Effective interventions

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Effective interventions


The comprehensive obesity control strategy recommended by the National Preventative Health Taskforce in 2009[1] was based on the best available evidence for effective public health measures to address obesity. This chapter focuses on some of the key evidence-based interventions for the prevention of overweight and obesity recommended by the Taskforce.

A comprehensive, multi-sectoral approach

The health behaviours which contribute to overweight and obesity are underpinned by a complex range of social, economic, educational and environmental factors[1][2][3][4]. The evidence has demonstrated that strategies targeting individual behaviours relating to diet, energy intake and physical activity without changing the many determinants of these behaviours have not achieved significant or sustained outcomes[1][2][3][4].

As such, interventions addressing overweight and obesity, physical inactivity, and poor nutrition require an approach that is broad in scope and integrated with an overarching strategy. Central to this approach is the need to change a range of environmental elements to support individuals to make healthier choices. This approach requires action from all levels of society, including individuals and families, industry, schools, workplaces, communities, and health and other professionals, with a steering role for governments[1].

Consequently the National Preventative Health Taskforce has recommended a long-term, comprehensive and integrated multi-sectoral approach to improving physical activity levels and nutrition aimed at reducing overweight and obesity at the population level in Australia[1].

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Public education

Public education campaigns utilise commercial marketing principles and mass media to distribute and promote public health messages. Increasingly, social marketing has been used as a public education strategy. The value of social marketing as a public education tool – as seen in tobacco control – is in its role in influencing attitudes and shifting cultural norms with regard to health behaviours. The National Preventative Health Taskforce in 2009[1] has highlighted public education using social marketing as a key action area for improving healthy eating and physical activity.

Evidence increasingly shows that well designed and executed social marketing campaigns on health issues can be effective in changing health knowledge, beliefs, attitudes and behaviours across large populations[5][6][7]. While the bulk of current evidence relates to tobacco control, social marketing interventions have also been shown to be effective in increasing physical activity and improving nutrition[7][8][9][10]. Limited evidence has demonstrated some success of social marketing interventions in targeting rising rates of obesity in regional Australia[11].

In a public health setting, public education mass media campaigns are often supported by complementary messaging through other channels including healthcare providers and community programs[12]. This allows for integrated universal and targeted approaches, such that approaches such as social marketing are supplemented and supported by local level initiatives tailored to the needs of specific communities.

The effectiveness of social marketing interventions is improved when they are one component of a comprehensive approach targeting population health behaviours; outcomes of these interventions are generally better when they are supported by complementary policies and programs to support behavioural change and competing marketing messages are restricted[7]. See below for more information on restricting competing health messages through marketing to children.

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Settings based interventions

Structured settings in which individuals spend large amounts of their time have the capacity to heavily influence health behaviours. Further, such settings provide an opportunity for public health interventions to target specific populations[1]. Settings based interventions targeting schools, workplaces and communities have demonstrated some success with regard to improving rates of overweight and obesity, levels of physical activity, and nutrition.

Schools, childcare and out of school hours care

Childhood is an important time during which children develop the knowledge, behaviours and skills which can influence their health throughout their lives. Consequently, schools, and increasingly childcare and out-of-school-hours care services, are an important setting for health promotion which can influence both children and their families[1].

Evidence suggests that school-based approaches targeting overweight and obesity, physical inactivity and poor nutrition are most effective when a whole-of-school approach is taken[13][14][15]. This approach involves the integration of supportive school policies (e.g. healthy canteens, walk to school days), curriculum (e.g. nutrition and physical education) and environment (e.g. availability of recreational space), supported by contact with families.

In Australia, school based programs have shown some success in slowing the rise of obesity levels. The Eat Well Be Active project comprising canteen menu changes and healthy breakfast days in schools, walk to school programs, and improved access to sports equipment and coaching resulted in significantly lower increases in body weight amongst children exposed to the program[11].

There is little published evidence relating to childcare and out of school hours care, but the available evidence indicates that programs involving parents are the most effective[15].

Workplaces

Workplace health promotion presents enormous potential to access large numbers of people and to improve the health and productivity of the workforce.

There is strong evidence that workplace interventions targeting overweight and obesity, physical inactivity and poor nutrition are effective. Settings based interventions implemented through the workplace have demonstrated modest improvements in physical activity and nutrition, reduction in weight and other chronic disease risk factors, and reductions in medical and absenteeism costs in the workplace[16][17][18][19].

Effective workplace based strategies include the use of prompts to increase stair use, improved opportunities for physical activity, providing healthy food and beverages, education, and the involvement of employees in program development and implementation[17][18].

Communities

Community-wide interventions have demonstrated some effectiveness in improving physical activity and nutrition, and slowing the increase of obesity rates. However, a recent review of 25 studies of community based interventions designed to increase physical activity levels found research in this area generally of poor quality and yielding inconsistent results[20].

Internationally, a number of community based nutrition and lifestyle interventions have shown success in stabilising obesity rates and decreasing chronic disease mortality, including cancer mortality[11][21][22]. Typically, these interventions integrate multiple strategies, utilising a number of community channels including health care professionals, food retailers, and voluntary organisations, together with the media[21][22].

