Technical Paper 1:
Obesity in Australia: a need for urgent action

Reshape urban environments towards healthy options

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Tackling obesity is about reshaping behaviours for positive outcomes in an environment of nutritional abundance that serves aesthetic and emotional needs as well as nutritional requirements. Food and alcohol play an important part in the social fabric of life, as does sedentary social behaviour; simply lecturing people or taking a prohibitionist approach is unlikely to be successful or appropriate.

The energy balance equation is strongly affected by dietary and physical activity patterns – ‘the major modifiable factors through which many of the external forces promoting weight gain act’.[81] The relative contributions of eating and activity patterns have been subject to substantial scientific debate;[82] however, it is clear that there is a strong and positive relationship between dietary factors (including fat and energy intake) and excess body weight, while decreasing physical activity levels and increased sedentary behaviour also play a key role in weight gain and the development of obesity.[81]

In August 2008, an independent expert panel was appointed to make recommendations and investigate reforms on improving the ways in which sport is run, promoted and managed in Australia.[83] Chaired by David Crawford, the expert panel is examining sport at the elite and grassroots community level. The review will pay particular attention to the most effective way in which sport and physical activity can play a strong role in building a healthier Australia, and will form part of the Australian Government’s preventative health agenda. This is included as one of the Terms of Reference to which recommendations will be particularly directed: Better place sport and physical activity as a key component of the Government’s preventative health approach. This covers:

• Examining Australian Government frameworks to ensure an on-going focus on grassroots and community sport and physical activity
• Examining Australian Government programs to increase participation rates in sport and physical activity, including analysis of existing programs
• Identifying and recommending opportunities to break down barriers to participation at junior, adult and senior ages with a view to making it simpler and easier for Australians to participate in the sport or physical activity of their choice, including for women, the disabled and Indigenous people
• Recommending strategies to increase the effectiveness of the promotion of sport by the Australian Government to better communicate positive health and activity messages to the broader community

The Panel is due to report to the Australian Government in 2009.¹⁷

Cycling strategy

In April 2009, the Australian Government announced a $40 million cycle path fund for bicycle infrastructure to be administered by the Department of Infrastructure, Transport, Regional Development and Local Government. The funding was made under the Local and Community Infrastructure Program (CIP). Applications were due in May 2009 for funding to commence in July 2009 and to end in June 2011.¹⁸ Over 100 councils have committed to allocating some of the funding received through the CIP for cycling and shared path infrastructure.[84]

The funding may be provided for new routes and extensions or refurbishment of existing infrastructure, including off-road bicycle paths (but not dedicated mountain bike trails); on-road bicycle lanes (for example, road-widening and marking bike lanes on an existing road); and bicycle parking facilities. Projects of up to $2 million could be funded, with a requirement for a 50% joint funding contribution from each project.
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Urban planning and design

It is worth noting that more disadvantaged areas have more retail outlets selling fruits and vegetables, but also more fast food outlets.[85] One effective regulatory action for local government to reduce access to foods high in fats and salt is the adoption or strengthening of planning regulations to manage the proliferation of fast food outlets in particular areas; for example, near schools and in socially disadvantaged neighbourhoods. Research from the United States and Australia indicates that less-advantaged areas tend to have greater access to fast food retailers.[86]

An Australian study examined the association between neighbourhood fast food outlets and obesity in children and adults (the CLAN Study). Children’s measured and parents’ self-reported heights and weights were used to calculate BMI, while locations of major fast food outlets were geocoded. Bivariate linear regression analyses examined associations between the presence of any fast food outlet within a 2km buffer around participants’ homes, fast food outlet density within the 2km buffer, and distance to the nearest outlet and BMI. Each independent variable was also entered into separate bivariate logistic regression analyses to predict the odds of being overweight or obese.

Among older children, lower BMI z-scores were found among those with at least one outlet within 2km. Fathers’ BMI increased with the distance from an outlet. Among 13–15-year-old girls and their fathers, the likelihood of overweight/obesity was reduced by 80% and 50%, respectively if they had at least one fast food outlet within 2km of home. Among older girls, the likelihood of being overweight/obese was reduced by 14% with each additional outlet within 2km. The odds of fathers being overweight/obese increased by 13% for each additional kilometre to the nearest outlet.

