Australia: the healthiest country by 2020
National Preventative Health Strategy – the roadmap for action

Key action area 10: Build the evidence base, monitor and evaluate effectiveness of actions

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Develop a comprehensive national research agenda for overweight and obesity

‘Creating new evidence from innovative and untested strategies and projects should be considered alongside those strategies and interventions that we know work’ (Quote from submission)

There is a clear need to increase the evidence base regarding obesity prevention and management through research, evaluation, monitoring and surveillance. This requires a much higher investment in research and evaluation related to weight reduction interventions and the causes of obesity.¹⁹

The development of a comprehensive national research agenda for obesity is essential. It is also vital to develop an agreed national assessment tool and reporting levels for overweight and obesity, particularly as they relate to children, young people and minority groups. A specific research agenda must be developed with appropriate levels of public and private funding, which must be supported by improved monitoring and harmonisation of surveillance systems across Australia. If the relative lack of evidence on obesity prevention and management is to be addressed, existing and future interventions require well-designed, rigorous evaluation (including economic analysis such as the assessment of cost-effectiveness).

Partnerships between the NPA and the National Health and Medical Research Council (NHMRC), the Australian Research Council (ARC) and other state-based research funding organisations such as health promotion foundations and non-government organisations will be important to ensure a coordinated investment in research and evaluation. Clearly the establishment of the NPA would greatly assist a coordinated approach and would be a mechanism for achieving this. Such an agency would be able to commission research and develop targeted social marketing and public education campaigns. This mechanism would also be used to coordinate national media advertising with local program delivery, and to evaluate campaign effectiveness. The success of the National Tobacco Campaign and the recent Measure Up campaign clearly indicates that such models for campaign development, implementation and evaluation are feasible and well accepted by all those involved. There is a unique opportunity to build upon the recent experience with the Measure Up campaign, and to ensure this momentum is maintained.

National data collection – adults

The Taskforce has identified the need to establish a comprehensive national surveillance system focused on the behavioural, environmental and biomedical risk factors for chronic disease (including factors such as food availability and food composition) to track and report on performance and outcomes, including the impact of health inequalities. The current plans to enhance nutrition and physical activity data through the collection of national biomedical data are strongly supported by the Taskforce. This data should be collected on an ongoing basis every five years through the National Health Risk Survey and other national data bases, and must include the capacity to collect data from the Australian Indigenous population.

Such a database will assist with the monitoring and reporting of the COAG National Partnership Agreement on Preventive Health performance indicators and allow reports on progress in achieving the COAG partnership interim targets.
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National data collection – children and adolescents

There is also a need to ensure there is an appropriate mechanism for the ongoing collection of national data on children. This should cover two components. Firstly, the capacity to repeat at regular intervals the Australian National Children’s Nutrition and Physical Activity Survey undertaken in 2007. Secondly, the Taskforce is very supportive of the national data collection to be undertaken among adolescents by the state Cancer Councils, Cancer Council Australia and the National Heart Foundation of Australia, which will commence in 2009.

This survey aims to build on the well-established Australian Secondary Students’ Alcohol and Drug (ASSAD) surveys, and will monitor overweight and obesity prevalence, eating and physical activity behaviours among a nationally representative sample of around 20,000 secondary school students from year levels 8 to 11. Measured height, weight and waist circumference, food intake, dietary habits, physical activity, sedentary behaviour, barriers and enablers of physical activity and data on the school food and activity environment will be collected. This will be a rich data source and will enable ongoing monitoring of the attitudes and behaviour of adolescents, a group that is very important to influence if we are going to successfully halt and reverse the current trend in overweight and obesity in Australia.

Evaluation of interventions in Indigenous communities

There are several key principles for successful interventions in the Indigenous context,[189] including ensuring programs are adequately resourced for evaluation and monitoring so they can contribute to intervention policy knowledge. The evidence of ‘what works’ to address alcohol, tobacco or obesity is in some cases highly developed, but this evidence base is predominantly from mainstream and/or overseas populations. Taking account of this evidence is important. However, given the need to work with Indigenous communities’ own histories, priorities and capacities, flexibility and innovation on the basis of the evidence is likely to be more effective than attempts to rigidly apply interventions that worked elsewhere. It is important to ensure that programs contribute to evidence-based intervention policy knowledge through adequate resourcing for evaluation.

