Australia: the healthiest country by 2020
National Preventative Health Strategy – the roadmap for action

Key action area 3: Embed physical activity and healthy eating in everyday life

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Acting where adults, children and families live, work, learn and play

Interventions to counter obesity are premised on the need for simultaneous action in the structural environment – through legislation and regulation – and at the local community and individual level. The notion of a 'settings' approach becomes particularly important.

A 'setting' is a context – and a complex set of relationships and structures – within which people live, work, trade and socialise.[96] A settings approach has long been seen as a way of reaching a captive audience, providing entry points and access to specific populations as well as channels for delivering health promotion programs. Settings are also understood as 'creating supportive environments' to 'make healthy choices easy choices'.

'There are many positive changes that families and individuals can make, but if the environment in which they exist – where they work, play, interact and experience life – is not conducive to health, the impact of individual behaviours may be severely limited' (Quote from submission)

For these reasons, it is important to undertake a combination of interventions in schools and workplaces, as well as in local government areas to make local environments healthy and active. Local governments are in a unique position to shape the local natural and built environment, and to integrate efforts in different sectors. The linking of the work within these settings at the local level may particularly benefit disadvantaged communities.

The potential benefits in terms of health and from an economic perspective are significant. It is estimated that:
  • Increasing fruit and vegetable consumption in Australia by just one serve a day would save between $8.6 million and $24.4 million in healthcare costs relating to various types of cancer. In addition, over $150 million would be saved in costs related to cardiovascular disease.[97]
  • If more people were physically active for 30 minutes a day, the Australian healthcare system could save $1.5 billion annually.[98]
  • $8 million per year could be saved for every 1% increase in the proportion of the adult population that is sufficiently active.[97]
For children, the home environment can influence active recreation and play through factors such as whether children have television sets in their bedrooms and a yard large enough to play in.[99] These characteristics are within the 'micro-environments' of families, and therefore potentially amenable to parental control. For example, parents can instigate simple but effective rules such as limiting the amount of television that their child watches and switching off the television during meal times. Support for families to modify home environments can assist parents to create more active environments for children. Workshops and other resources can be used to empower parents to overcome the 'nag factor' and restrict screen-based activities and television viewing.

Limiting the delivery of extended teaching blocks where children are sitting for up to 90 minutes at a time in class, and encouraging schools to provide children with physical activity 'breaks' during class time may substantially benefit children's health.[100]
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Active play and sports participation at school can be increased by providing open spaces (not necessarily grass), fixed equipment (such as basketball hoops), playground markers, loose equipment (such as balls) and teacher supervision. Physical education and sport can be promoted by having a classroom teacher who encourages physical activity, core curriculum requirements for physical education/sport, and access to sporting equipment and playing fields. In particular, health and physical education should be included in the national core curriculum for schools.[27]

Addressing 'too much sitting'

A body of new evidence identifies the time that adults spend sitting as being an important ingredient of the physical activity and health equation.[101] Research has shown a dose-response relationship between sitting time and mortality, independent of leisure time activity.[102] In the context of chronic disease prevention, the impacts on health of too much sitting need to be considered, in addition to the well-established preventative-health concerns about too little exercise. Findings from the national AusDiab study[101, 103] have shown television viewing time – which may reflect some people's broader dispositions to spending a lot of time sitting[104] – to be significantly related to metabolic health. Prolonged television viewing time (particularly more than four hours a day) has been shown to be associated with:
  • Higher waist circumference
  • Higher blood sugar levels
  • Higher blood fat levels
  • Higher risk of the metabolic syndrome
The detrimental associations of television viewing time with metabolic health were observed even in adults who met the criteria for the National Physical Activity Guidelines for Adults.[105]

