STEPHEN LEEDER. Two roads converge in a yellow wood

Mar 6, 2018

Two roads converge in a yellow wood when it comes to preventing obesity – blaming the victim (eat less sugar, exercise more, you lazy sloth) and thinking that if we focus on children all will be well.  Follow either and you will end up in the same sulphurous place – lost.

The first road ignores the impact of the environment on individual behaviour.  A Mt Druitt (less privileged area of western Sydney) woman put it to me like this:

“Get real! My partner leaves home at six to drive to work in the centre of Sydney and then I have to get the kids ready for school.  I work in a day care centre and I walk there.  By the time my partner gets home he’s buggered and so am I.

Don’t talk to me about cooking healthy meals – there are no shops selling that stuff within walking distance and anyway it costs a bomb and I don’t have the energy to cook it and yes, so we eat a lot of Maccas and chips.  As for jogging and the rest of exercise thing – nonsense!  Great for people on the North Shore!”

So if we are to address the problem of obesity realistically, let’s begin with reality – with the real behaviour of societies and people in them.  What do we have for the Mt Druitt mother?  Stats that show fat kids grow into fat adults? That they should cut down on sugar? A myriad other messages?

Unless we advocate for social change to enable individual change to occur then problem of obesity will be with us until something explodes.

So much for the first road.  Then we have the second road populated by people who say, “Let’s focus on children.”  This was one of former NSW premier Mike Baird’s captain’s picks, a brave attempt made towards the end of 2016 to identify a dozen or so important things where action might pay off, compared with the hundreds of lesser projects that might be done if one had unlimited magical power.  Baird wanted to tackle and prevent childhood obesity.

The arguments for such an approach are strong.  As Melissa Wake, from Murdoch Children’s Research Institute and the University of Melbourne, writes in an editorial in the British Medical Journal of 7 February this year,

‘The economic and societal gains from achieving [effective childhood obesity reduction] are immense. The consequences of not doing so are potentially catastrophic. But progress is painfully slow. Common sense approaches endorsed by governments worldwide mainly comprise universal, primary and secondary care strategies to motivate, educate, and facilitate lifestyle change. Unfortunately, these have largely failed a generation of children.  Publication of null trials in high impact journals could perhaps help break the cycle of policy makers continuing with ineffective educational preventive approaches that can never hope to greatly impact on the obesity epidemic…In the words of Winston Churchill, “However beautiful the strategy, you should occasionally look at the results.”’

Alas, as the most sophisticated research studies using randomised trials demonstrate, most recently in the same issue of the British Medical Journal as Wakes’ editorial of UK primary schools from the West Midlands, intensive school based programs of increased exercise at school, nutrition education, parental engagement, and getting the local football team involved simply do not work.  This is not an isolated finding.  The better the study the less likely there is to be a benefit.

These results call for a further examination of the social and economic factors that shape powerfully the world we and our children inhabit.

Another aspect is this: although no-one wants to see obese children, the major health problems we have today with obesity occur in fat adults. What will we offer them?  “Educate the parents to make healthier choices for the kids and it will trickle up to the parents”.  Possibly, but this is similar to saying that if you educate the children, adults might stop smoking.  Well, sorry.  We have heard of this trickle-up child labour approach many times in relation to proposed improvements in Indigenous health.

But it is the adults who are most at risk of serious illness from obesity – now -and to do nothing for them and with them (other than beating them up and shouting at them to eat less junk food) makes no sense.  It is also lacking in compassion.

Many pre-diabetic overweight adults (evidence available) can avoid diabetes with 10% reductions in body weight – and that weight loss may be in range of intensive educational effort for some although not all. But once again, we should not deflect our attention from the necessity for environmental change.

As the authors of the  RCT of the childhood obesity program in the UK conclude, such things as access to healthy foods, food pricing as a way of assuring equity, walkability of new residential areas, encouraging reduced serving sizes in all restaurants and takeaway outlets, progressively reducing the colossal and absurd amounts of added sugar and salt in our diet and so forth are an essential backdrop if programs of the sort they implemented and tested are to have a snowflake’s chance of success.

Can we not work to achieve community enlightenment with regard to the fact that the origins of obesity are to be found in the commerce and conduct of food supply, the way we build new suburbs, our transport systems and other social infrastructure?

It is essential to recruit many community advocates to convince politicians to act to require that the food industry do more in the provision of healthy products: less salt, less sugar, smaller portions, and greater availability of fresh food.

The effects of these measures will be health-enhancing for the entire community and the net benefits greater than those achieved by beating up individuals who consume too much fat, salt, sugar and alcohol.  They are straightforward reversals of how we got ourselves into the obesity mess.

It is a matter of community health literacy.  This is well within our grasp. As the late President John Kennedy observed, the problems created by humans can generally be solved by humans – here’s our chance for 2018.

Avoid the yellow wood – sulphurous demons live there.

Stephen Leeder, PHAA Life Member, Emeritus Professor of Public Health and Community Medicine, Menzies Centre for Health Policy and School of Public Health, The University of Sydney


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