Indigenous communities require evidence-based approaches that are reflective and that involve the local community in adapting what is known to be effective elsewhere to local conditions and priorities. Obesity, tobacco and alcohol are not necessarily the top priorities for all communities. Any sustainable program needs to make provision for flexibility and negotiation between local priorities and program priorities. Community-controlled health services and their peak bodies provide an important arena in which the dialogue between community priorities and an evidenced-based approach to population health challenges can take place.

Action 10.1
NPA to develop a national research agenda for overweight and obesity with a strong focus on public health, population and interventional research.

Action 10.2

• Ensure that the National Health Risk Survey Program will cover:
• Adults
• The Indigenous population

Action 10.3
Ensure that the National Children’s Nutrition and Physical Activity Survey is repeated on a regular basis to allow for the ongoing collection of national data on children.
Action 10.4

Support ongoing research on effective strategies to address social determinants of obesity in Indigenous communities.

Issues outside the scope of a National Preventative Health Strategy

A few issues highlighted during the consultation and submission process were outside the scope of a National Preventative Health Strategy. The Taskforce provides the following comments in relation to two of these issues in the obesity area.
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Is there a role for the commercial weight-loss industry in prevention?

There are currently inadequate regulations and voluntary codes of practice which apply to weight loss products and programs. A plethora of over-the-counter products and programs are available and promoted for weight loss in Australia, including through pharmacies, many with unsubstantiated claims of efficacy. Insufficient consultant training, lack of qualified supervision and no capacity to individually tailor advice and plans have been identified as common problems in a range of pharmacy-based weight loss programs in Australia.[218]

While these kinds of products and services cannot be recommended as part of a national obesity prevention strategy, it is an area that needs to be addressed through adequate action to ensure Australians have access to effective weight loss products and services. For complementary medicines, this would be addressed through the Therapeutic Goods Association (TGA);²⁰ for the weight-loss industry, this is likely to be achieved through the Trade Practices Act.

There is a need to develop mechanisms that ensure safe industry practices within the commercial weight-loss industry and ensure access to effective weight loss products and services, including:

• Development of a national accreditation system (for example, based on the Weight Management Code of Practice, administered by the Weight Management Council of Australia²¹) for weight management programs (including minimum training standards for consultants, nutritional standards, and eligibility criteria such as age of clients)
• Identification of a responsible administering body, and consideration of monitoring, compliance, enforcement and sanctions
• Implementation of industry and consumer education regarding the accreditation standards and criteria

Bariatric surgery

Bariatric surgery is the most effective weight-loss treatment in severely obese patients.[162] It is being increasingly used in the treatment of obesity, particularly in the private health sector. However, there is no role for this procedure in the obesity prevention arena. Bariatric surgery is considered appropriate in well-defined clinical situations such as morbid obesity where non-operative methods (such as behavioural interventions) have failed. Appropriate protocols for this procedure, covering guidelines on patient selection, assessment (medical and psychological) and post-operative monitoring, should be followed.[162]

The Taskforce also notes that the lack of access to high quality publicly funded behavioural approaches to obesity management is potentially distorting choices in favour of surgery.

¹⁹ The Australasian Child and Adolescent Obesity Research Network (ACAORN) has called for increased funds targeted specifically at childhood obesity research, and for a national childhood obesity research agenda. In an examination of funds allocated by major medical research funding bodies to obesity, ACAORN found, for example, that 5% of funding in the NHMRC December 2008 statement was for obesity-related projects (with a small proportion for childhood obesity). Baur LA, Wake M, Espinel PT. Audit of Australian childhood obesity research funding 2005–09. On behalf of the Australasian Child and Adolescent Obesity Research Network (ACAORN). April 2009.
²⁰ Consultation was undertaken by the TGA for a draft guideline on evidence for listed medicines with indications and claims for weight loss (February–April 2009). See www.tga.gov.au/cm/ consult/drweightloss.htm The effectiveness of TGA requirements for listings of herbal and complementary medicines (for example, lack of burden of proof and product analysis) compared with requirements for registration of pharmaceutical drugs has been questioned; see www.theaustralian.news.com.au/ story/0,25197,25306329-23289,00.html.
²¹ This would require review as the Weight Management Code of Practice applies to businesses in the Weight Management Industry who are members of the Weight Management Council of Australia; this has very limited membership (five companies) given the size of the commercial weight-loss industry. See www.weightcouncil.org/Activity.asp?page=350.

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