Health care interventions
9.1
Health interventions are essential for treating those already living
with obesity. As described by Dr Shirley Alexander, Staff Specialist and Head
of Weight Management Services at The Children's Hospital at Westmead, 'you need
prevention and you need clinical intervention for those that are affected'.[1]
9.2
Prevention programs and early clinical and allied health interventions
to reduce the prevalence of childhood obesity are also important. Indeed, the
World Health Organisation (WHO) pointed out that without intervention, obese
infants and young children will likely continue to be obese during childhood,
adolescence and adulthood.[2]
9.3
Health practitioners play a significant role in identifying, supporting
and treating people who are overweight and obese. However, issues around
access, availability, appropriateness and affordability of treatments are
impeding the delivery of effective health interventions.
Interventions aimed at preventing childhood obesity
9.4
To mitigate the negative influences facing children, many submitters
stressed the importance of prevention programs, early interventions and
providing guidance to parents as obesity is completely preventable in early
life.[3]
9.5
In terms of actions to prevent both childhood obesity itself, as well as
interventions to prevent associated health issues, Dr Alexander cited clinical
and allied health interventions known to be effective:
Interventions using family-centred behavioural change in diet
and activity have been shown to be effective...
We recommend, amongst other things, that all states and
territories provide dedicated training for health professionals as well as
services to clinically manage childhood obesity. At a federal level, we would
recommend a review of Medicare rebates associated with accredited allied health
professional consultations for children with obesity to encourage and enable
greater support in healthcare intervention, including an increased number of
sessions for families of children and adolescents with obesity. [4]
9.6
Professor Anna Peeters from the Global Obesity Centre at Deakin
University (GLOBE) discussed the integrated approach adopted in Amsterdam, and
its success in reducing the prevalence of childhood obesity:
In essence, what they've done in Amsterdam—and they've seen a
three percentage point drop in childhood obesity over the last four years, so
you do need a long time frame—is they've had quite a concentrated effort in
schools around nutrition, activity and standards around the schools, but then
also around the cities—things like removing unhealthy food and drink
advertising from public transport, and sponsorship of sports. So they've done
quite a wide range of things across the city, but they've made really intensive
efforts in schools.[5]
9.7
Ms Alexandra Jones from The George Institute emphasised the need for a
whole‑of‑government approach to addressing the problem, pointing to
the experience in New South Wales:
New South Wales have a Premier's priority on childhood
obesity, and they've recognised that this can't just be the responsibility of
the health ministry. A lot of these policies engage with transport, education
and a whole range of things. So having a task force or a body at a national
level that could coordinate action is absolutely necessary, and we can't just
leave it up to the health department.[6]
9.8
Similarly, the ACT government suggested that, to be effective, a
national framework would need to be coordinated across all levels of government
and across diverse portfolios. It also stressed the importance of considering the
social determinants of health:
ln addition, it is important to consider social determinants
of health as key factors, along with physical activity, active travel,
consideration of the structure of workplaces in terms of work/life balance and
the role urban design plays in creating and maintaining accessible public
spaces and natural environments to support healthy connected communities.[7]
9.9
The Menzies School of Health Research highlighted the importance of a
cohesive strategy to tackle obesity, starting in pregnancy and continuing
throughout a person's life:
First, effective policies are needed across the life span,
from maternal health to infancy, childhood and youth and through to adulthood.
