The role of obesity, physical inactivity, and poor diet in the development of cancer and other chronic diseases has led to the development of policy frameworks aimed at reducing their impact.
The World Health Organization (WHO) published a Global Action Plan for the Prevention and Control of Non-communicable Diseases in 2013, aimed at reducing the burden of Non-communicable Diseases by 2025 through action on nine targets (including halting the rise in obesity) measured by 25 indicators of performance. Recently, the recommended interventions were updated to take into consideration new cost-effectiveness evidence. The WHO has stated that all signatory countries need to set national Non-communicable Disease targets; develop and implement policies to attain them; and establish a monitoring framework to track progress.
The World Cancer Research Fund (WCRF) International has developed a food policy package for healthy diets and the prevention of obesity and diet-related Non-communicable Diseases, known as the NOURISHING framework. The NOURISHING Framework brings together 10 policy areas across three domains of food environments, food systems and behaviour change communications. The framework is based on the principle that food policies to prevent obesity and improve food intake should aim to improve dietary behaviours by improving the availability, affordability and acceptability of healthy diets, while decreasing the availability, affordability and acceptability of unhealthy diets. Importantly, NOURISHING provides global level recommendations, within which policy-makers have the flexibility to select specific policy options that are appropriate for their national/local contexts and target populations.
The WCRF has published the following recommendations relating to nutrition, physical activity and cancer prevention:
- Be a healthy weight - Keep your weight as low as you can within the healthy range
- Move more - Be physically active for at least 30 minutes every day and sit less
- Avoid high-calorie foods and drinks - Limit high-calorie foods and avoid sugary drinks
- Enjoy more grains, vegetables, fruit & beans - Eat a wide variety of wholegrains, vegetables, fruit and pulses such as beans
- Limit red meat and avoid processed meat - Eat no more than 500g (cooked weight) a week of red meat. Eat little, if any, processed meat.
- Eat less salt - Limit your intake to less than 6g a day
- For cancer prevention, don’t drink alcohol - If you do, limit alcoholic drinks and follow national guidelines (see National Cancer Control Policy - Alcohol and cancer for further information).
The International Agency for Research on Cancer has published the European Code against Cancer which also made recommendations to reduce cancer risk:
- Take action to be a healthy body weight.
- Have a healthy diet:
- Eat plenty of whole grains, pulses, vegetables and fruits.
- Limit high-calorie foods (foods high in sugar or fat) and avoid sugary drinks.
- Avoid processed meat; limit red meat and foods high in salt.
- If you drink alcohol of any type, limit your intake. Not drinking alcohol is better for cancer prevention.
Guidelines developed by the Australian Government outline recommendations for a healthy weight as well as healthy eating and physical activity to reduce the risk of diet and lifestyle-related diseases. In general, these recommendations are consistent with recommendations to reduce cancer risk and are endorsed by Cancer Council Australia.
The Australian Dietary Guidelines provide evidence-based recommendations on types and amounts of foods, food groups and dietary patterns to promote health and reduce the risk of chronic disease. The guidelines include specific dietary advice for pregnant and breastfeeding women, infants, children and adolescents, adults and older Australians. These guidelines recommend healthy eating patterns that are consistent with cancer prevention and should be the foundation of all food and nutrition policy and regulation in Australia.
Australia’s Physical Activity and Sedentary Behaviour Guidelines for children, young people, adults and older Australians provide evidence-based recommendations on minimum levels of physical activity required to gain a health benefit, as well how to minimise sedentary behaviour to reduce the risk of chronic disease and obesity.
The Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children in Australia provide evidence-based guidelines to clinicians regarding the management of individuals who have a body mass index greater than 25. In addition, the Australian Government has developed a National Healthy Weight Guide for Australians, designed to provide advice on how to achieve and maintain a healthy weight.
Current policy environment in Australia
The Australian Government has identified programs, including the Healthy Food Partnership and the Health Star Rating system, as part of a broader national nutrition framework. However, there is currently no national food and nutrition plan. The Australian Prevention Partnership Centre’s report on tackling obesity identified this as an area where Australia is significantly lagging behind other countries and is a priority area for action.
In 2015, the Government launched the Healthy Food Partnership which focuses on improving the dietary habits of Australians by making healthier food choices easier and more accessible and by raising awareness of better food choices and portion sizes. This program aims to provide a non-regulatory platform for collective, voluntary action between Government, the public health sector and the food industry, and includes three main themes, (i) reformulation, (ii) portion control, and (iii) communication, education and meal planning.
As part of this program, the Government will work with the food industry to reformulate their products in order to reduce the content of saturated fat, added sugars and sodium, and increase the content of agreed beneficial dietary components (fruit, vegetables, and fibre/wholegrains) in processed foods. Five working groups have been established as part of the Healthy Food Partnership, including one for each of the three themes outlined above, as well as one for food service, and another focused on strategy and evaluation of program effectiveness. The Healthy Food Partnership replaced the Food and Health Dialogue, which has been criticised for its limited success in achieving significant food reformulation.