The authors concluded that while consumption of fast food has been shown to be associated with obesity, the study provided little support for the concept that exposure to fast food outlets in the local neighbourhood increases risk of obesity.[87]

A systematic review examining the relationship between obesity and the community and/or consumer food environment identified the need for additional research in this area.[88] The authors identified only seven studies for review. These studies used cross-sectional designs to examine the community food environment defined as the number per capita, proximity or density of food outlets. The studies varied substantially in sample populations, outcome variables, units of measurement and data analysis. Two studies did not find any significant association between obesity rates and community food environment variables, while five studies found significant results. Many of the studies were subject to limitations that may have mitigated the validity of the results.

The authors identified several gaps in knowledge in this area and concluded that research examining obesity and the community or consumer food environment is at an early stage. They suggested that future research should directly measure multiple levels of the food environment and key confounders at the individual level.[88]

Consumption of fast food products, which have high energy densities and glycaemic loads, and expose customers to excessive portion sizes, may be greatly contributing to and escalating the rates of overweight and obesity in the United States. A systematic review of the relationship between weight gain and fast food consumption found that while more research needs to be conducted, specifically in regard to the effects of fast food consumption among subpopulations such as children and adolescents, sufficient evidence exists for public health recommendations to limit fast food consumption and facilitate healthier menu selection.[89]
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The author concluded that the scientific findings and corresponding public health implications of the association between fast food consumption and weight are critical, due to the increase of the fast food industry globally.[89]

Interventions for children

Since the Technical Report was published, several evidence reviews relating to the management and prevention of obesity have been released. In January 2009, an updated Cochrane review examining the evidence on interventions for treating obesity in children was published.[90] It concludes that family-based, lifestyle interventions, which include a behavioural program aimed at changing diet and physical activity, provide significant and clinically meaningful decreases in overweight and obesity in both children and adolescents compared with standard care or self-help regimes. Family-based lifestyle interventions that not only modify diet and physical activity but also include behaviour therapy programs can help obese children lose weight and maintain that loss for at least six months. The review also found that in adolescents the effect lasts for at least 12 months. Adding the weight-controlling drugs orlistat or sibutramine to behaviour change programs for adolescents may provide additional benefits.

These findings represent a difference from a systematic review performed in 2003 which could not find enough data to draw any conclusions about the effects of different programs.[91] This time the researchers identified 64 randomised controlled trials involving 5230 participants, enabling them to see some definite effects.[90]

Research gaps identified include what types or aspects of different interventions work better for different groups of children, depending on their age, gender, socioeconomic background, faith or ethnic groups; the importance of self-esteem in influencing how successful an intervention will be; and whether there are any characteristics of individual families or patients that could help to identify success.[90]

A systematic review and meta-analyses of randomised trials on behavioural interventions to prevent childhood obesity was published in 2008.[92] The objective was to summarise evidence on the efficacy of interventions aimed at changing lifestyle behaviours (increased physical activity and decreased sedentary activity, increased healthy dietary habits and decreased unhealthy dietary habits) to prevent obesity. Trials with interventions lasting more than six months (compared with shorter trials) and trials with post-intervention outcomes (compared with in-treatment outcomes) yielded marginally larger effects.

The authors concluded that paediatric obesity prevention programs caused small changes in target behaviours and no significant effect on BMI compared with control. The authors also concluded that trials evaluating promising interventions applied over a long period, using responsive outcomes and with longer measurement timeframes, are urgently needed.[92]
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Pre-school setting

A study examining the relationships between weight status and child, parent and community characteristics in pre-school children in Australia collected cross-sectional data from 140 children and their parents from 11 randomly selected pre-schools in New South Wales. Compared with non-overweight children, overweight children spent more time in quiet play and watching television and less time in active play and physical activity. Perceived competence and motor development were similar for both overweight and non-overweight children. The study concluded that the results showed little difference between overweight and non-overweight children in relation to a variety of child, parent and community variables. However, for some characteristics, differences in older children have been reported.

The authors concluded that longitudinal studies are required to confirm when these characteristics begin to differ, what effects these differences have on behaviour and weight status, and therefore when targeted treatment should be provided during a child’s development.[93]

School-based programs

A Cochrane systematic review of studies on physical activity programs in schools published in January 2009 concluded that school-based health and exercise programs have positive outcomes despite having little effect on children’s weight or the amount of exercise they do outside of school. The researchers reviewed data from 26 studies of physical activity promotion programs in schools in Australia, South America, Europe and North America. Most studies tried to encourage children to exercise by explaining the health benefits and changing the school curriculum to include more physical activity for children during school hours. Programs included teacher training, educational materials and providing access to fitness equipment.[94]

The review showed that school-based programs increased the time children spent exercising and reduced the time spent watching television. Programs also reduced blood cholesterol levels and improved fitness – as measured by lung capacity. However, programs made little impact on weight, blood pressure or leisure time activities.[94]

