Obesity: Policy priorities

Cancer Council supports the recommendation of the National Preventive Health Strategy that action on food and nutrition should be guided by a specific national policy document. Cancer Council recommends a National Nutrition Policy which consists of a comprehensive, multi-strategic approach including a focus on improving the sustainable supply of healthy foods; promoting healthy foods; and decreasing the production, supply and promotion of unhealthy food.^1-3

To assist people in making better informed choices and to improve the availability of healthier food options, Cancer Council recommends the Health Star Rating (HSR) system:

• be mandatory,
• regularly reviewed to allow for improvement to align with emerging evidence and changes to the food market,
• incorporates transparent processes,
• is underpinned by robust governance structures which are free from commercial conflict of interest and align with best practice dietary advice. 

Following the implementation of a mandatory system, we recommend that changes be made to ensure it is strengthened and enhanced for ongoing efficacy and usability.

There is strong evidence that food and beverage marketing influences the types and amounts of food and beverages children demand, desire and consume.^4-6 In Australia, voluntary industry codes aimed at restricting the marketing of unhealthy food and beverages to children have proven ineffective.^{6, 7} To reduce children’s exposure to unhealthy food advertising, Cancer Council recommends developing regulation for a comprehensive food marketing policy framework.   

Cancer Council supports the four action areas in the Brands Off our Kids! Report⁸, including all online environments and TV, radio and similar media are free from unhealthy food marketing at all times when children are viewing or listening, preventing processed food companies from targeting children, and ensuring public spaces and events are free from unhealthy food marketing. Studies have shown strong support by Australians for restricting unhealthy food advertising to children on television (79% support) and on digital media (76% support).^{9, 10}

Cancer Council also supports the implementation of independent and consistent nutrition criteria to determine which foods and drinks are classified as unhealthy and are therefore unsuitable to be promoted to children. Cancer Council recognises the Council of Australian Government Health Council National interim guidelines to reduce children’s exposure to unhealthy food and drink marketing (the COAG Guide)¹¹ as an agreed tool for assessing the healthiness of food and drink products for marketing to children. We acknowledge that further work could be done to enhance the COAG Guide and develop nutrition criteria that could be used across a range of nutrition policy areas.

Price is a key driver of consumer decision making when purchasing foods and drinks and therefore adjusting food taxation has the potential to affect population diets.

The introduction of health levies on energy dense and nutrient poor food products, such as sugar-sweetened beverages (SSB), to reduce consumption has been identified as an area where Australia is significantly lagging behind other countries and is a priority area for action. Cancer Council recommends that the Federal Government implement a sugar-sweetened beverage health levy to affect a price increase of at least 20%, aimed at encouraging reformulation, changing purchasing habits, achieving healthier diets and raising revenue for initiatives aimed at promoting healthy behaviours such as school sport and breakfast clubs.¹² 

To date, 115 countries have introduced some form of levy on sugar-sweetened beverages, including the UK, South Africa, and Mexico.¹³ Evaluations from these countries indicate that levies have demonstrated success in driving reductions in SSB consumption, as well as industry reformulation of SSBs to reduce sugar content.^{14, 15}

There is also high community support for sugar-sweetened beverage policy initiatives, and community appetite for government action on consumption of sugar-sweetened beverages.¹⁰ In particular, sugar-sweetened beverage levies are likely to be highly cost-effective, and are supported by members of the public. ¹⁶

As more people are diagnosed with overweight and obesity in Australia there is a need to consider innovative strategies to help an already stretched healthcare system deliver quality and holistic care for all.²¹ To support GPs in providing appropriate care and referral to multidisciplinary clinics where indicated, there needs to be clear and flexible referral pathways to multi-disciplinary, specialist weight assessment and management clinics. Technology is an important lever in delivering equitable care. Improved and ongoing access to telehealth options using hub and spoke models of care will enhance care for those residing further away from treatment centres or those physically unable to travel to clinics due to their weight.

Clinical practice guidelines support healthcare professionals to deliver evidence-based, quality care. The review and update of the Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults is currently underway. Cancer Council recommends funding the implementation and promotion of the revised Clinical Practice Guidelines to ensure healthcare professionals can be informed by the guidelines to deliver evidence-based best-practice care. It is also important that the Guidelines support healthcare professionals to use non-stigmatising language and challenge biases held in the community and their patients.

