More of Me to Love | Australian Bodies to Become Biggest in the World Within the Next Ten Years

Lily O’Hara

In Australia we have developed a size complex focused on bigness. We live on the biggest island continent in the world, we call ourselves a big country, and scattered throughout our wide brown land are innumerable icons: the Big Banana, Big Merino, Big Prawn, Big Oyster, Big Bull, Big Mower, to name a few. Here in my own backyard on the Sunshine Coast we have the Big Pineapple, Big Cow, Big Kart, and the lesser known but equally “interesting” Big Stubby (international translation: a stubby is a small beer bottle, as opposed to a big one).

We love nothing better than to prove ourselves by beating much bigger countries at any sort of sporting endeavour. Witness our absurdly swollen national pride when we took the wind out of American sails and knocked off the America’s Cup. No one had ever heard of the millionaires’ yacht race before then, but when we won the whole country went crazy, including the eloquent quote from the sports loving Prime Minister of the day who said “any boss who sacks a worker for not coming to work today is a bum.” And many people didn’t go to work. They celebrated the day that little old Australia beat great big America at something, even something as obscure as yacht racing.

But there’s one big race we are definitely not keen on winning—the race for the biggest bodies. Like many other countries, the average weight of the population is increasing, though not at anywhere near the rising rate of hysteria about it. And now the latest health reports from Australia suggest that we’re on track to overtake America and become the biggest people in the world.

According to a recent report, an additional one percent of Australian children are becoming overweight each year, second only in the world to Canada and greater than the increase in prevalence rate in the USA. If the trend continues, the report warns that in the next decade “Australia is predicted to have the greatest prevalence of obese and overweight children in the world” (Queensland Government, 2005, Smart State).

The issue of increasing weight in Australia has been the subject of the same degree of intense scientific, political, and media attention in Australia as it has in many other parts of the world (Queensland Public Health Forum, 2002; Swinburn & Egger, 2004; Swinburn & Kumanyika, 2004). In the four years from 2000–2004, there was a 2,000% increase in the incidence of obesity reporting in the major Australian daily newspapers, as illustrated in Figure 1 (O’Hara, L, 2005). Obesity is now referred to in Australia as an epidemic, and the consequences of obesity are regarded as being medically and psychologically problematic.

CHART CHART CHART CHART CHART

The War on Obesity in Australia

Australia developed its first national action plan on weight in 1997 (National Health and Medical Research Council, 1997). Acting on Australia’s Weight was a strategic plan for the prevention of overweight and obesity. Despite being published by the National Health and Medical Research Council, the plan failed to receive any attention, and sat untouched on most policy makers’ and practitioners’ book shelves.

In the next five years the climate on weight changed significantly. In November 2002, the Commonwealth, State and Territory Health Ministers declared that “overweight and obesity are significant public health problems that threaten the health gains made by Australians in the last century” (Australian Government, 2003). The health gains referred to are indeed significant, with Australians on the whole (Indigenous people excluded) enjoying excellent health status, as evidenced by health indicators such as life expectancy. Australians currently have one of the highest life expectancies in the world. Female life expectancy of 83 years is third highest in the world after Japan (85) and France (84), and male life expectancy of 78 years is equal highest with Japan and Iceland. Life expectancy in Australia is a little higher than countries such as Canada, Norway, and Germany, and higher again than in the United Kingdom and the United States, which rank 20 and 24 respectively (Australian Institute of Health and Welfare, 2005).

The desire by the Australian Health Ministers to preserve such health gains is therefore understandable. However, the naming of “overweight and obesity” as the most significant problems that threaten health gains was not based on any solid evidence linking these issues with health status. The Australian Health Ministers were simply relying on the “evidence” provided by the World Health Organisation, the Centres for Disease Control and Health Promotion in the USA, and other international agencies that have described weight as being a central determinant of health.

The Ministers decided that the problem of excess weight required an Australia-wide response, and agreed to establish a National Obesity Taskforce to develop a national action plan for tackling overweight and obesity, and to identify roles and responsibilities for implementing the nationwide plan. In 2003 the Commonwealth, State and Territory Health Ministers signed off on the action plan called Healthy Weight 2008—Australia’s Future: the National Action Agenda for Children and Young People and their Families (Australian Government, 2003).