AusDiab findings also show that the average person spends more than half of their waking hours (~9 hours) in sedentary behaviours – primarily prolonged sitting. The remainder of the day is spent in light-intensity activities, with only 4–5% of the day spent in moderate-to-vigorous intensity physical activity.[106, 107] Importantly, participation in light-intensity activities (which can include housework, standing and moving about in office environments or shopping) has been shown to be beneficially associated with blood sugars and waist circumference.[101, 106] Additionally, those who interrupted their sedentary time more frequently (for example, got up to get a drink, stood up to answer the phone) had a better health profile, compared to those whose sitting time was mostly uninterrupted.[106]

Key components of the approach will include:
  • Broadening Australia's Physical Activity and Health Guidelines to address explicitly increasing 'incidental' activity and reducing prolonged sitting time in all aspects of daily life
  • Funding, implementation and promotion of the:
    • National Physical Activity Recommendations for Children 0–5 years (due to be released in late 2009)
    • National Physical Activity Recommendations for Children and Youth (these cover 5–18-year-olds)
    • National Physical Activity Guidelines for Adults
    • National Physical Activity Recommendations for Older Australians (released in March 2009)
  • Ensuring that physical activity is embedded in the national school curriculum

Schools

'Preschools and schools are agencies for social change and offer opportunities to build understanding and awareness, as well as creating healthy environments' (Quote from submission)

Schools are able to influence the nutrition and physical activity environment, and to educate children, families and the broader community about healthy lifestyles.

Case study: Primary school children and healthy eating

The Stephanie Alexander Kitchen Garden Program (SAKGP) is a school-based program providing primary school children with the opportunity to grow, harvest, prepare and eat fresh nutritious food. The program aims to positively influence children's food choices and attitudes towards environmental sustainability. In April 2009 there were 49 Victorian schools and 43 schools participating nationally, with a further 147 schools to undertake the program over the next three years. Longitudinal evaluation of the program by researchers from Melbourne and Deakin universities is being conducted over 2.5 years to assess the program's impact on school communities and students, including an economic appraisal. Preliminary findings indicate that school community members state they are willing to donate time to fundraising and general program maintenance, while parents have indicated willingness to pay increased voluntary school levies for the introduction or maintenance of the program at their school. Interestingly, each of the six matched comparison schools in Victoria (not participating in the program) indicated that they had an existing or planned garden program at the school.[108]
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Promotion of healthy eating in schools may be weakened by a high level of unhealthy foods and beverages available in school canteens, and the presence of soft drink and confectionery vending machines.[109] Recent Australian data indicate that children purchasing foods from school canteens had a higher energy intake from energy-dense foods than those who did not use the canteen.[109]

Evidence-based guidelines recommend ensuring that all school policies and the school environment help children and young people to maintain a healthy weight, eat a healthy diet and be physically active. This includes policies relating to building layout and recreational spaces, catering (including vending machines) and the food and drink children bring into school, the curriculum (including physical education) and school travel plans (including provision for cycling).[110]

The United Kingdom has recently announced that it will implement a ban on fizzy drink and junk food in school vending machines.[111] France banned vending machines in schools in 2005.[112] In 2006, former President Bill Clinton and the American Heart Association brokered a deal with the beverage industry in the United States, removing most soft drinks from almost every US primary and secondary school by the 2009–10 school year.8 Following the introduction of the agreement, the level of calories due to beverages delivered to schools in the 2007–08 school year decreased by 58%.[113]

The Taskforce recognises that significant work has already been undertaken at the state and territory level to improve nutrition and physical activity in schools, particularly in relation to healthy school canteens. The Taskforce believes that there are significant opportunities to build on this action and develop policies and programs that support children and their families to adopt healthier lifestyles. The Taskforce proposes that schools should maintain a priority focus on health, nutrition and physical activity in the curriculum and believes that the provision of mandated opportunities for all children to undertake appropriate levels of physical activity as part of their education is a fundamental strategy in addressing rising obesity levels in children. The Taskforce recommends that the existing policy requirement of at least two hours of physical activity per week for all K–10 students should be maintained in the state and territory government education/curriculum policy requirements of all schools, regardless of the system or sector. Further, the Taskforce recommends that the two hours of physical activity should form part of the quality assurance and reporting framework for all schools.