In 2014, the Health Star Rating system was implemented on a voluntary basis by the Australian food industry. The Health Star Rating is a front-of-pack labelling system that rates the overall nutritional profile of packaged food and assigns it a rating from ½ a star to 5 stars; more stars indicate a healthier choice within a given food category. The system was developed and funded by the Australian and state and territory Governments in collaboration with the food industry, public health and consumer groups. The system aims to provide consumers with a quick, easy, standardised way to compare similar packaged foods. Front-of-pack labelling has been identified as an area where Australia is meeting global best practice benchmarks. However, key stakeholders including Cancer Council Australia, have identified a number of issues to be addressed to further refine and improve the system.
Nutrition content and health claims on food labels
Nutrition content and health claims are used by the food industry to market the addition of nutrients to foods or highlight certain health benefits or other nutritional characteristics of foods. In Australia, the use of these claims is regulated under the Australia New Zealand Food Standards Code. Nutrition content claims are claims about the presence or absence of a nutrient, e.g. ‘contains calcium’. Health claims refer to a relationship between a food and health rather than a statement of content. There are two types of health claims: general level health claims, e.g. ‘contains calcium for strong bones’; and, high level health claims refer to a serious disease or biomarker, e.g. ‘contains calcium to prevent osteoporosis’.
Television food marketing in Australia operates under a system of co-regulation. The Australian Communications and Media Authority is responsible for the Children’s Television Standards 2009. These standards include limited regulations on certain types of advertising to children.
The Advertising Standards Bureau administers the industry codes of practice, developed by Free TV Australia, the Australian Food and Grocery Council and the Australian Association of National Advertisers. These are very general in scope and limited in application.
Two further self-regulatory codes were developed in 2009 by the food industry to address concerns about food marketing to children. These are the Responsible Children’s Marketing Initiative (RCMI), established by the Australian Food and Grocery Council, and the Australian Quick Service Restaurant Industry Initiative (QSRI) for Responsible Advertising and Marketing to Children, established by the ‘fast food’ restaurant industry. A total of 18 food and grocery companies and seven fast food companies are signatories to the RCMI and QSRI, respectively. The codes of practice add very little to statutory regulations. The Australian Prevention Partnership Centre’s report on comparing Australia’s progress in tackling obesity with global best practice has identified regulations to reduce exposure of children to marketing of unhealthy food as an area where Australia is significantly lagging behind, and flagging this as a priority area for action.
For further information see Position Statement: Food marketing to children
It is well recognised that many of the factors influencing physical activity do not typically sit within the scope of the health sector. Any effective strategy for increasing population physical activity levels will require a national plan focused on promoting physical activity through a variety of areas, including active transport, urban planning, and sport and recreation. Australia is one of the countries that does not have a plan to promote physical activity to prevent non-communicable diseases as reported in a 2015 Global Observatory for Physical Activity review.
A National Sport Plan, is in development and, focuses on using sport to reduce the burden of chronic diseases in Australia with limited focus on physical activity. The National Physical Activity Consensus Forum in 2015 produced the ‘Canberra Communiqué’ which sets out nine action areas and a comprehensive set of policy initiatives to underpin a National Physical Activity Action Plan. A comprehensive national strategy to address physical activity is a priority area for action.
Current Federal Government policy initiatives are focused primarily on encouraging increased participation of children and young people in sports and other physical activities. For example, the ‘Girls make your move’ campaign which supports girls aged 12-19 to be more active and the ‘Sporting Schools Program’ which provides funding to schools to deliver sporting activities for students.
State and territory initiatives
A range of strategies have been undertaken by state and territory governments to address overweight and obesity, physical inactivity, and poor diet.
Recent examples include the ‘Get healthy information and coaching service’ as part of the Healthy Eating Active Living (HEAL) Strategy in NSW. In Western Australia, the ‘LiveLighter’ campaign began in 2012 to help address rising rates of overweight and obesity in adults. In 2014, this successful campaign was extended to Victoria, the Northern Territory and the Australian Capital Territory. Tasmania commenced LiveLighter in 2017.
A recent study has assessed the extent to which Australian states and territories are implementing globally recommended policies for improving population nutrition and creating healthier food environments. States and territories varied in their level of implementation of recommended policies, however, some were recognised as meeting global best practice benchmarks. These included:
- menu labelling regulations in fast food outlets in the Australian Capital Territory, New South Wales, Queensland and South Australia
- support and training systems to help schools and organisations to provide healthy foods in Victoria
- independent statutory health promotion agencies in Victoria and Western Australia
- mechanisms to incorporate population health considerations into all policy development processes in South Australia.
- World Health Organization. Global Action Plan for the Prevention and Control of NCDs 2013-2020. Geneva: WHO; 2013 Available from: http://www.who.int/iris/bitstream/10665/94384/1/9789241506236_eng.pdf?ua=1.
- World Health Organization. 'Best Buys' and Other Recommended Interventions for the Prevention and Control of Noncommunicable Diseases - Updated (2017) appendix 3 of the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020. Geneva, Switzerland: World Health Organization; 2017 Available from: http://www.who.int/ncds/prevention/be-healthy-be-mobile/WHO_Appendix_BestBuys_Rev1.pdf?ua=1.
