedentary leisure, this means we are facing a seemingly unstoppable juggernaut of obesity and diabetes. This epidemic is guaranteed to continue, unless we accept that the decades-long reliance on health promotion and intense media coverage of obesity have had virtually no effect. Dietary advice from doctors has induced only minimal reductions in blood pressure and cholesterol levels, and the results for weight control are probably worse.3
Meanwhile, politicians and health professionals confine themselves to promoting the value of health education. Evidence-based approaches now require us to discard our prejudices and preconceptions and consider converting policymakers and politicians. We must also recognise the influential commercial forces that contribute to an ever more obesogenic and diabetogenic environment.
What, realistically, can our politicians do? Australia has a reputation for outstanding obesity research, ranging from public health and epidemiology to molecular biology. However, what is being done strategically about the problem? On the surface, Australia is making what are seen as major investments in promoting leisure time sports and other activities, especially for youth. Presumably, this is based on the recent advice that to cure the obesity problem we need only change input and output by a mere 100 kcal — which seems to be a minute change.4 This implies that all one has to do is get a pedometer to encourage walking, or eat one less slice of bread each day. Unfortunately, there is a dearth of evidence that this works.
The current rates of weight gain, varying perhaps from 0.5 to 2 kg/year in the very susceptible, amount to about 10–40 kcal (ie, 0.3%–2% of energy turnover) in the average daily discrepancy between input and output. However, we need to walk briskly for 80–90 minutes daily (ie, about 350 kcal of daily effort) to maintain energy balance on current diets.5 This is a near impossible population goal for leisure time activity. Alternatively, given our current sedentary state, we would need to change to a diet of 20% fat intake with minimal sugary drinks.6 This implies that our hypothalamic regulatory system works to minimise energy imbalance, so the external environmental changes must be of a greater magnitude than the induced energy imbalance. It is ludicrous to expect the whole population — including the disadvantaged — to voluntarily become very active on an optimum diet. Thus, we need to change substantially our living conditions and environment. Our politicians need to accept that major legislative and other regulatory measures are required (see Box).
We could arrest the development of obesity in children and adolescents within a year of introducing a coherent program. If the political will is there, then there is hope. The current pervasive marketing to children distorts their understanding, codifies their demands, and transforms their eating, drinking and exercise habits to generate obesity.7 Changing this requires legislative regulation of the marketing pressures (including television and other advertisements which now dominate children’s attention). Parliamentary enquiries in the United Kingdom have revealed that some food and advertising companies may be misleading consumers as blatantly as the tobacco industry did.7 Voluntary restrictions have never been shown to work.
Health professionals and their peer organisations must demand that all junk foods and soft drinks be kept out of health institutions, schools and public institutions, as these products can induce as much illness as tobacco.8 They should also go public, demanding political change to transform the school environment and curriculum to improve physical and nutritional education, as well as the food and drink on the premises.
In adults, the problem is greater. Nevertheless, a start could be made with statutory food labelling. Currently, labels cannot be understood by consumers nor converted into meaningful units for individuals with different energy needs. Furthermore, health claims are often misleading. Consumers’ views should dominate labelling design (eg, “traffic light” indicators of overall nutritional quality9). A universal display of nutritional health profiles of food products could dramatically change consumers’ choice. In Finland, the introduction of free vegetables and a salad bar with meals sold in canteens and restaurants was associated with a threefold increase in the population’s vegetable consumption. Standards are also needed for the nutritional content of all meals provided within the public sector. The food industry would respond rapidly to new requirements, to ensure continued sales and profits.
It is natural that politicians focus on evident benefits within a short parliamentary cycle. But the result is that nothing will happen until health professionals, including the medical profession, engage politicians and media opinion leaders to create a climate that will force politicians to respond to public opinion. Targeting the protection of children’s health, presenting clear analyses of the financial cost of political inertia, and highlighting the need to resist short-term commercial interests is the way to engage high-level politicians. A great example was Tony Blair’s response within 24 hours when Jamie Oliver started soliciting potential votes unless British school dinners improved.
The prevention of obesity and type 2 diabetes requires coordinated policy and legislative changes, with greater attention given to our urban environment, transportation infrastructure, and workplace opportunities for education and exercise. Governments — local, state and federal — should commit to optimising opportunities for exercise in a safe environment. A multidisciplinary, politically driven, coordinated approach in health, finance, education, sports, and agriculture can contribute to reversing the underlying causes of the diabesity epidemic. Our medical leaders must recognise their crucial role, and federal and state politicians must look beyond the next election. Is anyone in Canberra listening?
Regulatory measures needed to prevent diabesity in Australia
* Ban all marketing of food to children, including television advertisements.
* Establish strict food and physical activity requirements for schools.
* Remove junk foods and drinks from all publicly funded premises.
* Require “traffic light” food labelling (based on nutritional profiling) on all foods, drinks and meals, wherever sold.
* Adjust fiscal policies to progressively change the relative prices of foods and drinks high in fat or sugar in favour of vegetables and fruit.
* Specify urban environmental requirements favouring pedestrians and cyclists.
Author details: Paul Z Zimmet, AO, FRACP, FRCP(London), FTSE, Director1W Philip T James, MD, DSc, Chairman2
1 International Diabetes Institute, Melbourne, VIC.
2 International Obesity Taskforce, London School of Hygiene and Tropical Medicine, London, UK.
1. Dunstan D, Zimmet P, Welborn T, et al. The rising prevalence of diabetes mellitus and impaired glucose tolerance: the Australian diabetes, obesity and lifestyle study. Diabetes Care 2002; 25: 829-834.
2. Rosenbaum M, Goldsmith R, Bloomfield D, et al. Low-dose leptin reverses skeletal muscle, autonomic, and neuroendocrine adaptations to maintenance of reduced weight. J Clin Invest 2005; 115: 3579-3586.
3. Brunner EJ, Thorogood M, Rees K, Hewett G. Dietary advice for reducing cardiovascular risk [review]. Cochrane Database Syst Rev 2005; (4): CD002128.
4. Hill J. Physical activity and obesity. Lancet 2004; 363: 182.
5. Erlichman J, Kerbey AL, James WPT. Physical activity and its impact on health outcomes. Paper 2: prevention of unhealthy weight gain by physical activity: an analysis of the evidence. Obes Rev 2002; 3: 273-287.
6. Howard BV, Manson JE, Stefanick ML, et al. Low-fat dietary pattern and weight change over 7 years. The Women’s Health Initiative Dietary Modification Trial. JAMA 2006; 295: 39-49.
7. House of Commons Health Committee. Obesity. Third report of session 2003–04. London: Stationery Office, 2004. http://www.publications.parliament.uk/pa/cm200304/cmselect/cmhealth/23/23.pdf (accessed Jul 2006).
8. Ezzati M, Lopez AD, Rodgers A, et al; Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet 2002; 360: 1347-1360.
9. UK Food Standards Agency. Signposting [website]. http://www. food.gov.uk/foodlabelling/signposting/ (accessed Jul 2006).