Other key approaches will include:
  • Building on partnerships with the education sector to promote physical activity and healthy eating in schools
  • Ensuring a curriculum entitlement to Health and Physical Education (HPE) for all Australian children by incorporating HPE into the second stage of National Curriculum development
  • Australian and state governments to establish a national program to support implementation of the new curriculum, including teacher curriculum guidance and professional development opportunities
  • Education sector to encourage all schools to develop, implement and evaluate health, nutrition and physical activity policies
  • Ensuring implementation of the policy requirement of at least two hours of physical activity per week for all students K–10
  • Expanding coverage of out of school care health programs such as Active After School, and Eat Smart, Play Smart
  • Education sector to examine how to build the capacity of schools and teachers to promote health and resilience more effectively
  • Development of comprehensive health policies in schools including:
    • Implementation of policies relating to building layout and recreational spaces
    • Strengthened school nutrition policies (for example, provide a healthy breakfast program for disadvantaged children; modify school canteen service; increase healthy options; provide healthy eating education; increase the availability, appeal and encouragement of fruit and vegetables at school; and increase the availability of healthy food options in all school environments: canteens, vending machines, fundraising, classroom rewards, excursions, and the food and drink children bring into school) and use of alternatives to foods in fundraising and other programs
    • Introduction of school travel plans and support for active transport options to and from school, including cycling and walking
  • Improved access to school-based recreational facilities by the community, especially after hours and in neighbourhoods that lack park and recreational facilities
  • Promotion and support through state and territory governments for the National Healthy School Canteens Project, ensuring a nationally consistent approach to making healthy food available in school canteens, and the provision of foods and beverages in line with Australian dietary guidelines
  • A comprehensive national approach to phasing out soft drinks in school canteens and vending machines
There is also a need to ensure key policy elements are appropriately reflected within the National Prevention Agreements.
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Action 3.1
Fund, implement and promote school programs that encourage physical activity and enable healthy eating.

Workplaces

'The workplace provides an ideal opportunity to engage individuals in taking more control of their own health' (Quote from submission)

Workplaces represent an arena for social leadership and peer support in tackling behaviour change, while work and employment policies and practices can enable or work against positive changes within the workforce. Furthermore, workplaces provide an ideal opportunity to reduce sedentary behaviour in the population.

Prolonged inactivity, such as sitting, is now common during working, domestic and recreational time, and typically comprises over half of waking time activity.[106, 114] Over one-quarter of Australians (26%) report sitting for eight or more hours during a typical day.[115] Recent Australian research has demonstrated the benefits of avoiding prolonged uninterrupted periods of sedentary (mainly sitting) time,[106] interspersing periods of inactivity with breaks, and substituting (at minimum) light-intensity activity for sedentary time.[106, 114] These benefits include improved weight and metabolic outcomes.

While it is important to continue to promote the significant health benefits of regular moderate to vigorous physical activity, this research indicates that extended periods of sedentary time (as are common among office workers) may undo the benefits of such activity.[106, 114, 115] The results suggest that simple interventions that can be implemented in the workplace and domestically to decrease passive sitting time and increase the number of breaks can also lead to substantial health improvements. The evidence highlights behaviours that may be more appealing and feasible for some people to undertake, which can still result in improved weight and metabolic effects; for example, the importance of lower-intensity activity throughout the day (including incidental activity such as standing) rather than a focus on more purposeful moderate to vigorous activity, such as going to the gym or jogging.

Simple strategies, such as standing up while talking on the telephone or watching television, using a telephone headset at the office to keep moving during phone calls and arranging regular short breaks during sit-down meetings, can be introduced and sustained in daily routines.