Since the first national action plan on weight in 1997, all of the state and national weight related plans have had an exclusive focus on the dual strategies of increasing physical activity levels and improving nutritional status. In addition, all of the physical activity and nutrition policies and programs that have been developed over the last two years have been singularly predicated on the impact they will have on the “epidemic of overweight and obesity.”

The two most recent programs released in my own state of Queensland are Smart State: Healthy Weight for Children and Young People Action Plan 2005–2008 and Smart Choices: Healthy Food and Drink Supply Strategy for Queensland Schools. (Queensland calls itself the Smart State so everything has to be “Smart.”)

While these are state based programs, they are consistent with policies and programs that are being developed around the country. Australia has a chequered history of federalism that has lead to such idiosyncrasies as different environmental protection regulations, different health systems, and even different railway tracks, which forced the drivers to stop the trains and change tracks at the state borders! On the issue of weight though, there is unanimity in the approach adopted by State, Territory and Commonwealth governments to the weight-centred, dual-strategy health policies and programs. These two programs are therefore useful examples of current Australian programs to consider further.

Smart Choices: Healthy Food and Drink Supply Strategy for Queensland Schools begins with the rationale “In recent years, levels of overweight and obesity in children and young people have increased dramatically—now around a quarter of our children are overweight or obese. This is a serious issue as overweight and obesity carry a greater risk of a number of immediate and long-term health and psychosocial problems. Excess weight gain in children is usually a result of excess energy intake through eating too much food or the wrong type of food, combined with doing too little physical activity or being inactive for too much of the day” (Queensland Government, 2005, Smart Choices).

Smart Choices is a program that regulates the supply of foods and drinks in the school environment including tuckshops (school canteens), vending machines, school excursions, school camps, fundraising, classroom rewards, school events such as celebrations and sports days, and food used in curriculum activities. The program uses the traffic lights colouring system of green, amber, and red to label foods: have plenty (green), select carefully (amber) and occasional (red).

Under the new program, red foods are not to be supplied by the school on more than two occasions per term (there are four terms per school year). Red foods include any deep fried foods, fried chips, chocolate, lollies (candy), donuts, sports drinks, and soft drinks. Birthday cakes that come from students’ homes are not covered by the program regulations so will be unrestricted. According to the Education Department, this is one of the most frequent questions asked by parents.

The Smart Choices program represents the most stringent and farreaching school based program regulating food and drink supply in Australia. It is expected that other States and Territories in the country will follow suit with similar programs.

Smart State Healthy Weight for Children and Young People Action Plan 2005–2008 was released in October 2005 by the Queensland Health Department. The Action Plan is consistent with the national agenda, and all other states are expected to follow suit with the development and implementation of similar state based action plans to “stop and then reverse the trend towards overweight and obesity in our population” (Queensland Government, 2005, Smart State).

The stated aim of this Action Plan is to achieve healthier weight in Queensland children and young people. The Action Plan includes two main action areas: 1) reaching kids where it counts and supporting parents and caretakers; 2) creating healthier communities for kids.

The number one strategy under the first action area of reaching kids where it counts is “getting the message out” and the first action is to “produce a healthy weight information pack to be directly mailed to every Queensland home, parent and caretaker.” This action is predicated on the belief that a note home from the government telling families that their fat kids really are a problem is likely to have positive outcomes. However, the evidence base for the effectiveness of this strategy, or any of the others in the Action Plan, is not provided.

The Action Plan includes seven guiding principles for its development, three of which are:

• Concentrate on solutions not problems
• Promote the positive benefits of healthy eating, active living, and healthy weight
• Reduce stigmatization and avoid blaming young people, parents, or caretakers

However, these principles shape up as very poor guides indeed, and evidence of their guiding hand in the Action Plan are extremely hard to find.

The entire Action Plan is explicitly predicated on the “problem of overweight and obesity” as are many of the specific strategies and actions, for example the Smart Choices program described above.

The principles of promote the positive benefits and reduce stigmatization should be stripped of their guide’s licenses completely, because there is only the flimsiest evidence of their guiding abilities in this Action Plan.

Promote the positive benefits may just get a reprieve thanks to a last ditch effort after the whistle has blown. Buried deep within Appendix 1 Definitions and Common Questions, in the last two paragraphs of the very last section Other guiding concepts is a brief mention of some of the other benefits (besides their obvious importance in healthy weight) of physical activity and eating well.