The lead researcher suggested that physical activity classes may be too closely associated with school work, meaning some students may feel like they are being made to do more work. In this case, a key strategy would be to promote physical activity by getting children and adolescents to ‘play’ in ways that represent fun and adventurous activities, while at the same time promoting better fitness levels.[95]

A systematic review of school-based interventions that focus on changing dietary intake and physical activity levels to prevent childhood obesity was conducted to update the obesity guidelines produced by the National Institute for Health and Clinical Excellence and published in 2009. The review found that school-based physical activity interventions may help children maintain a healthy weight but the results were inconsistent and short term. Physical activity interventions may be more successful in younger children and in girls. Studies were heterogeneous, making it difficult to draw conclusions on what interventions were effective. While the findings were inconsistent, they suggested overall that combined diet and physical activity school-based interventions may help prevent children becoming overweight in the long term. Physical activity interventions, particularly in girls in primary schools, may help to prevent these children from becoming overweight in the short term.[96]
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As with the Cochrane systematic review,[94] a systematic review and meta-analysis undertaken by Canadian researchers found that school-based physical activity interventions did not improve BMI, although they had other beneficial health effects.[97] The review to determine the effect of school-based physical activity interventions on BMI in children found that BMI did not improve with physical activity interventions (weighted mean difference -0.05kg per square metre, 95% confidence interval -0.19 to 0.10). The authors concluded that current population-based policies that mandate increased physical activity in schools are unlikely to have a significant effect on the increasing prevalence of childhood obesity.[97]

Ecological approaches that recognise the interaction between individuals and the settings in which they spend their time are currently at the forefront of public health action. In a literature review published in 2009, Canadian researchers examined schools as a setting for action on physical inactivity, as they have been identified as a key setting for health promotion.[98] The review addressed the promotion of physical activity in schools and showed that school-based strategies (elementary or high school) using classroom-based education only did not increase physical activity levels; one notable exception was screen time interventions. The authors concluded that although evidence is sparse, active school models and environmental strategies (interventions that change policy and practice) appear to promote physical activity in elementary schools effectively. The review also found strong evidence to support multi-component models in high schools, particularly models that incorporate a family and community component. An emerging trend is to involve youth in the development and implementation of interventions.

The authors highlighted the importance of modest increases in physical activity levels in school-based trials in the context of childhood obesity and sedentary lifestyles.

The review also concluded that school initiatives must be supported and reinforced in other community settings. The key role of health professionals as champions in the community, based on their influence and credibility, was also identified: health professionals can lend support to school-based efforts by asking about and emphasising the importance of physical activity with patients, encouraging family-based activities, supporting local schools to adopt an ‘active school’ approach, and advocating for support to sustain evidence-based and promising physical activity models within schools.[98]

An Australian study examining the predictors of BMI changes in Victorian 5–10-year-old primary school children found BMI change (measured in 1997 and 2000/2001) to be positively associated with frequency of takeaway food, food quantity, total weekly screen time, non-Australian paternal country of birth, maternal smoking during pregnancy, and maternal and paternal BMI.[99] Inverse associations were noted for the presence of siblings and rural residence. Multivariable models suggested individual determinants have a cumulative effect on BMI change. The authors found that while it was hard to identify predictors of change based on strong short-term tracking of BMI, putative determinants across all six domains assessed (children’s diet, children’s activity level, family composition, sociodemographic factors, prenatal factors and parental adiposity) were independently associated with adiposity change.

The study concluded that multifaceted solutions are likely to be required to successfully deal with the complexities of childhood overweight.[99]
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A systematic literature review published in 2009 examined the effectiveness of school-based food and nutrition policies in improving diet and reducing obesity.[100] Drawing on published and unpublished literature, most evidence of effectiveness was found for the impact of both nutrition guidelines and price interventions on intake and availability of food and drinks, with less conclusive research on product regulation. Despite the introduction of school food policies worldwide, few large-scale or national policies have been evaluated. All included studies were from the United States and Europe. The authors concluded that while some current school policies have been effective in improving the food environment and dietary intake in schools, there is little evaluation of their impact on BMI. As schools have been proposed worldwide as a major setting for tackling childhood obesity, it is essential that future policy evaluations assess the long-term effectiveness of a range of school food and nutrition policies in tackling both dietary intake and overweight and obesity.

