lecture 11: a population health approach to managing metabolic syndrome

Question 1

What have you learnt about the causes/triggers of metabolic syndrome?

Answer 1

• genetic? epigenetic?
• external food supply and its availability and composition?
• behaviour?
• psycho-social?
• association with inequality? the embodiment of being a ‘loser’
• the complexity of the condition and its associated morbidities that have been treated, alleviated
• the life-long dangers of childhood obesity: prevention is critical

Question 2

What are traditional options open to public health?

Answer 2

• education and incentives to change population’s knowledge base re. healthy eating: Health Promotion
• regulation of the food or beverage found to be dangerous to health: controlling its composition, preparation, and points of sale
• consumer behaviour modification via price: e.g. taxing alcoholic drinks or tobacco products accordinh to their alcohol content → higher prices to deter consumers
• regulation of advertising that might influence vulnerable groups in the population, especially children
• economic policy to reduce price of fresh food at the expense of fast food

Question 3

What is health promotion?

Answer 3

• necessary but over time has shown limited effectiveness in making a signficant and sustainable difference
• ‘BE ACTIVE, EAT WELL’
• 6789 person hours
• reducing unhealthy weight gain in children through community capacity-building: results of quasi-experimental intervention program. Be Active Eat Well
• 3 year trial in Colac schools: appointed school dietitian, trained canteen staff and teachers, supplied healthy lunches, exervise programmes, walking school buses, widespread publicity, community activites, community garden etc etc → over three years reduction in weight gain of 1kg and waist circumference of 3 cms and this occurred across the full social gradient BUT the prevalence of obesity in both the experimental group and the control group still increased. Problem, the three major international studies of interventions have ‘not produced results of sufficient magnitude to reduce the incidence of overweight or obesity’

Question 4

What is regulation of food for quality and safety?

Answer 4

• colonial victoria: severe alcohol addiction and dipsomania: colonial beers adulterated with poisons because of poor manufacturing
• colonial drinks far stronger than in Europe: 5-6% more alcohol than in England; wine 50% more alcohol than in France; Victorian spirits - 32% proof, Spirits; local importers mixed cheap UK gin, Brandy and “glasgow whisky” at 11d a gallon, mixed with ‘plain spirit’ e.g. methanol and sold it as ‘best spirits’; medicinal and Temperance wines sold by grocers = 25% -32% prood spirit. Result →
• 1905 Victorian Pure Foods Act + regulation of hotels (closings) and hotel hours despite massive organised resistance from Liquor Trade
• how do we manage the food problem because that is going to mean intervening in the businesses of a lot of people → both big and small business will be affected
• massively complicated political problem which will take a lot of time to work through
• at the end of the day we have to wean people off eating certain types of food and above all eating at home more and cooking (fresh food)

Question 5

Can we regulate fast food?

Answer 5

• we can ban trans-fats as a toxic substance (New York is trying it) forcing replacement with unsaturated oils. Coercive: needs sound scientific evidence
• we can require accurate food labelling: but will people read it?
• we could legislate for a staged reduction in the use of HFCS as a sweetener and as a preservative: supermarkets stock products that last long on the shelf and cater to the sweet tooth (even in fresh fruit like apples)
• BUT: millions of people depend on food manufacturing and retailing for their livelihoods. Therefore vested interests that range from multinational corporations to the smallest of small retailers.
• Note: recently small retailers objected to graphic warnings on cigarette packets because they were reducing their sales

Question 6

What are considerations of tax to raise prices and modify behaviour?

Answer 6

• shown to work with alcohol, where we tax according to the proof alcohol in the standard drink
• but remember alcopops and the resistance to increasing the tax by the senate, in particular the champion of family values, Senator Fielding
• Rudd government finally won the vote and the effects on sales to young people have been significant
• latest ABS figures show a reduction in Ready to Drink pre-mixed drinks, while there has been a steady increase in wine and spirit consumption
• but tax was stopped by Fielding, even though the Distillers were going to be compensated by the govt.
• this would mean taxing take-away-food, sweetened drinks and fruit juice according to the amount of trans-fats and HFCS55 or concentrated frustose → increase in prices (good); major problems of implementation and policing because of size and complexity of the sector
• it would be easier to tax big retailers like McDonals only BUT: the fury that would be unleashed on politicians

Question 7

What is the regulation of advertising?