The term reduce stigmatization is a real struggle to convince anyone of its role in guiding the document. Its defense relies on some content in the same Other guiding concepts section at the end of Appendix 1. This section describes how “healthy weight” is a more positive way to focus on the prevention of overweight and obesity in children. This is important given the potential for social discrimination of overweight children and other associated psychosocial factors.

I’m not sure if the implied subtle difference between the social discrimination felt by children that are not a “healthy weight” and those that are “overweight or obese” is really true. To me, both sets of words send the same message—there is such a thing as a “healthy weight” and if you’re over it, then you’re labeled overweight or obese. The meaning is clear: health = weight and weight = health. The suggestion that using the term “healthy weight” rather than “overweight or obese” will reduce stigmatization is not based on evidence and is just a furphy or nonsense.

These are only three of the seven guiding principles, but there is no convincing evidence that these three have had any role at all in the development of this Action Plan. What is evident is that they have been included for their looks alone, and they have done nothing more than laze around in the front end of the document refusing to get their hands dirty by actually guiding any content of this Action Plan.

However, while these principles were taking it easy in the front of the house, the HAES principles have managed to get into the backyard in Appendix 1. In a section headed “A few words on eating disorders,” adults are told they can play an important role to help prevent eating disorders and promote positive body image in young children (only young children?). The work of the HAES principles is evident in some of the pointers given, for example:

• Encourage positive self-esteem
• Encourage children to feel good about their bodies and to listen to their bodies
• Allow children to eat when they are hungry and to stop when they are full
• Try not to label foods as “good” or “bad” and avoid using foods as bribes or punishment

However in some cases the HAES principles got mixed up with the contradictory healthy weight principles:

• Encourage and participate in regular, but not obsessive, physical activity to help maintain your child’s healthy weight and foster their body confidence
• Encourage acceptance of a wide range of body shapes and healthy weights

The messages? That physical activity is primarily useful for weight maintenance, and that one should accept only those with a healthy weight.

These two programs described above are symptomatic of the complete dominance of the weight-centered health paradigm operating in the development of government and non-government programs in Australia at present. Such programs are generally developed with restricted community input, and there is no opposing voice that gets to be heard anywhere powerful or important. Everyone from the federal Health Minister down seems to have an unswerving belief that demonizing weight and making huge financial and human investments in physical activity and nutrition based solely on their potential impact on weight will have a universal positive benefit for our community.

THE HAES Response

Given the level of certainty within government about the righteousness of these approaches, it is somewhat surprising to see some sensitivity developing within government circles to any perceived criticism of their weight focused programs. Yet that is just what Queensland Health recently demonstrated when invited to participate in a seminar on Australia’s Weight.

As a member of the Australian Health Promotion Association’s Queensland Branch committee working group for professional development, I am in the process of co-organising a seminar aimed at raising some questions about the health impact of the weight-centered health paradigm. The three major public health related professional associations—the Australian Health Promotion Association, the Public Health Association of Australia, and the Australasian College of Physicians’ Faculty of Public Health Medicine—are jointly sponsoring this event, but a colleague from the Health Promotion Association and I are the organizers.

The full title we developed for the seminar is Australia’s Weight: Are we promoting health for all? The brief for the seminar that I prepared was as follows:

Obesity now sits heavily on the agenda of governments and health agencies throughout Australia and much of the developed world. But what impact are current weight-focused programs really having on the health of all people in the community? Are current programs addressing the social determinants of health? Are these programs inadvertently causing any harm? And are there alternatives to the current strategies and directions?

This brief was used to provide guidance to speakers, including those from Queensland Health, to develop their presentations. My colleague provided the brief to the prospective speakers, whom had all previously agreed to participate. However, after reading the brief, a manager at Queensland Health interpreted the seminar as an attack on Queensland Health and communicated to my colleague that Queensland Health was unwilling to participate in an event with this focus.

As a consequence of this criticism, my colleague modified the brief, assured the manager that none of the professional associations sponsoring the event had any intentions of attacking Queensland Health, and apologized for anything she may have done to cause this confusion.

The new brief she distributed to me and the representatives from the other sponsoring organisations read as follows:

Obesity now sits heavily on the agenda of governments and health agencies throughout Australia and much of the developed world. But what is the evidence behind weight-related programs and policies? Do some population groups need special consideration or can we use a “one size fi ts all” approach? Should we be addressing Australia’s weight problem differently or are we on the right track?