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The physical environment

A range of components of the physical environment have been shown to have a significant impact on the physical activity levels and obesity rates of individuals and communities[1][2][23].

The body of evidence suggests that 'walkable' environments are associated with decreased obesity and higher levels of physical activity[24][25][26]. Key characteristics of a walkable environment include mixed land use, higher residential density, street connectivity and design, availability of footpaths, attractive surrounds and perceptions that the environment is safe[1][3][27][28]. One study found that each kilometre walked per day was associated with a 4.8% decrease in the risk of obesity[24].

Physical environments designed to facilitate active transport such as cycling, walking and public transport are associated with increased physical activity[26][28]. Infrastructure enabling active transport between residential, commercial and business areas, and access to recreational facilities and sporting infrastructure are key components of such environments[26][28]. An Australian study found that individuals who drove to work were less likely to achieve recommended levels of physical activity and were 13% more likely to be overweight or obese than non-car users[29].

There is some evidence that the physical environment can influence diet - improved access to healthy foods may increase their consumption[28]. There is a body of evidence from the US to suggest that neighbourhoods with better access to supermarkets and fewer fast food outlets tend to have healthier diets and lower levels of obesity[3][30][31]. However, evidence of a link between proximity to fast food restaurants, and diet and obesity, from outside the US is mixed[3].

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National Food and Nutrition Framework

To support healthier and less energy dense diets, and a safe and sustainable food supply, the National Preventative Health Taskforce recommended the implementation of a National Food and Nutrition Framework[1]. The Framework is designed to drive change in food policy to ensure that all Australians have access to affordable, healthy, fresh and good quality foods, with a focus on disadvantaged groups, and rural and remote communities[1].

The Australian Government is currently developing a National Food Plan to provide an overarching approach to food policy. The scope of the plan includes food safety and security, health and nutrition, supporting a competitive, productive and efficient food industry, trade opportunities, and sustainability[32]. An appropriate emphasis on public health and nutrition is important in the development of this plan.

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Food labelling

Front-of-pack nutrition information has the potential to improve dietary behaviours by assisting consumers to identify healthier food choices at the point of sale[1][33]. There is evidence that front-of-pack food labelling may provide incentive for the food industry to increase the availability of healthier products through product reformulation and innovation[1][33].

A number of front-of-pack labelling formats are in use globally, with different levels of effectiveness. Systems with an interpretive element to indicate the healthiness of a product generally perform better in assisting consumers to identify healthier foods[34][35][36][37]. The evidence suggests that the traffic light system is most effective at conveying clear health information to consumers[34][35][36][38][39]. Traffic light labelling ranks a product's total fat, saturated fat, sugar and salt/sodium levels as high (red), medium (amber) or low (green). The 2011 report of the review of food labelling law and policy in Australia recommended the voluntary introduction of multiple traffic light labelling on processed foods and on menus at chain food outlets[40].

The voluntary percentage daily intake guide introduced in 2006 by the Australian Food and Grocery Council lacks an interpretive element. This system displays the percentage of recommended daily requirements of the major nutrients in food products. Evidence suggests that monochrome systems such as the percentage daily intake guide can be difficult for consumers to interpret, particularly for disadvantaged groups where obesity is more prevalent, and perform less well in assisting consumers to correctly identify healthier food products[34][35][36][37].

For more information, see Position statement: Front-of-pack food labelling.

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Health claims

Several studies have demonstrated that health claims on food products influence consumers' perceptions of the healthiness of the product and their willingness to buy that product. Health claims are often misinterpreted, and can lead to an increased perception of healthiness and willingness to buy[41][42][43].

Recent evidence suggests that foods making specific health claims often do not satisfy the criteria of nutrient profiling models to identify healthy food products. Total fat, saturated fatty acid, sugar and/or sodium levels of products making health claims are often too high to be considered healthy[44].

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Food marketing to children

Children in Australia are exposed to a high volume of unhealthy food advertisements on television and through non-broadcast media. Between 54% and 82% of food advertising during television programs popular with children are for unhealthy foods and beverages high in fat, salt and sugar[45][46][47].

Substantial exposure also occurs through the internet[48][49][50], children’s magazines[51][52] and packaging promotions[48][53][54].

Restricting unhealthy food marketing to children is a key area for action in obesity prevention[1][55]. Evidence indicates that food marketing to children generates positive beliefs about the advertised products, and influences food preferences, purchasing requests and consumption, as well as dietary habits and health statuses[56][57][58]. Further, the high level of unhealthy food advertising may limit the effectiveness of social marketing campaigns for healthy foods and lifestyles[7].

Current food marketing regulations are limited, and only apply to specific children’s programming on television[59]. The highest numbers of children watch commercial television between 6pm and 9pm when the regulations do not apply[60]. Self-regulatory codes are in place, but their effectiveness is limited as they are typically voluntary, permissive, and poorly monitored and enforced[61][62][63].

For more information, see Position statement - Food Marketing to children

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Food reformulation

Many processed foods are high in salt, sugar, fat and energy and low in overall nutritional quality. Improving the nutritional quality of the food supply through product reformulation and innovation has enormous potential for improving population nutrition and health[3]. Reducing portion sizes of processed foods, which have increased substantially in recent years, also has the potential to decrease energy intake as evidence indicates that people tend to consume more kilojoules when they are presented with larger portions of food and beverages[3].