'Workplaces are best placed to provide the supportive cultures often needed to sustain lifestyle change' (Quote from submission)

Common factors of worksite health promotion programs with successful outcomes include regular participation, intervention intensity, the inclusion of dietary advice, supervised physical activity, support for physical activity outside the workplace, counselling and plant reorganisation.[116] A meta-evaluation of research into economic returns associated with worksite health promotion programs found strong evidence that worksite health promotion was associated with average reductions in sick leave, health plan costs and workers' compensation and disability costs of just over 25%.[117]

A review of workplace-based interventions targeting dietary behaviours through various education and environmental initiatives that were focused around the work canteen found positive modest changes in diet and food purchases or no impact.[118] Some workplace initiatives promoting physical activity (interventions included health checks, motivational prompts and physical activity programs) have found inconsistent or inconclusive evidence,[119, 120] with some strong evidence for increased physical activity behaviour but inconsistent or no evidence for improvements in cardiovascular outcomes, body weight or general health.[120] More comprehensive interventions, incorporating individual approaches and changes in workplace culture and organisational structure, were more successful.[119]
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WorkHealth is a recent initiative of the Victorian Government.9 It is a five-year, $218 million program aimed at improving the health and wellbeing of Victorian workers through workplace-based health checks, and providing access to advice and education programs to help workers reduce their risk of chronic disease. The aims are to reduce absenteeism, improve productivity, reduce injuries and reduce the burden of chronic disease on the Victorian health system. This initiative uses the workplace as an opportunity for health promotion and disease prevention, and establishes partnerships between government, employers and workers, develops joint effective health solutions, and creates links to existing health initiatives and services.


These kinds of programs and opportunities could be provided to Australian employees more broadly as a standard condition of employment. Workplaces could offer risk assessment and risk modification programs, nutritional education for workers and families, and physical activity embedded in, or in association with, regular daily work practice. Incentives could be provided to employers to reduce the chronic disease risk profile of their employees.

'Not only does the workplace provide a captive audience to which messages can be targeted, but there is also a secondary effect through the influence on family and friends' (Quote from submission)

The Taskforce believes that the development of comprehensive healthy workplace programs will provide new opportunities to promote healthy living. Therefore the Taskforce proposes the funding, implementation and promotion of comprehensive workplace programs through the COAG Healthy Workers initiative, including:
  • Development of a national accord to establish best practice principles for workplace programs including protecting the privacy of employees, workplace risk monitoring, risk assessment or risk modification programs
  • Development of a voluntary industry scorecard, benchmarking and award scheme for workplace health
  • Development of nationally agreed accreditation standards for providers of workplace health programs
  • Development of a national action research project to strengthen the evidence of effective workplace health promotion programs in the Australian context
  • Establishment of a national workplace health leadership program and a series of resources, tools and best practice guidelines
  • A review of potential legislative changes to promote the take-up of workplace health programs, including options such as:
    • Changes to Fringe Benefits Tax Assessment Act and Income Assessment Act to provide incentives
    • Employer commitment to a percentage of annual payroll allocated to workplace health programs (similar to the former Training Guarantee Levy)
    • Reforms to the Private Health Insurance Act 2007, to enable private health insurance firms to provide health screening to workplaces
  • Investigation of the feasibility of rewarding employers – through grants or tax incentives – for achieving and sustaining benchmark risk factor profiles in their workforce
Action 3.2
Fund, implement and promote comprehensive programs for workplaces that support healthy eating, promote physical activity and reduce sedentary behaviour.

Community initiatives

The community is where prevention actually happens. Every sector of society will need to change in order to reduce obesity rates and achieve healthier lifestyles. Shifts of this magnitude are not simple but the rewards will be great – both for ourselves and our children.

There are number of community-wide interventions already under way that aim to control childhood obesity. For example, Eat Well Be Active recently published results following several years of community implementation in Colac, in regional Victoria.[121] The program was designed to build the community's capacity to address childhood obesity through the promotion of healthy eating, physical activity and healthy weight in 4–12-year-olds and their families. The action plan was designed and implemented by local organisations, including schools and parents, and local health, housing and government services. The program used nutrition strategies such as support from school-appointed dietitians, canteen menu changes, training for canteen staff and healthy breakfast days, while physical activity strategies included walking to school programs, sporting club equipment and coach training.