Answer 7

• Tony Abbot: Minister for Health, interviewed for Four Corners 17 May 2005
• Q: Do you think there’s a connection between marketing and childhood obesity?
  
  • A: obviously anyone who is marketing a product is determined to try make the product as attractive as possible, there’s nothing inherently wrong with that, but if the product in large quantities is not so good for people, it’s up to the people who are out there in the market place to exercise appropriate discipline
• Howard govt favoured self-regulation by the industry: 25 jan 2010 VicHealth media release condemned self-regulation as a failure, citing Hungry Jack’s “Kids Club Meal” as ‘making a mockery of self-regulation’

Question 8

What is economic policy to reduce price of fresh food?

Answer 8

• essence of problem is that fast food is cheaper than fresh food, both in australia and overseas
• USA data:
• farmers can’t make good quality produce without government subsidy

Question 9

To whom is fresh food available?

Answer 9

• less available to poor
• food deserts/insecurity
• identified in 1990s as areas in UK, later US and elsewhere local shops selling fresh food have close, people lack transport to good supermakerts, prices of fresh food too high
• in chicago those who live in food deserts (areas with little or no access to healthy foods, seen in red on the map on the left, have high BMI

Question 10

What is to be done in Australia?

Answer 10

• the commercial drivers of the obesity epidemic are so influential that obesity can be considered a robust sign of commercial success – consumers are buying more food, more cars and more energy-saving machines
• it is unlikely that these powerful economic forces will change sufficiently in response to consumer desires to eat less and move more or corporate desires to be more socially responsible
• when the free market creates substantial population detriments and health inequalities, government policies are needed to change the ground rules in favour of population benefits
• concerted action is needed from governments in four broad areas:
  
  • provide leadership to set the agenda and show the way
  • advocate for a multi-sector response and establish the mechanisms for all sectors to engage and ehance action
  • develop and implement policies (including laws and regulations) to create healthier food and activity environments
  • secure increased continued funding to reduce obesogenic environments and promote healthy eating and physical activity
• policies, laws and regulations are often needed to drive the environmental and social changes that, eventually, will have a substantial impact on reducing obesity
• an ‘obesity impact assessment’ on legislation such as public liability, urban planning, transport, food safety, agriculture, and trade may identify ‘rules’ which contribute to obesogenic environments
• in other areas, such as marketing to children, school food, and taxes/levies, there may be opportunities for regulations to actively support ovesity prevention
• legislation in other areas such as to reduce climate change may also contribute to obesity prevention (‘stealth interventions’)
• a political willingness to use policy instruments to drive change will probably be an early hallmark of successful obesity prevention
• leadership from govt and health agencies: including lifting priority for health v. commercial outcomes
• advocacy and funding (via tax e.g. on tobacco) for health promotion and service funding for obesity prevention
• banning marketing of unhealthy foods to children; subsidising public transport; ‘traffic light’ labelling on food product packaging; restriction of unhealthy foods in schools

Question 11

What could be done and is being asked for by rural Australia?

Answer 11

• Withdraw from “free trade” agreements that permit importing into Australia of fresh food: e.g. oranges from California, cured pork products from Denmark, USA etc.; beef from Brazil; apples from New Zealand etc etc
• there should be no need to import any fresh foodstuffs into Australia
• follow example of USA, EU, UK etc and subsidise food producing agriculture to make farming viable, save rural economies and bring price of fresh food down in the shops (US subsidises is corn producers: ~400 billion USD pa)
• fund subsidisation of agriculture by taxes on tobacco, alcohol. fast food chains, additives, dangerous preservatives, HFCS55 containing drinks and foods
• support farmers, especially horticulturalists, to invest in hi-tech solutions/relocation to survive climate change effects on water and summer heat