Children are an integral part of families, and their diets are formed and
influenced by family behaviours.[8]
9.10
Professor Steve Allender from GLOBE emphasised the need for
comprehensive data and an evidence base to assess whether specific
interventions are successful:
What we also need to discuss with you is Australia's obesity
evidence base or, in fact, the lack of an evidence base. There is a need for
rigorous monitoring of childhood obesity, using a legislated opt-out consent
approach, to give us meaningful and timely data.[9]
First 1000 days
9.11
There is strong evidence that the first 1000 days of life—from conception
to age two—is a critical period influencing the likelihood of obesity in
infancy, childhood and late in life.[10]
9.12
The focus on maternal and early childhood, running through a person's
life course, was expanded on by Professor Susan Sawyer from the Royal
Children's Hospital in Melbourne. Professor Sawyer discussed the concept of the
first 1000 days of a person's life, and went further to look at it in terms of
the first 1000 weeks:
[T]hat life course perspective tells us that the most
effective interventions are going to be those that take place during what we
would refer to as the developmental years of zero to 24—that is the notion of
the first 1,000 days from preconception—and that it continues through. Many of
us are referring to the importance of the first 1,000 weeks and not just the
first 1,000 days.[11]
9.13
Professor Peter Davies, Chairperson of The Early Life Nutrition
Coalition, explained to the committee that there are five key elements in the
1000 days, which have a profound effect on the chances of a child becoming
overweight and obese:
- high pregnancy body mass index in the mother;
- inappropriate maternal weight gain;
- an increased birth weight;
- rapid growth during infancy; and
- prenatal tobacco exposure.[12]
9.14
A recent study found that infants experiencing rapid weight gain between
birth and two years had nearly four times greater odds of being overweight or
obese later in life.[13]
Preconception and pregnancy risk
factors
9.15
The committee heard that maternal weight prior to and during pregnancy
is important in terms of the future child health outcomes and weight.[14]
9.16
Professor Jacqueline Boyle from the Monash Centre for Health Research
and Implementation explained that maternal obesity affects oocytes, early
embryo development, and a baby's weight.[15]
9.17
Professor Sawyer pointed out that the issue of preconception weight is
relevant for both parents as evidence would suggest that there are also male
epigenetic factors in terms of sperm in relationship to obesity.[16]
9.18
The Boden Institute at the University of Sydney stressed the importance
of monitoring and managing appropriate gestational weight gain as part of
antenatal care.[17]
Early life nutrition
9.19
There is a growing body of evidence linking the nutritional environment
in early life to an increased risk of obesity.[18]
9.20
The Australian Dietary Guidelines (ADG) recommend that children
receive breast milk, and where that is not possible, suitable formula, until 12
months of age. The ADG also state that children do not require formula beyond
12 months of age.[19]
9.21
Professor Sawyer stressed the importance of breastfeeding:
All the evidence is that, long-term, any breastfeeding is
beneficial and protective against overweight and obesity in children.[20]
9.22
However, although 96 per cent of women start breastfeeding, there is a
rapid decline in breastfeeding rates with each month after birth. The
proportion of infants receiving any breastmilk in the age group seven to 12
months drops to 42 per cent.[21]
9.23
Professor Sawyer outlined other factors such as socioeconomic trends in
breastfeeding, which can impact the weight and overall health of both mothers
and children:
[T]he importance of promoting breastfeeding, for example, as
one of those elements that is healthiest for the infant and also healthiest for
the mother in terms of reducing rates of overweight. Yet we know that we see
socioeconomic trends in terms of rates of breastfeeding. [22]
Infant food products
9.24
Research undertaken by the Centre for Research Excellence in the Early
Prevention of Obesity in Childhood (CREEPOC) shows compliance with the infant
feeding guidelines from the ADG is low.[23]
9.25
Indeed, the early introduction of solids and inappropriate infant
formula feeding practices are significantly increasing the likelihood of
obesity in infancy and childhood.[24]
9.26
For example, Professor Elizabeth Denney-Wilson described to the
committee how inappropriate use of formula can lead to overfeeding babies:
Now what we see is people over concentrating infant formula,
which gives babies more calories, in the belief that might help babies to sleep
a bit better.[25]
9.27
Food companies have developed a range of products aimed at young
children, including toddler formula, junior milks and infant foods, which
undermine optimal infant and young child feeding.[26]
9.28
These infant foods are heavily promoted by food companies and often
contain a lot of sugar and unnecessary ingredients.[27]
9.29
CREEPOC pointed out that the use of concentrated juices and trans-fats
in ready to eat foods for infants and young children greatly contribute to poor
