Why the media gets it wrong on obesity

“I’m not overweight”, writes columnist Katrina Grace Kelly in The Australian.  “I’m just the helpless pawn of a vicious corporate conspiracy”.

Amusing read, but it also illustrates why public health researchers are failing to cut-through with governments and the broader community on obesity.

“The ‘obesogenic environment’ is the culprit here, apparently”, Kelly writes, referring to a recently-released report from the Obesity Collective, and to recommendations from the Senate Select Committee into the Obesity Epidemic in Australia.

“The creators of the obesogenic environment are government, society in general and the harbingers of all evil – corporations, specifically, companies in the food and beverage sector, now being referred to as Big Food.”

She adds: “We are fortunate to have researchers on the public payroll, so they can conduct studies to arrive at such previously unimaginable conclusions”.

 

It’s all personal responsibility, stupid

Kelly’s beliefs about obesity illustrate why the problem is so hard to tackle at a population level.

The dominant framing of obesity as purely a matter of personal responsibility seems obvious, intuitive.  No one is force feeding us, right?

But it has a downside: if you’re fat, look in the mirror, you only have yourself to blame.

According to the Australian Bureau of Statistics, the proportion of adults who are overweight or obese has increased from 56% in 1995, to 67% in 2017-18, with an additional 900,000 adults becoming overweight in the 3 years since the previous survey in 2014-15.

There is a troubling trend here, but for many people, it’s difficult to accept that the causes of the trend might be different from the causes of an individual’s obesity.

 

Personal policy, and public policy

If you are obese, having greater personal responsibility is an excellent suggestion – it’s an excellent “personal policy”.

But it turns out to be a rather silly and unproductive explanation for the trend towards population weight gain.

For one thing, personal responsibility is not a new idea; in fact, it’s a strategic failure, so urging people to have more of it is unlikely to reduce obesity rates in future.

Viewing obesity in terms of the failure of personal responsibility also means that the dramatic trend towards weight gain over the past couple of generations – affecting many millions of people in most countries of the world – is best explained in terms of an unprecedented, mass deterioration in self-control.

Who could have guessed?!

Framing obesity in terms of individual responsibility probably does little to help those who are obese, although it might make the rest of us feel smug.  It also deflects attention from both the causes of, and the solutions to, the problem at a population level.  And that’s what healthy public policy needs to be directed towards.

Are you interested in health and medical law?  Sydney Law School offers a Master of Health Law, a Graduate Diploma in Health Law, and single unit enollment.  For more information, click here, or here.  For more information on what it’s like to study at the Law School, click here.

Beyond the “hot tub”: Australia’s runaway obesity epidemic

How sure are you that you won’t lose your feet or toes to diabetes?

According to a new report by the Obesity Collective, based at the Charles Perkins Centre at the University of Sydney, obesity in Australia is getting much, much worse.

Between 2014-15 and 2017-18, the obesity rate in Australian adults rose from 27.9% to 31.3%.

In other words, over the past 3 years, an additional 900,000 Australians became obese.

Sixty-seven percent of Australian adults are now either overweight or obese (2017-18), an increase from 63.4% in 2014-15.

That’s astonishing.

Astonishingly bad news.

Australia now ranks 5th out of 44 OECD countries in the obesity stakes – it’s a race we shouldn’t be trying to win.

If this trend persists, how will we look in 2027-28?

By that time, nearly nine million Australians will be obese.

Think of the cost – not only costs to our taxpayer-funded health care system, but premature deaths from cardiovascular disease, obesity-related cancers, limbs, feet and toes amputated due to our runaway diabetes epidemic.

According to Diabetes Australia, 4,400 diabetes-related amputations already occur each year in Australia.

That’s set to get worse.

 

Australia’s runaway obesity epidemic needs to become an election issue

How long till we see concerted national action that is not choreographed by the big food lobby?

Did you know that the Australian Food & Grocery Council seeks a “constructive and collaborative response to obesity”?

They’ve been saying stuff like that for years.

I call it the “hot tub approach”.  Let’s all jump into the hot tub together and soap each other’s backs, and see what we can achieve…together.

This “constructive and collaborative approach” – characterised by voluntarism, and weak accountability structures – has been official policy in Canberra for years.

It would be great if it actually worked.

But if it was going to work, wouldn’t we be seeing positive results by now?