Only the first sentence remains the same, and the resultant brief poses a very different set of questions. Naturally I responded my dissatisfaction with this proposed change, and indicated that it was totally reasonable for Queensland Health to be expected to provide information on the potential health impact (gains or otherwise) that would result from their weight-centered health programs. The central tenet of democracy is the right to hold our governments and public services accountable for the way they spend the public’s money. I cannot see how such questions could be interpreted as an attack on Queensland Health—but they were.

Despite all the media friendly government announcements and glossy high coloured publications that talk up the benefits of the huge government investments in weight-centered health programs, perhaps there is a slight chink in the armour of self-righteousness that this small professional association seminar has tapped.

Looking to The Future

Asking questions about current weight-centered health programs is one form of activism, but it is not enough. We must have something different to propose. Linda Bacon and colleagues have done just that with their HAES versus traditional dieting research (Bacon, et al, 2005), and now a group of people here on the Sunshine Coast in Queensland, Australia, are trying to do the same with a community based health promotion program.

At the University of the Sunshine Coast, the Centre for Healthy Activities, Sport and Exercise (CHASE) has identified the problematic nature of weight-centered health programs as a priority issue for community based research.

In response to this need, in April 2003 researchers from CHASE organised a meeting of health, education and child-care professionals, government and non-government organisations and community based people from the Sunshine Coast region in Queensland to discuss alternative approaches to the dominant weight-centered health paradigm. Participants at that meeting decided to work together to explore better ways to develop health and happiness than the dominant obesity-focused projects. They quickly established a consortium and initiated the Everybody Research Project (hereafter referred to as Everybody).

Everybody aims to assess the effectiveness of new community strategies to positively influence the determinants of health and happiness for people of all shapes and sizes. The project takes a fresh approach to the issue. It specifically focuses on valuing the natural diversity of bodies, healthy and pleasurable eating, and active living for all people, within the family, school and community environments. The project logo was developed to reflect health and happiness, and the natural diversity of body shapes and sizes (see Figure 2).

FIGURE-2 FIGURE-2 FIGURE-2

Consortium members include representatives from the University of the Sunshine Coast, local childcare centres, schools and health services, numerous government departments, general practice and a range of other community based organisations. A pro-active, operational, working partnership exists among members of the consortium. Community-based health promotion theory, concerned with participation and empowerment, underpins the Everybody consortium processes.

Guiding principles developed by the consortium cover the project’s context, process and practice.

CONTEXT: seeing, understanding, challenging, responding to the issue using a socio-ecological framework and the principles of the Health at Every Size paradigm

PROCESS: a collaborative process that is equitable, transparent and accountable.

PRACTICE: using scientific health promotion practice in the project’s design, implementation and evaluation.

The major emphasis in the first two and a half years of the project has been on the development of the project consortium, and planning the community based strategy and its evaluation. Three formative research projects have been undertaken to identify geographical areas of greatest need, the project evaluation framework, and preferred evaluation indicators for Everybody. Current research is developing the section of the evaluation framework focusing on “valuing body size diversity.”

Presentations on Everybody have been made to state and federal politicians, community meetings, forums, workshops, the Australian Health Promotion National Conference, and an international short course for students from Wyoming, USA.

The consortium has recently developed a school-based project called Everybody in Schools, which uses the Health Promoting Schools model, a values education approach, and the technique of mindfulness. Strategies include professional development for teachers, administrators, and parents, a curriculum- based strategy for school students Years 1, 3, and 5, and suggestions to support the school environment and ethos. Funding is now being sought for the implementation of this project.

Projects such as Everybody represent a minnow swimming against a tsunami of weight-centered health programs. But it’s the minnow’s message that most ordinary people in the community can relate to. Despite the tidal wave of anti-fat rhetoric that continues to be dumped on health professionals and the community alike, in Australia, as in many other parts of the world, it is the HAES argument that actually makes sense to people. Whenever I talk about the problems of the weight-centered health paradigm, and the HAES alternatives, most people intuitively know that there is something wrong with the former and something incredibly sensible about the latter.

But there are still too few minnows in the sea that are willing or able to swim against the tide. Here in Australia we have no professional or community organisation that provides any support or collectivity. There are a number of people telling the HAES story, and we are beside ourselves with excitement when we happen to find each other.