While overweight and obesity levels in children from both the campaign and the nearby comparison areas did not differ significantly and increased over time, children in the project area gained less weight and had smaller waist circumference measures (about 3cm) after several years of the project. Project results were also promising in reducing obesity-related health inequalities: in Colac, changes in weight and other measures were not related to children's SES, while in the comparison group the more disadvantaged children experienced greater unhealthy weight gain.[121]

There are also a number of international community based obesity prevention programs.
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Ensemble prévenons l'obésité des enfants (EPODE) – 'together, let's prevent obesity in children' – is a community-based, family-oriented nutrition and lifestyle education methodology from France. The initiative involves local physical activity and healthy eating strategies aimed at parents and children, with engagement of influential community groups and individuals, including education and health professionals, retailers and the media.

At the local level, the program is led by a number of key partners supported by the Ministry for Health and Family, with private sector partners (including food and insurance companies) that have committed human and technical resources as well as US$1million.[122] While results from the 10 pilot towns will be published in 2009, initial results appear promising; for example, in one town, the prevalence of overweight children decreased markedly between 2004 and 2005 (from 19% to 13.5%).[32]

The EPODE program[123] now covers almost 1.8 million inhabitants in 225 French cities, 32 cities in Spain and 13cities in Belgium (in all communities) and five cities in Greece, with implementation also planned for South Australia. In South Australia, it is called the Obesity Prevention and Lifestyle (OPAL) program and is to be implemented over five years with $22.3 million investment, with approximately 20 councils involved.[123, 124]

'The challenge is to increase the number and reach of sustainable community programs that build on existing efforts and to prioritise those most in need' (Quote from submission)

The Taskforce believes that it is important to generate new evidence about community-based obesity prevention initiatives within the Australian context. However, it is important that these community-based interventions are of a sufficient intensity and are adequately funded for a period of time that allows evidence of effectiveness to be assessed. Experience tells us that small-scale, ad hoc projects will not deliver results in obesity prevention. An integrated, well-funded, sustained effort is required.

The Taskforce suggests the following approaches:
  • Establishing, as part of the COAG Healthy Communities initiative, a national series of comprehensive five-year intervention trials in 10 to 12 communities (including low SES and Indigenous communities), with a major focus on healthy eating and active living, building on effective approaches within Australia and internationally
  • Development of strategies to mobilise and engage local communities including:
    • Development and delivery of a national healthy community leadership and education program
    • Establishment of an online national forum for organisations, local governments, businesses and industry, community groups, families and individuals to share their commitments and plans to making Australia the healthiest country
    • The development of a national recognition and award scheme for outstanding contributions, large and small, to making Australia the healthiest country by 2020
  • Development, piloting and implementation of a new Healthy and Active Families initiative as an additional intervention to the activities proposed for Healthy Communities sites, beginning with the intensive intervention sites and rolling out successful program elements as results become available. This may include:
    • Provision of education that encourages parents to be positive role models for their children through healthy eating and regular physical activity
    • Locally targeted information on family-oriented physical activity opportunities
    • Development of programs that involve all family members within sporting and community clubs
    • Offering free/subsidised physical activity and nutrition programs in public spaces such as parks, beaches and recreation centres (for example, introduce free outdoor gym equipment in recreational areas)
The Taskforce recognises the important role that local governments can play in promoting healthy lifestyles. The role of local government in relation to urban design and infrastructure and the link to physical activity and sedentary living has already been discussed. The Taskforce suggests that as part of the Healthy and Active Families initiative outlined above, funding should be allocated to local governments and community organisations to support development of programs that aim to get families healthy and active and include a focus on existing infrastructure (for example, fun at the pool days, active parks programs).

Action 3.3
Fund, implement and promote comprehensive community-based interventions that encourage people to improve their levels of physical activity and healthy eating, particularly in areas of disadvantage and among groups at high risk of overweight and obesity.

8 See www.parentsjury.org.au/tpj_browse. asp?ContainerID=soft_drink_ban_in_us_schools and [113].
9 See www.workhealth.vic.gov.au/wps/wcm/connect/ WorkHealth/Home.


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