 

Life outside of the “hot tub”

There is life beyond the hot tub.

Feasible policy options to halt Australia’s obesity epidemic have been identified.  We know what we could and should do.

The “Australian Obesity Prevention Consensus” sets out an evidence-based policy agenda for the federal government.

Implementing the (surprisingly strong and certainly welcome) recommendations of the Senate Select Committee into the Obesity Epidemic in Australia would also be a good place to start.

The INFORMAS Network monitors the actions of state and federal governments and has issued scorecards on the performance of Australian governments, with priority recommendations.  (Watch out for the 2019 Food Policy Index Progress report, to be launched on 2 April 2019).

These reports include recommendations for legal and regulatory changes that the processed food industry will resist.

Like implementing credible – as distinct from voluntary, weak and loophole-ridden – standards to protect children from exposure to unhealthy food and drink marketing.

Like setting ambitious, time-sensitive and independently-monitored targets for reformulation to be met by food manufacturers, retailers and caterers.

Like a health levy on sugary drinks.  (Remember folks, at the end of the day, it’s only sugar water, not holy water).

Like making the Health Star Rating system mandatory.

No one likes sharing hot, soapy water with the folks from “big food” more than me, but the statistics speak for themselves.

Over the last 10 years, the number of Australians with obesity has more than doubled, from 2.7 million (2007-08) to 5.8 million in 2017-18.

It’s time to get out of the hot tub, and to implement long-recommended, evidence-based policies to create healthier food environments.

Put another Winfield on the Barbie

Having actor Paul Hogan headline Cure Cancer’s “Barbecure” makes no sense to me.

Put another shrimp on the barbie, I get it.  But so what?

Hogan may regret the staggeringly successful “Anyhow, have a Winfield” advertising campaign he headed in the 1970s, but his presence in a cure cancer campaign is inept.  It muddies the message.

Winfield is a brand of cigarettes now owned by British American Tobacco Australia.

Of his former campaign for Winfield, Hogan has said “Yeah, we were encouraging people to smoke.

“Young ones were taking up smoking and all going for Winfield. It was a staggering success but I was a drug dealer. But who knew then?”

This is not to suggest that Hogan is not sincere in wanting to help.  I’m sure he is.

But why does an organisation raising funds to support cancer research ask one of the most effective promoters of tobacco in Australian history, someone who is still, apparently, a smoker – to front the campaign?

Curing cancer…a tale of two strategies

Cure Cancer’s Barbeque concept seems to be about raising money for what we might call “techy” solutions to treating cancer – funding research towards a new drug or therapy.

(Must say, though, I love the idea about hosting a barbie, telling the guest list they’re not invited and hitting them for hard cold cash instead).

Cancer research is, of course, worthy and deserving of funding.  Who knows, many of us may one day benefit from such research and the therapies that result.

But there’s another way to cure cancer as well…it’s called reducing the risk that Australians will get cancer in future.

Using smart public policies, we can prevent the risk that Australians will get heart disease, and diabetes too.

Unfortunately, preventive health enjoys a fraction of the profile – and almost none of the money – that techy solutions like research towards new drugs or therapies attract.

This could be because one important dimension of prevention at the population level is regulation, and that makes prevention a political matter.

Australia has a pretty shabby record in using law and regulation to reduce modifiable risk factors for the non-communicable diseases that are responsible for the overwhelming share of death and disability in this country.

When it comes to food and diet-related risk factors, for example, see the scorecard and priority recommendations for Australian governments issued by the Global Obesity Centre, a WHO Collaborating Centre for Obesity Prevention, at Deakin University.

How many lifetimes till these are implemented, I wonder?

A decade ago, the National Preventative Health Taskforce released a blueprint for improving the health of Australians.

I can no longer find that report on the Australian Government’s website.

Although the government has raised the excise on tobacco and implemented plain tobacco packaging, no formal targets have been set for reductions in obesity or dietary risk factors, and prevention policy has been described as “flapping in the wind” (Swannell 2016).

Preventing cancer is “curing” cancer too

The Australian Preventive Health Agency, which was established to spearhead preventive efforts, and to fund preventive research, was de-funded and is extinct.

This move damaged momentum on preventive health in Australia, as Leeder, Wutzke, and many others have pointed out.

Which is a shame, because preventing cancer is “curing” cancer too.