- Hawkes C, Jewell J, Allen K. A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework. Obes Rev 2013 Nov;14 Suppl 2:159-68 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24103073.
- World Cancer Research Fund. Cancer Prevention Recommendations. [homepage on the internet] London, UK: World Cancer Research Fund; 2018 Available from: https://www.wcrf-uk.org/uk/preventing-cancer/cancer-prevention-recommendations.
- International Agency for Research on Cancer. European Code Against Cancer. [homepage on the internet] Lyon, France: International Agency for Research on Cancer; 2019 Feb 19 Available from: https://cancer-code-europe.iarc.fr/index.php/en/.
- National Health and Medical Research Council. Australian dietary guidelines. Canberra: NHMRC; 2013 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/publications/n55_australian_dietary_guidelines1.pdf.
- Department of Health. Australia's Physical Activity and Sedentary Behaviour Guidelines. [homepage on the internet] Canberra, Australia: Department of Health; 2014 [updated 2017]. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pubhlth-strateg-phys-act-guidelines.
- National Health and Medical Research Council. Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: NHMRC; 2013 Available from: http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57_obesity_guidelines_130531.pdf.
- Department of Health. Healthy Weight Guide. [homepage on the internet] Canberra, Australia: Department of Health; 2013 Available from: http://healthyweight.health.gov.au.
- Department of Health. Healthy Food Partnership. [homepage on the internet] Canberra, Australia: Department of Health; 2016 Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/Healthy-Food-Partnership-Home.
- Australian Government. Health Star Rating. [homepage on the internet] Canberra, Australia: Australian Government; 2014 Available from: http://healthstarrating.gov.au/internet/healthstarrating/publishing.nsf/content/home.
- Global Obesity Centre and The Australian Prevention Partnership Centre. Food Policy Index. [homepage on the internet] Global Obesity Centre and The Australian Prevention Partnership Centre; 2017 Available from: http://www.opc.org.au/what-we-do/food-policy-index.
- Jones A, Magnusson R, Swinburn B, Webster J, Wood A, Sacks G, et al. Designing a Healthy Food Partnership: lessons from the Australian Food and Health Dialogue. BMC Public Health 2016 Jul 27;16:651 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/27465746.
- Food Standards Australia New Zealand. Attachment 10 - Final Assessment Report for Proposal P293 - Nutrition, Health & Related Claims. Canberra, Australia: Food Standards Australia New Zealand; 2008 Available from: http://www.foodstandards.gov.au/code/proposals/Documents/P293%20Health%20Claims%20FAR%20Attach%2010%20FINAL.doc.
- Food Standards Australia New Zealand. Australia New Zealand Food Standards Code – Standard 1.2.7 – Nutrition, health and related claims. [homepage on the internet] Canberra, Australia: Australian Government; 2016 Available from: https://www.legislation.gov.au/Details/F2016C00161.
- Australian Communications and Media Authority. Children's television standards 2009. [homepage on the internet] Canberra, Australia: Australian Communications and Media Authority; 2014 Available from: https://www.acma.gov.au/Industry/Broadcast/Television/Childrens-TV/previous-childrens-television-standards-2009-childrens-tv-i-acma.
- Australian Food & Grocery Council. Advertising to children. [homepage on the internet] Canberra, Australia: Australian Food & Grocery Council; 2014 Available from: https://www.afgc.org.au/our-expertise/health-nutrition-and-scientific-affairs/advertising-to-children/.
- Australian Food and Grocery Council. 2014 Annual compliance report for the RCMI and QSRI. Canberra, Australia: Australian Food & Grocery Council; 2015 Available from: https://www.smh.com.au/cqstatic/gjcb5q/2014-RCMI-QSRI-Annual-Compliance-Report2.pdf.
- Global Observatory for Physical Activity. Country Cards. [homepage on the internet] USA and Brazil: Global Observatory for Physical Activity; 2012 Available from: http://www.globalphysicalactivityobservatory.com/country-cards/.
- Heart Foundation. Move more, sit less. Sydney, Australia: Heart Foundation; 2015 Available from: https://www.heartfoundation.org.au/images/uploads/main/Events/COR-210.v2_Canberra_communique-4_web.pdf.
- Department of Health. Girls Make Your Move. [homepage on the internet] Canberra, Australia: Department of Health; 2016 Available from: https://campaigns.health.gov.au/girlsmove.
- Australian Sports Commission. Sporting Schools. [homepage on the internet] Canberra, Australia: Australian Sports Commission; 2016 [cited 2018 Mar]. Available from: https://sportingschools.gov.au/.
- NSW Health. NSW Health Eating and Active Living Strategy: Preventing overweight and obesity in New South Wales 2013-2018. Sydney, Australia: NSW Health; 2013 [cited 2018 Mar] Available from: http://www.health.nsw.gov.au/heal/Publications/nsw-healthy-eating-strategy.pdf.
- LiveLighter. LiveLighter Campaign History. [homepage on the internet] Perth, Australia: LiveLighter; 2012 [cited 2018 Mar]. Available from: https://livelighter.com.au/About/History.