Some of us have discovered such fabulous professional resources as the Health At Every Size Journal, and excellent list serves such as Show Me The Data, Science and Health at Every Size, and Fat Studies. These new international virtual communities are particularly invaluable as a support to those of us working in more isolated environments such as Australia, especially as the pace and strength of the weight-centered waves are still growing, and the effort to keep swimming in the opposite direction can take its toll. The support that comes from this international community is vital, but the real, on the ground, day-to-day oxygen comes from the pain I see in the faces (and bodies) of people who tell me their stories.

At each talk or presentation I give at least one person, and usually many more, share their all too familiar struggles with body- and weight-based messages about good and bad, right and wrong, acceptable and unacceptable, valued and unvalued, excluded and included. They urge me to keep up the work that I am doing: for themselves, and their children, clients, friends, and lovers. This is vital, lifesaving work and we need to develop our own strategies for sustaining ourselves.

There is a ragged line of little yellow Post-it notes stuck to the side of my computer that contain some of the quotes that provide succour to this minnow in my daily HAES swim upstream. From Margaret Mead: “Never doubt that a small group of thoughtful citizens can change the world. Indeed it is the only thing that ever has.” From Ralph Emerson: “Do not go where the path may lead. Go instead where there is no path and leave a trail.” From Martin Luther King: “Our lives begin to end the day we are silent about things that matter.”

All of these quotes help reinforce my commitment to the HAES cause. But it is the top one, by the prolific Anon, that perhaps best sums up my strategies for facing that weight-focused tsunami head on: “Live well, laugh often, and love much.” Fear and loathing are central to the weight-centered health paradigm, and their use has never in history created health or social gains. Life and laughter and love are central to HAES, and it will be their use that creates a healthier, happier living community.

Lily O’Hara, BSc, PG Dip Hlth Prom, MPH, is a Lecturer in Public Health at the University of the Sunshine Coast in Queensland, Australia. She is a co-founder of the Everybody Research Project. Lily is currently undertaking doctoral studies investigating the full range of known and potential health impacts of the weight-centred health paradigm and the health at every size paradigm. She is a member of the Australian Health Promotion Association, and the Association for Size Diversity and Health.

Author Contact:
Faculty of Science, Health and Education
University of the Sunshine Coast
Maroochydore DC QLD 4558
Australia
Tel: 61 7 5430 2824
Fax: 61 7 5430 2881
E-mail: .(JavaScript must be enabled to view this email address)

References

Australian Government. (2003). Healthy Weight 2008, Australia’s Future: The national action agenda for children and young people and their families. Accessed 21 November 2005. Available at: http://www.healthyactive.gov.au/docs/healthy_weight08.pdf

Australian Institute of Health and Welfare. (2005). Mortality FAQs. Accessed 21 November 2005. Available at: http://www.aihw.gov.au/mortality/data/faqs.cfm

Bacon, L., Stern, J. S., Loan, M. D. V., Keim, N. L. (2005). Size acceptance and intuitive eating improve health for obese, female chronic dieters. 105(6): 929-936.

National Health and Medical Research Council. (1997). Acting on Australia’s Weight: A strategic plan for the prevention of overweight and obesity. Canberra: Commonwealth of Australia; 1997.

O’Hara, L. (2005). Reporting of obesity in major daily Australian newspapers 2000-2004: unpublished.

Queensland Government. (2005). Smart Choices: Healthy food and drink supply strategy for Queensland schools. Accessed 21 November 2005. Available at: http://education.qld.gov.au/schools/healthy/food-drink-strategy.html

Queensland Government. (2005). Smart state healthy weight for children and young people action plan 2005-2008. Accessed 21 November 2005. Available at: http://www.health.qld.gov.au/phs/Documents/shpu/29187a.pdf

Queensland Public Health Forum. (2002). Eat Well Queensland 2002-2012: Smart eating for a healthier state. Accessed 21 November 2005. Available at: http://www.health.qld.gov.au/QPHF/Documents/EatWellQld.pdf

Swinburn, B. & Egger, G. (2004). The runaway weight gain train: Too many accelerators, not enough brakes. BMJ, 329: 736-739.

Swinburn, B. & Kumanyika, S. (2004). Obesity prevention: A proposed framework for translating evidence into action. Proceedings of International Obesity Task Force Workshop, Melbourne.