Are you interested in health law?  Sydney Law School offers a Master of Health Law with mid-year entry.  See here and here for more information.

Update and summary guide to the WHO report: Advancing the right to health: the vital role of law

In September 2018 the World Health Organisation published an Update and Summary Guide to the report Advancing the Right to Health: the Vital Role of Law.

[See here for a previous post on the full report].

The summary Guide, like the full report, was a collaboration between the World Health Organisation, International Development Law Organisation, Sydney Law School, and the O’Neill Institute for National and Global Health Law at Georgetown University, Washington DC.

The aim of the original report, published in January 2017, was to raise awareness about the role that the reform of public health law can play in advancing the right to health and creating the conditions in which people can live healthy lives.

The Update and Summary Guide keeps the same focus: providing an introduction to the role of law in health development, with links to the full report, while also drawing attention to topics that were beyond the scope of the original report, and to links between law and the health-related Sustainable Development Goals.

The Update and Summary Guide integrates new health data and refers to new developments, including a list of highly cost–effective legal measures for reducing risk factors for non-communicable diseases (“NCDs”), drawn from the updated Appendix 3 of the WHO Global Action Plan for Prevention and Control of NCDs. It also references selected new decisions, such as the unsuccessful claim by a tobacco company against Uruguay’s tobacco control laws, and the decision of the Constitutional Court of Colombia confirming the right to receive information about the health effects of sugary drinks.

Public health law in the USA: What can Australia learn?

SEMINAR ANNOUNCEMENT: 

Public Health Law and Health Leadership in the United States: What can Australia learn?

Thursday 19 July, 6.00-7.30pm, Sydney Law School

In 2016, life expectancy at birth in the United States fell for the second year in a row.  Since his inauguration in 2017, President Trump and his administration have taken a number of actions that arguably weaken America’s public health infrastructure.

At the same time, the Unites States remains one of the world’s great innovators. With 52 States and more than 89,000 local and city governments, the United States frequently functions as a social laboratory for social policies, and public health laws and practices. While constrained in some areas by its constitutional design, the United States remains a leader: its influence and innovations in public health law cannot be ignored.

What can Australia learn from recent American experience with public health law and regulation?  What are the good ideas?  What should be avoided?  How can Australian jurisdictions adapt the best American innovations and create an enabling legal and political environment for public health and wellbeing?

This seminar features presentations reviewing public health law and leadership in the United States, with particular reference to: communicable diseases and pandemic preparedness, non-communicable diseases, health care, injuries and global health leadership.

This seminar is co-hosted by the United States Studies Centre at the University of Sydney, and Sydney Law School.

This event features a keynote presentation by Professor Lawrence Gostin, who is the Linda and Timothy O’Neill Professor of Global Health Law, Georgetown University Law School, Washington DC, and Faculty Director of the O’Neill Institute for National and Global Health Law. Prof. Gostin is also the Director of the WHO Collaborating Center on National and Global Health Law.

For further information on this event, further speaker details, and to register for this event, click here.

Trump: the war on breastfeeding

The New York Times reports that US officials threatened to unleash trade sanctions and withdraw military aid from Ecuador unless it withdraw a resolution at May’s World Health Assembly calling on governments to “protect, promote and support breast-feeding”.

The article is worth reading in its entirety.

As the father of a currently breastfeeding infant, I find this kind of behaviour utterly repellent.

There are echoes of Right to Health language (respect, protect, fulfil) in the resolution which might have displeased the Americans, but the real motivator was American support for large corporate manufacturers of breast-milk substitutes.

(Like Chicago-based Abbott Laboratories.)

Ecuador backed off from the offending resolution, as did “at least a dozen other countries, most of them poor nations in Africa and Latin America”.

Then Russia stepped in, and the intimidation apparently stopped.

“We’re not trying to be a hero here”, said a Russian delegate to the World Health Assembly, “but we feel that it is wrong when a big country tries to push around some very small countries, especially on an issue that is really important for the rest of the world.”

Plenty of ironies here.  But they have a point.

According to the New York Times report, a Department of Health and Human Services spokesperson said: “The resolution as originally drafted placed unnecessary hurdles for mothers seeking to provide nutrition to their children.  We recognize not all women are able to breast-feed for a variety of reasons. These women should have the choice and access to alternatives for the health of their babies, and not be stigmatized for the ways in which they are able to do so.”