A 2009 article by Story et al.[101] explored the role of schools in obesity prevention efforts in relation to four key areas: school food environments and policies; school physical activity environments and policies; school BMI measurements; and school wellness policies. Focusing on the US context, the authors concluded that:

• Competitive foods (foods sold outside federally reimbursed school meals) are widely available in schools, especially secondary schools. Studies have related the availability of snacks and drinks sold in schools to students’ high intake of total calories, soft drinks, total fat and saturated fat, and lower intake of fruits and vegetables.
• Physical activity can be added to the school curriculum without academic consequences and can also offer physical, emotional and social benefits. Policy leadership has come predominantly from the districts, then the states, and, to a much lesser extent, the federal government.
• Few studies have examined the effectiveness or impact of school-based BMI measurement programs.
• Early comparative analyses of local school wellness policies suggest that the strongest policies are found in larger school districts and districts with a greater number of students eligible for a free or reduced-price lunch.

The authors found that while studies show schools have been making some progress in improving the school food and physical activity environments, much more work is needed. Stronger policies are needed to provide healthier meals to students at schools; limit their access to low-nutrient, energy-dense foods during the school day; and increase the frequency, intensity and duration of physical activity at school.[101]

In the European Union (EU), public health, particularly obesity, is for the first time being seen as a driver of agricultural policy.[102] In 2007, European Ministers of Agriculture were asked to back new proposals for school fruit and vegetable programs as part of agricultural reforms, and in 2008 the European Commission (EC) conducted an impact assessment to assess the potential impact of this new proposal on health, agricultural markets, social equality and regional cohesion.

A systematic review published in 2008 examined the effectiveness of interventions to promote fruit and/or vegetable consumption in children in schools.[102] The review was conducted to inform the EC policy development process. The results showed that school schemes are effective at increasing both fruit and vegetable intake and knowledge. Of the 30 studies included, 70% increased fruit and vegetable intake, with none decreasing intake. The majority of the studies (23) had follow-up periods of more than one year and provided some evidence that fruit and vegetable schemes can have long-term impacts on consumption. One study led to both increased fruit and vegetable intake and reduction in weight, while one study showed that school fruit and vegetable schemes can also help to reduce inequalities in diet. Effective school programs have used a range of approaches and been organised in ways which vary nationally depending on differences in food supply chain and education systems.
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The authors concluded that EU agriculture policy for school fruit and vegetable schemes should be an effective approach, resulting in both public health and agricultural benefits. Aiming to increase fruit and vegetable intake amongst a new generation of consumers, it will support a range of EU policies including obesity and health inequalities.[102]

A systematic review and meta-analysis published in 2008 was undertaken to determine the effectiveness of school-based strategies for obesity prevention and control.[103] Peer-reviewed studies published between 1966 and October 2004 were considered for review, with criteria including 3–18-year-olds targeted in a school setting, reported weight-related outcomes, control measurement included and at least a six-month follow-up period. Studies employed interventions related to nutrition, physical activity, reduction in television viewing or combinations of these. Twenty-one papers describing 19 studies were included in the systematic review, with eight of these included in the meta-analysis. Nutrition and physical activity interventions resulted in significant reductions in body weight compared with control. Parental or family involvement of nutrition and physical activity interventions also induced weight reduction. Combination nutrition and physical activity interventions were effective at achieving weight reduction in school settings.

The authors concluded that several promising strategies for addressing obesity in the school setting were suggested, warranting replication and further testing.[103]

A related article by Katz[104] published in 2009 drew on the same evidence as in the systematic review and meta-analysis described above[103] and concluded that available research evidence does present a case for school-based interventions. The author found that despite marked variation in measures, methods and populations in studies examining school-based interventions for obesity prevention and control and for related health promotion, evidence clearly demonstrated that school-based interventions had significant effects on weight. Katz states that the urgency of the obesity and diabetes epidemics demands action, in spite of limited evidence to date; intervention and methodologically robust evaluation is necessary based on current evidence and common sense.[104]

Community setting

In spite of greater awareness of the need for action to reduce obesity, the evidence on sustainable community approaches to prevent childhood and adolescent obesity is surprisingly sparse. A paper published in 2008 described the design and methodological components of a demonstration site for obesity prevention in the Barwon south-west region of Victoria, Australia, that aims to build the programs, skills and evidence necessary to attenuate and eventually reverse the obesity epidemic in children and adolescents.[105] The Sentinel Site for Obesity Prevention is based on a partnership between the region’s Deakin University and the health, education and local government agencies. The three basic foundations of the Sentinel Site are: multi-strategy interventions across multiple settings; building community capacity; and undertaking program evaluation and population monitoring. While three intervention projects cover different age groups – pre-school (2–5-year-olds), primary school (5–12-year-olds) and secondary school (13–17-year-olds) – each project has many common characteristics. These include community participation and ownership of the project; intervention duration of at least three years; and full evaluations with behavioural impact and anthropometric outcome measures compared with regionally representative comparison populations.[105]