Cancer Council also recommends that ongoing efforts are funded to update the guidelines based on rigorous and emerging scientific evidence to ensure the guidelines are appropriately maintained. By creating and promoting living guidelines, healthcare providers can be assured that they are delivering best-practice and up-to-date care for people with overweight and obesity.^{22, 23} The rapidly evolving evidence base associated with the treatment and management of overweight and obesity requires monitoring of emerging interventions, technologies and treatments,²⁴ and regular updates to the guidelines.

Ongoing funding for living guidelines will allow Australians with overweight and obesity to have access to the most recent and relevant evidence-based care.

Some people who have obesity will benefit from medication and surgery in conjunction with lifestyle interventions. Currently, access to these clinical interventions is restricted and very inequitable, with significant waiting lists and high costs common barriers to access. Public hospitals have limited capacity to deliver bariatric surgery, with 95-97% of bariatric surgeries undertaken in Australia in the private sector with patients indicated for the surgery incurring large out-of-pocket costs.²⁵ Similarly, despite there being a number of TGA-approved medicines with proven effectiveness in treating obesity on the market in Australia, none are available on the PBS for the treatment of obesity. The availability of these medications can fluctuate, and therefore these treatments are more commonly accessed by those with greater financial and social resources; this is not fair or equitable. Access to medication and surgery should be triaged, with those requiring the service the most receiving access first. Access can then be increased over time while the cost-benefit can be established systematically at each stage.

Before and after care for bariatric surgery and support while on pharmacotherapy is also poor, with obesity care seen as being a luxury. To achieve long term outcomes from these treatments, patients should be holistically supported by a team of health professionals, providing ongoing support to further encourage healthy habits, including access to nutrition care, exercise programs and mental health services.

Existing services such as the Get Healthy Coaching and Information Service offered by the NSW Government or the Better Health Coaching Service delivered in SA and WA could be enhanced to provide care for people who have or are undergoing treatment for obesity. This could include:

• Delivering evidence based one on one care
• Providing psychological assessment where indicated and with appropriate referral
• Focussing on behaviours and co-morbidities/health outcomes, rather than weight, to address issues of weight stigma
• Providing clear referral pathways for GPs/other clinicians to ensure consistent referrals but also feedback to the referring doctor about patient progress.

For more information see the evidence informing policy section.

Effective weight management strategies require a person-centred, holistic and multi-disciplinary approach, necessitating strong collaboration and partnerships between primary, secondary and tertiary healthcare. It is therefore important that health services and systems create services that are multi-disciplinary, can holistically treat people with obesity to address their overall health, and not just weight, and offer appropriate evidence-based interventions people with overweight and obesity. Further, the multi-disciplinary care team should consider how they may be best suited to provide support and treatment options to help increase access to appropriate interventions for people with overweight and obesity.²⁶

Interventions targeting modifiable risk factors such as dietary and sedentary behaviour have been demonstrated to improve overall health and wellbeing regardless of weight loss, ^27-29 so it is important that individuals with overweight and obesity are supported and encouraged to engage in healthy eating and physical activity. The provision of psychological support services should also be included as part of the patient’s routine care.

Weight bias and stigma are pervasive in Australian society, with derogatory language the most common form. People with overweight and obesity may experience stigma in their interpersonal interactions with family, friends and colleagues, with healthcare professionals, and in the broader social norms.³⁰ This may then be internalised and impact the willingness and ability to access appropriate care.^{31, 32} There is a need for inclusive weight-based language to be promoted across Australia to ensure that weight stigma is reduced. This may include adoption of appropriate language guides by media outlets, public health campaigns, inclusive policy development, and education resources and opportunities.

In 2019, the National Association of People Living with HIV developed a Stigma and Resilience Framework ³³ to address HIV stigma and strengthen resilience capacity among people living with HIV. The Federal Government could build on this existing work through the development of a similar national framework that addresses weight stigma. The Framework must support the development of policies, legislation, programs, interventions, services and practices within the weight management sector at all levels of government to ensure all people with overweight and obesity benefit equally from advances in prevention, treatment, care and support.

By integrating the perspectives of people with a lived experience of overweight and obesity in the public discourse, there is an opportunity to reduce the impact of weight stigma. Promoting lived experience stories will also have the effect of reducing internalised stigma as people can relate to the stories, and this may increase their help seeking behaviours, will inform best practice approaches in the care setting and will help to shape and refine existing and future health care services.

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