Well gosh, that ought to sort out the doubters.

The Lancet reports that scaling up breast-feeding to near universal levels could avoid 823,000 deaths of children under 5 each year, and 20,000 maternal deaths from breast cancer.

Breastfeeding protects both mother and child, and it’s free, which is important if you’re poor.

Yet for billion dollar formula companies, the temptation to monetise the act of feeding by targeting young mothers, is just irresistible.

Read the Guardian’s investigation into Nestle’s marketing practices flogging formula to poor women in central Manila here.  Then weep.

Here is the resolution that eventually passed in the World Health Assembly, with American support.

Amongst other things, it requests the WHO Director-General to provide, upon request, “technical support to Member States to establish, review and implement national laws, policies and programmes to support infant and young child feeding”.

However, US hostility scuttled language that would have called on WHO to provide “technical support to member states seeking to halt “inappropriate promotion of foods for infants and young children.”

“Inappropriate” in this context would refer to the promotion of foods in contravention of the International Code of Conduct of Breast-milk Substitutes.

The Code prohibits the advertising of infant formula and other breast-milk substitutes to the general public, to pregnant women and mothers, and to health workers who are concerned with infant and maternal nutrition.  It also prohibits the giving of samples and other incentives for purchase. Governments are urged to implement the Code through national legislation, regulations or other suitable measures.

In addition, the Code states that infant formula should contain a clear statement of the superiority of breastfeeding, and a statement that the product should only be used following advice from a health worker. The container and labels should not contain pictures of infants, or include pictures or text that “may idealize the use of infant formula”.

Appropriately, the resolution does urge Member States (of the World Health Organisation) to strengthen national initiatives to implement the Code.

However, when you put it all together, it appears the Trump administration does not want sovereign countries receiving technical support from WHO about how best to frame their laws and policies to prevent predatory marketing practices that breach the Code.

It’s the Trump administration’s war on breastfeeding women.

Click here for information about the Australian Breastfeeding Association.

ANNOUNCEMENT: Sydney Law School and the United States Studies Centre at the University of Sydney are co-hosting an evening seminar entitled “Public health law and health leadership in the United States: What can Australia learn?” on 19 July 2018, 6.00-7.30pmClick here for the brochure and further details.  A separate post will follow about this event.

If you’re interested to learn more about law and non-communicable diseases, Sydney Law School is offering a Masters unit, “Law, Business & Healthy Lifestyles” in the coming semester.  Click here for more information.

What becomes of a country that cannot protect its young?

 

March for our lives, Washington DC, 24 March 2018

 

It’s too early to say if the grassroots social movement initiated by students who survived the gun massacre at Stoneman Douglas High School in Parkland, Florida will be successful in nudging America’s gun laws in the direction of rationality and evidence.

After killing 17 people with an AR-15 style semi-automatic weapon, and injuring 17 more, 19 year-old former student Nikolas Cruz left the school premises, blending in with the crowd and remaining free for an hour before arrested.

On March 24, students and gun control advocates took to the streets of Washington DC in a “March for Our Lives”.

They’re trying to start a movement.  You can join them.

“To the leaders, skeptics and cynics who told us to sit down and stay silent, wait your turn! Welcome to the revolution!” said student Cameron Kasky.

Barack Obama tweeted: “Michelle and I are so inspired by all the young people who made today’s marches happen. Keep at it. You’re leading us forward. Nothing can stand in the way of millions of voices calling for change.”

In the thick of it, as usual, my friend Professor Lawrence Gostin from Georgetown University Law School, who leads the O’Neill Institute for National and Global Health Law.  You can read about the march on his twitter account here.

He writes: “From a long life’s experience on health and human rights I have found that no meaningful change happens without bottom up social mobilization.”

He’s right.  This is true of gun control, tobacco control, and much else in public health.

Is there constitutional space for rational, evidence-based gun control laws in the United States?

It’s sometimes assumed that the US Second Amendment, which states that “the right of the people to keep and bear Arms, shall not be infringed”, leaves little room for rational, evidence-based gun control policies and laws.

This is not so, argues Professor Gostin in a recent paper published in the Journal of the American Medical Association.  For additional resources, click here, here, and here.