diets and obesity in young Australian children.[28]
Recommended initiatives and
programs
9.30
Inquiry participants recommended the development of programs and
campaigns to support, protect and promote breastfeeding for the first year of
life and beyond.[29]
9.31
CREEPOC recommended the development and/or continuation of obesity
prevention programs which provide:
- support to parents using home visiting or parents' groups;
- detailed advice related to nutrition, including the promotion and
support of breastfeeding and appropriate infant feeding, guidance on when to
introduce solids;
- advice on parenting that includes recognition of a child's hunger
and satiety clues; and
-
advice on promoting child sleep and active play.[30]
9.32
The Early Life Nutrition Coalition recommended expanding the Medicare
rebate to include early life nutrition advice during stages of pregnancy and
childhood to equip expectant and new parents with an understanding of the right
type of nutrition needed to benefit the long-term health of their child.[31]
Committee view
9.33
The importance of preventing childhood obesity is paramount to
preventing the onset of chronic disease as people move through their lives. The
health, economic, and social impacts of an unhealthy start in life are endemic
which is why there is so much focus on addressing the problem as early as
possible.
9.34
All submitters and witnesses for the inquiry agreed that childhood
obesity is a complex condition, with multiple factors influencing its
prevalence. With children in particular, almost all of the factors regarding
their diet and lifestyle are external. As Dr Seema Mihrshahi outlined
in Chapter 1, they range from their mother's breastfeeding behaviours, to
access to green space, to how much advertising they are exposed to.
9.35
The need for a comprehensive coordinated response is obvious. Because of
the plethora of factors, many of the actions and interventions to arrest the
trends are currently under the auspices of not only different government
departments, but different governments and different levels of government. Even
in a single state, such as New South Wales, they realised quite quickly that an
intervention went far beyond just the Health Department.
9.36
The committee notes and welcomes the recent communique from the Council
of Australian Governments Health Council on the creation of a national strategy
on obesity, which includes a strong focus on early childhood. The committee
therefore proposes that there should be a subset of the National Obesity
Taskforce created which would be responsible for the development and management
of a National Childhood Obesity Strategy.
Recommendation 15
9.37
The committee recommends that the National Obesity Taskforce, when
established, form a sub-committee directly responsible for the development and
management of a National Childhood Obesity Strategy.
9.38
The focus on a child's first 1000 days is a coherent, multi-pronged and
evidence based intervention strategy. Research by many eminent academic and
clinical research centres has found solid evidence around how low levels of
breast feeding, poor pre-conception and pre-natal health, and the low
nutritional value of some infant foods and formulas, can all contribute to
childhood obesity.
9.39
The committee is therefore of the view that a focus on educating
parents, rigid guidelines regulating infant foods and readily available advice
on a child's activities should all be integral to deliberations of the body
responsible for the development of the National Childhood Obesity Strategy.
Primary care interventions
Role of general practitioners (GPs)
9.40
Over 80 per cent of Australians visit their GP at least once a year and
therefore GPs have a significant role in identifying and supporting patients
who are overweight and obese.[32]
9.41
However, many GPs are not comfortable to raise weight related matters
with their patients. As discussed in Chapter 2, talking about weight can be a
very sensitive issue for medical practitioners.
9.42
Professor Lauren Williams, a Fellow Member of the Dietitians Association
Australia, explained that some GPs may also be hesitant to raise the issue of
weight with their patients because of their own personal circumstances:
Some GPs are reluctant to start the conversation because not
all GPs are in a healthy weight range themselves. I often get patients referred
to me saying, 'I was really surprised when the GP told me, because I'm thinner
than they are.' There's a lot of work that needs to be done.[33]
9.43
The committee also heard that many GPs and clinicians are not equipped
to support their patients because they lack expertise and experience in
treating people who are overweight and obese:
It's a 21st century chronic disorder that many
clinicians haven't had enough education and training and overt experience in.[34]
9.44
Many inquiry participants identified a need for training and recommended
the development of education programs for medical practitioners.[35]
9.45
The Australian Medical Association (AMA) recommended the development of
practical material for GPs so they can support their patients.[36]
Allied health services
9.46
At present, the current Chronic Disease Management (CDM) scheme is for
patients who are referred by GPs and who have a chronic and complex illness.