It is well known that obesity prevention initiatives must consider both physical activity and nutrition to be effective. Community sports venues have the capacity to promote healthy lifestyles through physical activity as well as healthy food choices. In research published in 2008, a telephone survey was conducted among parents of children aged 5–17 years in New South Wales to determine the nature of food and beverages purchased by children at community sporting venues, and to determine parental perceptions of the role that government should play in regulating the types of food and beverages sold at these outlets.[106]
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The majority of canteens at children’s sporting venues were considered to sell mostly unhealthy food and beverages (53%). Very few parents reported that canteens sold mostly healthy food and beverages. Parents reported that the food and beverage items their children most frequently purchased at outdoor sports fields were water, chocolate and confectionery, soft drink and sports drinks, and ice cream. At community swimming pools, the most frequently purchased items were ice cream, followed by snack foods, including chips, cakes and biscuits. Most parents (63%) agreed that government should restrict the types of food and beverages that can be sold at children’s sporting venues. The authors concluded that children are receiving inconsistent health messages at sporting venues, with healthy lifestyles being promoted through sports participation, but unhealthy dietary choices being provided at sports canteens.[106]

While overweight is often established by school entry age, not all mothers of children who are overweight at this point report weight concerns. Enhancing maternal concern might assist lifestyle change, but could lead to child body dissatisfaction. A prospective community study conducted in Melbourne investigated perceived/desired body size and body dissatisfaction in mothers and their 6.5-year-old children, and the impact of earlier maternal concern about overweight on children’s BMI status and body dissatisfaction.[107] BMI correlated with perceived body size for all three actual BMI perceived size pairings: mother self-report, mother’s report about her child, and child self-report. Similarly, all three dissatisfaction scores were greater with increasing BMI status. Children’s own dissatisfaction scores correlated with their actual BMI, but were not related to mothers’ own body dissatisfaction scores or with mothers’ dissatisfaction with children’s body size. Maternal concern about overweight at the age of four years was not associated with BMI change, or child body dissatisfaction by the age of 6.5 years.

The authors concluded that despite low rates of recognition of child overweight, maternal perceptions of the child’s body correlated strongly with the child’s actual BMI. Maternal concerns about child BMI did not appear to impact on child BMI change or child body dissatisfaction.[107]

Australian research published in 2008 examined associations between family physical activity and sedentary environment and changes in BMI among 10–12-year-old children over three years.[108] The study measured height and weight at baseline and follow-up; aspects of the family physical activity and sedentary environment (parental and sibling modelling, reinforcement, social support, family-related barriers, rules/restrictions, home physical environment) were measured with a questionnaire completed by parents at baseline. At baseline, 29.6% of boys and 21.9% of girls were overweight or obese. Over the study period there was a significant change in BMI z-score among girls but not boys. The authors concluded that sibling physical activity and environmental stimuli for sedentary behaviours and physical activity within the home may be important targets for prevention of weight gain during the transition from childhood to adolescence.[108]
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Workplace setting

A joint report by the World Health Organization (WHO) and the World Economic Forum notes there is clear and persuasive evidence that many workplace health promotion programs targeting non communicable disease have been successful at improving employees’ health by reducing risk factors, increasing employees’ fruit and vegetable consumption, improving employee engagement and productivity, and producing return on investment (through cost savings and increased productivity).[109]

A systematic review examining obesity status and sick leave was published in 2009.[110] While 36 studies on the relation between obesity status and sick leave were identified, pooling of effect estimates was not possible due to great heterogeneity between studies regarding definition of sick leave (short term/long term), measure of obesity (BMI/waist circumference/percentage body fat), definition of obesity status (WHO standards/other), study population (sex/age/occupation/country) and exposure and outcome ascertainment (self-reported/objectively assessed). Nevertheless, a clear trend towards greater sick leave among obese compared with normal weight workers could be discerned, especially for spells of longer duration. In studies from the United States, which consistently reported around five times a lower number of sick leave days per person-year than European studies, obese workers had approximately one to three extra days of absence per person-year compared with their normal weight counterparts. In European studies, the corresponding difference was about 10 days. The data were conflicting for overweight workers, indicating either increased or neutral level of sick leave compared with normal weight.

