Merely two months into the new year and we have already seen a plethora of local and international efforts aimed at curbing what appears to be the inexorable rise of obesity. Some of these initiatives are starting to reset the agenda for the community discussion around obesity.
Within the last week, there have been calls for the US Food and Drug Administration (FDA) to restrict the amount of "caloric sweeteners" in beverages because the scientific consensus is that the level of added sugars in those products is unsafe. And a ten-point action plan, including a 20% tax on soft drinks, to act against obesity before it becomes "unresolvable" has been presented to government bodies by the UK Academy of Medical Royal Colleges.
In Australia, Western Australia's graphic, hard-hitting obesity prevention campaign against "toxic fat" has been launched in Queensland. And the Heart Foundation, Cancer Council Australia and Diabetes Australia launched a new mass media campaign called "Rethink sugary drink" in January.
The latter campaign was borrowed from similar efforts in New York, informing people in a slightly humorous, informative and thoughtful way that many soft drinks or other sugary beverages contain up to "16 packs of sugar in one can of soft drink". The nutritional principle embodied in the tagline is that these are "empty calories", with little nutritional value. And that, in order to maintain "energy levels", other sources of food including complex carbohydrates may be much better than an excess of simple sugars.
To evaluate whether such campaigns are a good idea or a waste of effort, let's consider this last attempt in detail. First, to contextualise the campaign – it fits as part of a complex set of activities in the area of obesity prevention. Obesity is a complex problem with no single solution, and rates have increased dramatically over the last 20 years. It's associated with the increase in chronic (preventable) diseases, but no single program or intervention will rapidly fix the problem.
There's some opposition to current obesity prevention efforts. Some clinicians advocate that public health approaches, such as media campaigns, should be replaced by increased rates of bariatric (stomach banding) surgery, while, at the other end of the spectrum, are some sociologists who claim we are stigmatising obese people, not solving the problem.
Interestingly, both these apparently divergent opinions are similarly focusing on individual people who are overweight or obese. A public health approach to prevention usually takes a broader perspective than that and requires a long-term sequence of "upstream" strategies.
A combination of mass media campaigns, policies and regulations, and restricting smoking environments were responsible for Australia's remarkable successes in tobacco control from 1983. For the more recent issue of obesity prevention, we might need to consider more food regulation and policies that restrict fat content in food; limiting junk-food advertising to children; and creating active commuting and incidental physical activity opportunities in our communities.
All these measures are competing in the political space, with lobbyists from the food industry presenting alternate views to government. A recent paper in the prestigious medical journal, The Lancet, opined that efforts at self-regulation for the food industry have proved ineffective in reducing widespread exposure to unhealthy foods, so we clearly need to do more public health advocacy on this issue.
But implementing health policy is not a linear or logical process. We still live in a food environment characterised by a plethora of vending machines and local stores offering sweetened soft drinks. Add to that fast-food marketing that offers low-cost carbonated beverages and sweetened fruit juices in every suburb.
In terms of energy balance on whole-of-population level, even small contributions, such as the amount contributed by sweetened beverages, could tip total energy intake toward incremental annual weight gain, as opposed to weight maintenance. So, if we replaced sweetened drinks with water, the total number of calories not consumed would be significant enough to make a real contribution to preventing obesity.
Which brings us back to the role of mass media campaigns and social marketing. Two national "Measure Up" and "Swap It, Don't Stop It" obesity prevention campaigns between 2008 and 2012 increased community awareness about the problem of obesity, and identified the potential for making small changes to our lifestyles to prevent weight gain. A logical next step might be an advocacy-focused campaign.
The original "Rethink sugary drink" campaign was introduced by New York's Mayor Michael Bloomberg, and it was accompanied by policies to restrict super-sized sugared beverage sales. The measure was vigorously countered by the beverage industry, which even started litigation against the board of health for restricting their trade.
But as with tobacco companies, when an industry "doth protest too much", it may point to an effective public health policy.
The current campaign re-focuses community thinking away from obese people by using acceptable weight range models to demonstrate the silliness of eating 16 packs of sugar. It's an effective cue to get people thinking about the similar sugar content of soft drinks. And it aims to increase community concern and, in turn, to increase pressure on government to act. It's an antecedent to policy change.
If effective, the advocacy campaign will emphasise the need for sweetened beverage regulation as a necessary public health strategy. Ideally, this would be followed by government responses to provide regulatory limits to the currently untrammelled distribution and marketing of sugary drinks. And that will reduce total energy intake across the population.
The campaign also demonstrates the important independent role of the non-government organisation sector in Australia as the "conscience of the population", which helps catalyse governments into action.
Hopefully, the campaign has sufficient intensity; low-budget campaigns are unlikely to have sufficient reach to influence the community. There's a long way to go, but the net sum of our efforts are making progress in obesity prevention. And this advocacy campaign is an important contributor on the "long and winding road" to improved population health.
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