Under the CDM scheme, patients get five rebated visits per year to see
allied health professionals.
9.47
Obesity alone does not qualify them for that service. Overweight and
obese patients can only access the CDM scheme to see allied health
professionals such as dietitians when there is already a co-morbidity.[37]
Expand access to Chronic Disease Management
scheme
9.48
Nepean Blue Mountains Family Obesity Service argued that patients should
have access to the CDM scheme for obesity alone. This would enable GPs to co‑manage
their patients with appropriate allied health specialists, including
dietitians, clinical psychologists and physiotherapists.[38]
9.49
Similarly, Dr Alexander and Professor Williams are of the view that
obesity needs to be treated as a chronic disease.[39]
9.50
The Council of Presidents of Medical Colleges also recommended
recognising obesity as a chronic disease because this would facilitate access
to early interventions:
This will provide the framework for giving proper
consideration to early and better access to health care services and effective
treatments for people with obesity.[40]
Increase number of visits under CDM
scheme
9.51
The committee heard that the current limit of five visits a year to see
allied health professionals under the CDM scheme is inadequate to meet people's
needs.[41]
9.52
Access to allied health services, especially Accredited Practicing
Dietitians (APDs) to support dietary and physical activity interventions should
be increased.[42]
9.53
Professor Williams stated that 'five visits in a year is not best
practice' for managing an obese patient with a co-morbidity.[43]
9.54
She also pointed out that the five visits are shared across all allied
health professionals, which means that a patient may end up with only one or
two consultations with an APD:
When you've got someone with type 2 diabetes, as dietitian
you are sharing those five visits across a year with a podiatrist usually and
maybe an exercise physiologist.[44]
Surgical interventions
9.55
Bariatric surgery is currently recommended for patients with a Body Mass
Index (BMI) of 35 or more and with at least one obesity related medical
condition, such as fatty liver disease or hypertension, or in patients with a
BMI of 40 with no obesity related medical conditions. Bariatric surgery is also
recommended in patients with a BMI over 30 with Type 2 Diabetes Mellitus which
is poorly controlled with medication.[45]
9.56
All bariatric procedures are designed to reduce appetite and enhance
satiety. Professor Michael Talbot, an Executive Member of the Australian and
New Zealand Metabolic and Obesity Surgery Society (ANZMOSS), explained how the
surgery works:
It basically alters the physiology of appetite, hunger and
eating and changes patients' biological drive to eat so they become
disinterested in food so you switch off the hunger that's been driving them to
eat and then you train them to avoid food triggers that might create their
metabolic or obesity problem again.[46]
Benefits of bariatric surgery
9.57
According to Mr Ahmad Aly, President of ANZMOSS, 'bariatric surgery is
the single most effective treatment modality that exists for obesity, not only
in terms of weight loss but in reversing or improving the obesity related
diseases'.[47]
9.58
ANZMOSS submitted that bariatric surgery saves lives and is the best
therapy for Australians with type-2 diabetes and class I and II obesity.[48]
9.59
The Swedish Obese Subjects study, the longest running longitudinal
cohort study available, has demonstrated that obese patients treated with
bariatric surgery gained a 38 per cent reduction in cancer mortality and a 48
per cent reduction in cardiovascular death compared to the non-surgically
treated cohort.[49]
9.60
ANZMOSS reported that while most non-surgical treatment programs often
result in weight loss, maintenance of weight is virtually never achieved. In
contrast, bariatric surgery results in longer term maintenance of weight loss
in the majority of patients.[50]
9.61
However, some inquiry participants believe that bariatric surgery has a
very high rate of complication and failure.[51] For example, the Butterfly Foundation stated that 'bariatric surgery resulted
in improvements in eating behaviour and body image that were not sustained over
the long-term'.[52]
Access to bariatric surgery
9.62
Mr Aly explained to the committee that there are about 1.5 million
Australians that, on broad criteria, would be eligible for bariatric surgery.