Studies examining underweight were very few and concerns regarding direction of causality were greater. The review identified four interventional studies; all of these found that substantial weight loss in obese subjects resulted in at least temporary reductions in sick leave. The authors concluded that increasing obesity in children and adults is likely to negatively affect future productivity as obesity increases the risk of sick leave, disability pension and death.[110]

A recent literature review for the New Zealand Ministry of Health cites the workplace as a pivotal location for promoting and supporting wellness, as described in the Technical Report. The review states: ‘in terms of importance, the workplace is matched only by the education system as the most effective front line approach to preventing chronic disease and promoting health’ (page 6). Reasons for this crucial role of workplaces include ease of access to a large number of people, existing infrastructures in the workplace (for example, communication channels, teams), the cost-efficiency of workplace health promotion programs relative to clinical or community-based programs, and the opportunity to address multiple levels of influence, including individual, interpersonal, organisational and environmental factors on health.[111]

Examples of workplace health promotion programs cited in the report include: stress management, smoking cessation, weight management, back care, health screenings, nutrition education, workplace safety, prenatal and well baby care, CPR and first aid classes, employee assistance programs (EAP), work–life balance policies, flexi-time, exercise/fitness groups, discounts to local fitness facilities, healthful food choices at work meetings, events, training programs and family-friendly policies and facilities (such as bicycle racks, showers and gym equipment).[111]

Benefits to employees include health benefits (such as physical wellbeing and clinical health improvements: reduced cholesterol, reduced risk of chronic disease, reduced incidence of musculoskeletal disorders); increased mental wellbeing, energy and resilience, reduced stress and depression, and increased quality of life; financial benefits; and improved job satisfaction.[111]

Benefits to employers from workplace health promotion programs include:[111]

• A healthy, happy and present workforce with reduced absenteeism and presenteeism; improved employee engagement, recruitment and retention; a happier, more resilient workforce; a positive workplace culture; and improved industrial relations.
• Increased employee performance and productivity.
• Financial benefits including reduced healthcare costs; reduced costs relating to absenteeism and presenteeism; return on investment (from improved productivity or cost savings).

The review cites research showing that the economic return on investment for various workplace health promotion programs ranged from US$1.50 to US$5.96 saved for every US$1 spent.[111]
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The review notes that ‘the challenge for organisations today is no longer whether or not workplace health promotion programs should be implemented but rather how they should be designed, implemented and evaluated to achieve optimal benefits (i.e. health and cost-effectiveness)’[111] (page 7). Effectiveness of such initiatives can be achieved through careful planning and informed design; long-term focus and strategic goals; creating a culture of health (that is, a culture supportive of workplace health promotion, including active leadership and a healthy environment); maximising employee engagement and participation; having an appealing communications strategy; and research and evaluation.[111]


The review provides an outline of the design and implementation components of successful workplace health promotion programs based on the literature:[111]

Aspects of successful workplace health promotion program design:

• Being based on theory (for example, on improving self-efficacy, stage of change etc)
• Having clear goals and objectives (linked to organisational objectives)
• Being comprehensive (holistic, multi-component)
• Including tailored/targeted interventions (based on employee characteristics)
• Focusing on modifiable risk factors (for example, things employees can change such as diet and level of physical activity) and improving employees’ self-efficacy (belief in their ability to achieve certain outcomes)
• Promoting the inclusion of existing social support systems (for example, involving spouses/family) and the creation of new social support systems (such as weight loss teams, sports teams)
• Including a participatory approach to development and implementation (involving employees – using peers for design, promotion and delivery)
• Offering flexibility (for example, holding additional sessions in work time at different times of day, offering different options for participation)
• Including health risk assessments/screenings
• Having a long-term focus
• Removing barriers to participation
• Including research and evaluation

Aspects of successful workplace health promotion program implementation:

• Fostering networks and partnerships (for example, potential wellness collaborators)
• Using a variety of communication/education strategies
• Including environmental support (for example, environmental modifications such as healthy foods in vending machines, signage promoting healthy behaviours, provision of facilities such as bicycle racks, showers and changing rooms)
• Including the use of incentives and rewards
• Having strong management support (for example, endorsement, resourcing and policy sign-off)

Update on Victorian WorkHealth program

The Victorian WorkHealth pilot, delivered by WorkSafe, ran in 2008 and involved 657 workers in nine Victorian workplaces taking part in health checks at their workplaces. In March 2009 the Premier announced that the pilot of the initiative to screen workers for preventable diseases has been highly effective, with two in three workers referred to a GP for further medical attention.[112]

The five-year program commenced roll-out in regional Victoria in March 2009, with roll-out in Melbourne to start in mid-2009. The remainder of regional areas will follow in early 2010.