In fact, rational firearms laws are compatible with the Constitution and with recent caselaw, suggesting that the real problem is a political one.  Rational, evidence-based measures to reduce firearms deaths in the United States could include:

  • mandating a higher minimum purchasing age for firearms
  • prohibiting dangerous individuals from purchasing or owning firearms
  • requiring safe storage
  • banning weapons with especially hazardous properties such as military-style rapid-fire firearms and high capacity magazines, and
  • banning open carry of firearms (an emerging issue for college campuses, where academics receive advice about what to do in “active shooter” situations).

Young people exercising another of their constitutional rights, March for our lives, Washington DC, 24 March 2018.  (However, Rick Santorum suggests they would be better served taking CPR classes)

 

What makes bottom-up change happen?

This is a neglected but vitally important questions for public health lawyers.

Will the anger and conviction that fuels the “March for our lives” movement endure?  Will it prove capable of raising the resources that will be necessary to make a compelling case for change to the American people?

Public health advocates often focus on content: the technical content of the policies they advocate, the evidence, and the rational case for change.  And then nothing happens.

More than ever, advocates need to better understand the factors that catalyse change, the factors that make social movements successful, and enduring.

Jeremy Shiffman has written about why some global health issues attract attention while others languish: his scholarship is helpful in also analysing national public health issues.

For social constructionists like Shiffman, global health problems like HIV, polio, or non-communicable diseases do not have any inherent priority or significance.  The attention an issue receives, while not unrelated to epidemiological facts, is “always mediated by social interpretations”.

From a social constructionist perspective, the “core activity” of global health advocates is ideational: health advocates must advance truth claims about the problem and its solutions that resonate with the values and shared interpretations of political leaders and those who control resources.

On this view, global health (and the same could be said of national public health priorities) is a competitive – and brutal – process of portraying and communicating severity, neglect, tractability and benefit in ways that appeal to political leaders’ social values and concepts of reality”.

Yet increasingly, reality itself is no longer a shared experience.  Gun control advocates and gun enthusiasts might as well live in different universes.  Their sources of information are completely unrelated; the things they find persuasive utterly different.

Speaking in Sydney on a recent visit, Barack Obama said that “social and political structures had not yet worked out how to deal with rapidly changing communications technology, a world in which people no longer watched the same TV channels or read the same newspapers. The rapid pace of change was having a flow-on effect across the globe, and was likely to get faster still. Discourse was becoming increasingly fragmented, with people becoming hermetically sealed off from each other inside very different information universes.”

The triple cocktail of extreme individualism, neoliberalism, and populism have created a social landscape in which there is less and less shared ground when it comes to values and visions for a better life.

Speaking as a non-American, it seems to me that the scale of the challenge, for gun control advocates, is reflected in the reflexive tendency of the pro-gun lobby to castigate the very mention of rational gun laws, following [America’s latest semi-automatic gunfire massacre: insert details here] as exploitative – as politicizing a tragedy.

A couple of examples.  Jesse Hughes, whose band, Eagles of Death Metal, was performing at the Bataclan theatre in Paris on 13 November 2015 when terrorists stormed in and took hostages, eventually killing 89, went on an on-line rant, calling the Stoneman High School students “disgusting vile abusers of the dead”.

Another right-wing media type tweeted the following about David Hogg, one of the Florida students advocating for stricter gun laws: “I’ve been hanging out getting ready to ram a hot poker up David Hogg’s ass tomorrow.”

All because some students who survived a mass murder at their school dared express their opinion that government ought to introduce gun control laws to help make such rampages less frequent.

Like the tragedy of the massacre at Sandy Hook Elementary School, the gun massacre at Stoneman Douglas High School reflects the failure of policy, the failure of politics and politicians, and ultimately, the potential failure of a society.

What becomes of a country that cannot – or will not – protect its young?

Authoritarian regimes, that fail the protect basic freedoms, or do so only partially, start to look a whole lot better.

That’s bad news for freedom, and bad news for America.

 

Professor Larry Gostin will be speaking at Sydney Law School on 19 July, as part of an evening event titled: ‘Public health and health leadership in the USA: what can Australia learn’.  Sydneyhealthlaw.com will advertise this event in due course.  Professor Gostin will be teaching the unit of study, Global Health Law on 17-20 July; for more information on this unit, click here.  For more information on Sydney Law School’s Master of Health Law, click here and here.