Internationally, there has been some success with food reformulation having a positive health impact on reducing negative nutrients such as salt. In Mauritius, a government led change which saw soybean oil replace palm oil as the main cooking oil led to a pronounced reduction in population cholesterol levels, despite an increase in obesity[64]. In the UK, a government-industry partnership to reduce salt levels in processed foods, together with a public awareness campaign saw a 10% reduction in average daily salt consumption[65].

In Australia, food reformulation has been shown to be a cost-effective preventive health measure. An evaluation of 123 Australian preventive health interventions found that limiting the salt content of three basic foods (bread, cereals and margarine) on a mandatory basis, would have a large impact on population health. This intervention was shown to not only be cost-effective, but cost saving[66].

Food reformulation in Australia is driven by the Food and Health Dialogue, established in 2009 to enable government, industry and public health groups to work collaboratively on the issue. Under the program voluntary targets have been set for reducing salt and saturated fat levels in a range of foods. At this stage, targets have not been set by the Food and Health Dialogue for reducing energy content (kilojoules), but the food industry have indicated that reducing energy content in food products is a component of the Healthier Australia Commitment.

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The role of primary care

Around 86% of Australians visit their GP every year, making primary care an important setting for chronic disease prevention[67]. The Royal Australian College of General Practitioners supports GPs to address overweight and obesity, physical inactivity and poor nutrition with a range of evidence-based guidelines on preventive health and behavioural risk factors[67][68][69]. In addition, the Australian Department of Health and Ageing funds the lifestyle prescriptions program, Lifescripts, which provides evidence-based tools to GPs to help patients address lifestyle risk factors for chronic disease such as alcohol misuse.

While limited evidence suggests brief GP interventions can produce short-term increases in physical activity and small changes in dietary behaviour[70][71][72], programs delivered by multidisciplinary teams may be more effective at maintaining weight loss[1][72][73]. There is evidence that multidisciplinary teams that can comprise nurses, dieticians, exercise physiologists, behavioural therapists and GPs can deliver effective diet and physical activity interventions[73].

The capacity to deliver effective physical activity and dietary intervention programs in Australia will require substantial workforce development, and development of effective funding models for preventive interventions in primary care settings[1]. The Australian Government's national health reform agenda seeks to enhance the role of primary care in preventive health through supporting practice nurses to deliver preventive health programs[74].

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Special groups

Certain population groups have higher rates of obesity and overweight, poor nutrition and physical inactivity and are at higher risk of related chronic disease. In general, these risk factors are more prevalent among Australians in lower socioeconomic groups[75], people living in rural and remote areas[76] and Indigenous Australians[77]. Issues such as affordable access to healthy foods and opportunities to engage in physical activity are likely to be major contributing factors[1]. The development and implementation of specific interventions targeting the social determinants of health in these groups is key to addressing this clustering of risk factors[1].

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Economic interventions

Economic interventions, such as taxation, grants and subsidies can provide incentives and disincentives to help modify health behaviours relating to overweight and obesity, physical activity and nutrition[1].

In Australia, there are a lack of financial incentives and disincentives to support increased physical activity. The fringe benefits tax for private motor vehicle use promotes the use of private cars rather than active transport (such as walking, cycling and public transport), encouraging inactivity[1]. There is potential for subsidisation of recreational activities to improve physical activity levels[1].

Economic interventions targeting nutrition include taxation of unhealthy foods include portion size pricing, and subsidy schemes and rewards for food providers, advertisers and consumers. Currently, there is limited evidence of the effectiveness of food taxes and subsidies in reducing overweight and obesity, and improving nutrition[78][79]. However, the available evidence suggests that taxation and subsidies resulting in non-trivial pricing changes can contribute to healthy consumption patterns, particularly for children and adolescents, and low socio-economic populations[78][79].

The ACE-Prevention report identified a 10% tax on unhealthy foods as an effective and cost-effective preventive health intervention for Australia[66]. Criticisms of this model include concerns that taxing unhealthy foods would disproportionately affect lower income earners who spend a higher proportion of their income on food[1][2].

Further research and careful modelling of the impact of food taxation and subsidy interventions across population groups is required, particularly with reference to sustained behavioural changes, before widespread implementation[1].

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Research, monitoring and evaluation

Overweight and obesity is a relatively new public health issue. The evidence base regarding effective prevention and management interventions is still developing. As such, further research in this field is required to build the evidence to support public health and policy initiatives.

The National Preventative Health Taskforce recommend a 'learning by doing' approach to balance the need for better evidence with the urgency of the obesity problem[1]. This approach involves the integration of program implementation with close monitoring and evaluation, requiring enhanced health risk surveillance at the population level and an expanded preventive health research agenda.

Expanding the evidence for translation and dissemination through integrating and implementing evaluation frameworks at the beginning of dissemination of an intervention will allow the establishment of an evidence base for the efficacy of interventions and of their being scaled up to include more settings and populations[80].


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