As part of the program, participating workers fill out a questionnaire about lifestyle, personal and family medical history, followed by a one-on-one session with a trained health professional to assess health risk through waist circumference, blood pressure, blood cholesterol, diabetes score and blood glucose.

Employers with an annual remuneration of less than $10 million will be fully reimbursed the cost of health checks, meaning they are free, whilst those employers with annual remuneration greater than $10 million will be required to pay a $30 contribution per worker. Some organisations in regional areas will be eligible for a grant for health and wellbeing activities.
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Town planning and building design

The built environment plays an important role in influencing participation in physical activity. Australian research published in 2009 examined whether urban sprawl in Sydney was associated with overweight/obesity and levels of physical activity.[113] The authors used a cross-sectional multilevel study design to relate urban sprawl (based on population density) measured at an area level to overweight/obesity and levels of physical activity measured at an individual level, controlling for individual and area level covariates in metropolitan Sydney. Information was available on 7290 respondents using data from the 2002 and 2003 New South Wales Population Health Survey. The study found that living in more sprawling suburbs increases the risk of overweight/obesity and inadequate physical activity, despite the relatively low levels of urban sprawl in metropolitan Sydney. For an inter-quartile increase in sprawl, the odds of being overweight were 1.26 (95% CI=1.10–1.44), the odds of being obese were 1.47 (95% CI=1.24–1.75), the odds of inadequate physical activity were 1.38 (95% CI=1.21–1.57), and the odds of not spending any time walking during the past week were 1.58 (95% CI=1.28–1.93). The authors concluded that modifications to the urban environment to increase physical activity may be worthwhile.[113]

Active environments

A review of active transportation (walking, cycling and public transport) and obesity rates in Europe, North America and Australia between 1994 and 2006 was published in 2008.[114] Countries with the highest levels of active transportation generally had the lowest obesity rates. Europeans walked more than United States residents (382km versus 140km per person per year) and bicycled further (188km versus 40km per person per year) in 2000. Walking and bicycling were far more common in European countries than in the United States, Australia and Canada. Active transportation was found to be inversely related to obesity in these countries. While the results do not prove causality, they suggest that active transportation could be one of the factors explaining international differences in obesity rates.[114]

Recent declines in children’s active commuting (walking or cycling) to school has become an important public health issue. Recent programs have promoted the positive effects of active commuting on physical activity and overweight. However, the evidence supporting such interventions among schoolchildren has not been previously evaluated. A systematic review of the association between active commuting to school and outcomes of physical activity, weight and obesity in children was published in 2008.[115] The review identified 32 studies assessing the association between active commuting to school and physical activity or weight in children. Most studies that assessed physical activity outcomes found a positive association between active commuting and overall physical activity levels. However, almost all studies were cross-sectional in design and did not indicate whether active commuting leads to increased physical activity or whether active children are simply more likely to walk. Only three of 18 studies examining weight found consistent results, suggesting that there might be no association between active commuting and reduced weight or BMI. The authors concluded that although there are consistent findings from cross-sectional studies associating active commuting with increased total physical activity, interventional studies are needed to help determine causation.[115]

A review of interventions, policies and research on physical activity and food environments published in 2009 concluded that numerous cross-sectional studies have consistently demonstrated that some attributes of built and food environments are associated with physical activity, healthful eating and obesity.[116] Residents of walkable neighbourhoods who have good access to recreation facilities are more likely to be physically active and less likely to be overweight or obese. Residents of communities with ready access to healthy foods also tend to have healthier diets. Disparities in environments and policies that disadvantage low-income communities and racial minorities have been documented as well. Evidence from multilevel studies, prospective research and quasi-experimental evaluations of environmental changes are just beginning to emerge.

The authors recommend environmental, policy and multilevel strategies to improve diet, physical activity and obesity control, based on a rapidly growing body of research and the collective wisdom of leading expert organisations. They also conclude that a public health imperative to identify and implement solutions to the obesity epidemic warrants the use of the most promising strategies while continuing to build the evidence base.[116]
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Walking and physical activity

Australian research published in 2009 examined population trends in lifestyle walking in New South Wales between 1998 and 2006.[117] Telephone surveys were conducted in 1998 and annually from 2002 to 2006. The weighted and standardised prevalence estimates of any walking (AW) for exercise, recreation or travel (greater than or equal to 10 minutes per week) and of regular walking (RW; greater than or equal to 150 minutes per week over greater than or equal to five occasions) in population sub-groups were determined for each year. Adjusted annual change was calculated using multiple regression analyses.