However, only about 23 000 procedures are performed annually.[53]
9.63
The Australian Government Department of Health explained that bariatric
surgery is available to public patients in some public hospitals; however
waiting lists can be long.[54]
9.64
At a public hearing, Mr Aly stressed the lack of available public
services in bariatric surgery:
More alarmingly, of...about 23 000 procedures a year, only 10
percent are performed in public hospitals and only 4 percent are fully publicly
funded.[55]
9.65
Similarly, Dr Tony Bartone, President of the AMA, told the committee
that access to bariatric surgery in public hospitals is problematic:
There are significant waiting lists and significant
difficulties in obtaining and accessing this in a public hospital space.[56]
9.66
As a result, some people resort to access their superannuation early or
go into debts in order to pay for surgery in the private sector.[57]
9.67
The AMA and ANZMOSS recommended that access to bariatric procedures be
increased in public hospitals.[58]
9.68
Dr Stephen Duckett, Director, Health Program at the Grattan Institute,
also pointed out that 'the evidence now is that obesity bariatric surgery is
cost effective, and it is unfortunate that the public sector hasn't responded
by making access more available'.[59]
Committee view
General Practitioners
9.69
The committee believes GPs have a key role in identifying and supporting
patients who are overweight and obese. As discussed in Chapter 2, because of
the stigma associated with obesity, GPs are not always equipped to discuss with
their patients weight management and health issues related to obesity. The
committee reiterates the recommendation made in Chapter 2 around the training
of the medical profession and sees value in also developing practical materials
for GPs aimed at supporting patients who undertake treatment for obesity and
weight related conditions.
Chronic Disease Management scheme
9.70
The committee understands GPs are responsible for referring patients to
allied health services under the CDM scheme. However, at present, they cannot
refer patients for obesity alone as it is not recognised as a complex and
chronic disease. The committee is of the view that overweight and obese
patients should be able to access allied health services, especially APDs and
exercise physiologists, without a co-morbidity. This would provide early and
better access to health care services and effective treatments.
Recommendation 16
9.71
The committee recommends the Medical Services Advisory Committee (MSAC)
consider adding obesity to the list of medical conditions eligible for the
Chronic Disease Management scheme.
Bariatric surgery
9.72
The committee heard that bariatric surgery is a cost effective
intervention, which saves lives and improve obesity related diseases. The
committee noted that bariatric surgery items are on the Medicare Benefits
Schedule and that bariatric surgery is available through the public hospital
system. However, access to bariatric surgery services remains limited.
9.73
Firstly, too few hospitals offer bariatric surgery services. Indeed, the
committee heard that only 15 public hospitals in Australia have a specialised
obesity service that involves surgery.[60] Secondly, many health professionals continue to be reluctant to offer this
treatment option.
9.74
The committee believes that the lack of access and availability of
bariatric surgery services is partly due to the stigma attached to this type of
surgery. As discussed in Chapter 2, the stigma and prejudice around
surgical intervention to treat obesity cannot be underestimated. Attitudes and
perceptions need to change within the medical profession. At present, it is
resulting in some health professionals not offering this treatment option to
patients. Furthermore, given the higher prevalence of obesity in lower
socio-economic groups, it is imperative that affordable options are available
to all those who could benefit from surgical intervention. Finally, it impedes
the creation of new bariatric surgery services.
Recommendation 17
9.75
The committee recommends the Australian Medical Association, the Royal
Australian College of General Practitioners and other colleges or professional bodies
educate their members about the benefits of bariatric surgical interventions
for some patients.
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