The study found that the prevalence of AW was high in 1998 (80.0%), increasing to 83.5% in 2006. The prevalence of RW was stable at around 29% between 1998 and 2003, gradually increasing between 2004 (32.9%) and 2006 (36.5%). The annual increases differed in magnitude but were significant for all population sub-groups including 75 years and older, the obese, people living in remote locations and those in the most disadvantaged SES quintile. Socioeconomic differential in RW was no longer significant in 2006.

The authors concluded that over time, everyday walking has the potential to reduce health inequalities due to inactivity. Public health efforts to promote active living and address obesity, as well as a rise in petrol prices, might have contributed to this trend.[117]

A systematic review published in 2009 examining the effectiveness of walking in relation to prevention of cardiovascular disease in men and women found that generally there were dose-dependent reductions in cardiovascular disease risk with higher walking duration, distance, energy expenditure and pace.[118]

The need to increase physical activity in all aspects of daily life

Increasing participation in leisure-time physical activity has been central to strategies aimed at preventing major chronic diseases (type 2 diabetes, cardiovascular disease, breast and colon cancer) and obesity in developed and developing nations.[119, 120] The main focus of a wide range of strategies (from clinical practice to community programs and mass-media campaigns) has been encouraging and supporting individuals to be more active, largely during discretionary or leisure time. However, for most people, discretionary, leisure-time activity accounts for a small proportion of overall activity levels. Significant improvements in the physical inactivity of the population have therefore not been achieved using this focus.[121] The promotion of active commuting (using public transport, walking and cycling) must therefore feature more prominently in approaches from public health and other sectors such as urban planning and transport.

Sedentary behaviour

Lifestyle intervention programs encompassing exercise and healthy diets are an option for the treatment and management of obesity and type 2 diabetes, and have long been known to exert beneficial effects on whole-body metabolism, in particular leading to enhanced insulin-sensitivity. Obesity is associated with increased risk of several illnesses and premature mortality. However, physical inactivity is itself associated with a number of similar risks, independent of BMI, and is an independent risk factor for more than 25 chronic diseases, including type 2 diabetes and cardiovascular disease.[122]

In the context of chronic disease prevention, the impacts on health of too much sitting need to be considered, in addition to the well-established preventative health concerns about too little exercise. A recent body of work has identified sedentary behaviour (time spent sitting at work, at home and in various modes of transport) as a novel and potentially important risk factor for the development of chronic disease. Changes in transport, occupations, domestic tasks and leisure activities have had negative effects on daily energy expenditure. Sedentary behaviours represent those behaviours for which energy expenditure is low, including prolonged sitting time in transport, at work, at home and in leisure time.[123, 124]

A body of new evidence identifies the time that adults spend sitting as being an important ingredient of the physical activity and health equation.[123] Findings from the national AusDiab study[123, 125] have shown television viewing time – which may reflect some people’s broader dispositions to spending a large amount of time sitting[126] – to be significantly related to metabolic health. Prolonged television viewing time (particularly more than four hours a day) has been shown to be associated with greater waist circumference, higher blood sugar levels, higher blood fat levels and greater risk of metabolic syndrome. These detrimental associations of television viewing time with metabolic health were observed even in adults who met the criteria for the National
Physical Activity Guidelines.[127]
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AusDiab findings also show that the average person spends more than half of their waking hours (~9 hours) in sedentary behaviours – primarily prolonged sitting. The remainder of the day is spent in light-intensity activities, with only 4–5% of the day spent in moderate-to-vigorous intensity physical activity.[124, 128] Importantly, participation in light-intensity activities (which can include housework, standing and moving about in office environments, or shopping) has been shown to be beneficially associated with blood sugars and waist circumference.[123, 128] Additionally, those who interrupted their sedentary time more frequently (for example, got up to get a drink, stood up to answer the phone) had a better health profile than those whose sitting time was mostly uninterrupted.[128]

While further evidence from prospective studies and controlled trials is required, both national and international evidence strongly suggest that we may be sitting our way to poor health.[123] In order to address the high volumes of prolonged sitting time that now characterise the typical lifestyles of Australian adults and children, specific recommendations on reducing, and breaking up, sedentary time should be considered.

¹⁷See www.sportpanel.org.au/internet/sportpanel/publishing.nsf/Content/home.
¹⁸See www.infrastructure.gov.au/local/cip/index.aspx; www.deewr.gov.au/Employment/Documents/Jobs%20Fund%20Guidelines%20APPROVED%20FINAL%20_2_.pdf?utm_source=MailingList&utm_medium=email&utm_content=Cycling+Promotion+Fund+Information+Bulletin+-+Government+announces+details+of+%2440m+Cycle+Path+Fund.

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