The Inaugural Summit - Obesity: changing the rhetoric, solutions for the future The Summit was held

at the John Curtin School of Medical Research in Canberra December 3-4 2012. The program covered is appended as an attachment 1, and a list of participants as attachment 2. The summit attracted substantial media interest over the week of Dec 3-7, and the following communique is means to serve as both a consensus statement - where consensus exists - and suggestions for a plan of action. Among the diversity of presenters and participants, there would appear to be consensus on the following: 1. That obesity is a disease, with grave consequences for mental and physical health for the obese at a personal level, and for society more broadly. 2. That obesity leads to substantial productivity losses, and with its associated disorders (diabetes, cardiovascular disease, sleep apnoea, cancer, osteoarthritis, reproductive difficulty, depression, cognitive decline) represents major cost issues for the health system; 3. That given the percentage of Australians over the age of 18 who are obese (25%) or overweight(40%), obesity is not merely a personal issue, but one with wide community impacts necessitating effective action by government; 4. That obesity represents a response to the interplay of genetic and environmental factors, and is caused by calorie intake exceeding energy expenditure over the medium and long term 5. That the four-fold increase in obesity over the past thirty years in Australia reflects a complex input of environmental factors - possibly before conception, intrauterine, as infants, children and adolescents, and during adult life; 6. That environmental factors affect epigenetic mechanisms (on/off signals) in the brain before and over the 2-3 years immediately after birth; 7. That the effect of these environmental factors (maternal obesity/ maternal undernutrition/maternal diabetes/maternal stress) is to reset the fetal appetite and satiety centres in the brain to seek food/not feel full in later life, and that this pattern may be aggravated by inappropriate diet over the first 2-3 years of an infants life; 8. That this wired-in hedonic drive underscores the common inability to maintain weight loss without constant vigilance/mentoring; 9. That whereas well designed programs in schools have been shown to have some positive effects, exhortations to the already overweight and obese to eat healthily and exercise have been unsuccessful in stemming the tide;

10. That Australians are well-informed about overweight and obesity, as exemplified by the responses to the recent Bupa and Coles surveys of 2000+ respondents each; 11. That fewer than 1 in 10 respondents (8%) are against effective government intervention to stem the flow into obesity and treat the already obese; and finally

12. That given the extent of this consensus, we call on governments to implement effective policies in the area of obesity, in terms both of its prevention and its treatment.

Where there are differences between speakers and between organizations/institutions active in the obesity space is in their preferred points of proposed intervention. Across the area the following interventions are possible 13. Setting out guidelines for (prospective) parents to optimize their childs chances of not becoming overweight/obese in later life, by focussing on the four years before the childs third birthday; 14. Programs in schools, from education in health literacy to kitchen gardens to mentoring of the overweight (and underweight) pupils; 15. Urban planning, to foster appropriate facilities for exercise as part of everyday life, and to encourage the community to buy (and grow) fresh food; 16. Addressing socioeducational issues, in that obesity is skewed to less well educated/ less affluent members of the community, including the unemployed, single parent families and those with mental illness. 17. Altering patterns of consumption by recognised weight loss/weight loss maintenance programs, by food labelling legislation, by taxes on particular food/drinks, by bans on TV advertising of energy dense fast foods, by bariatric surgery or by weight loss medication. These interventions vary across their time frames, cost and community acceptability. Guidelines for prospective parents have a time frame of decades; the population increase predicted for Australia notwithstanding, urban planning is similarly a decades-long exercise for substantial impact. We are currently not serious in addressing income disparity, with increasing differences between the highest and lowest income ends of our population; mental illness is poorly addressed, and unemployment benefits static. For both urban planning and addressing socioeducational disparity obesity is one of a number of drivers; for the other interventions obesity is the prime focus. Within this grouping two areas are noncontentious, and inexpensive in terms of taxpayers money - programs for prospective parents, and effective school programs: neither address our current situation, of 25% of the adult population being obese, and 40% overweight. To do this there are a number of avenues, not mutually exclusive.

18. Accredited weight loss/weight loss maintenance programs. Such programs - as endorsed by the Weight Management Council of Australia - are shown to be effective in an increasing proportion of those undertaking them, who are supported (in part) in terms of their cost by the private health funds. No equivalent financial support is offered under Medicare for those without insurance. It should be noted that what might be thought to be suboptimal weight loss - for example 5-10% of starting weight - has considerable health benefits, such as reduction in blood pressure and the prevalence of diabetes. 19. Food labelling proposals range from ticks of approval to traffic lights to easily understandable listings of kilojoules/calories, and recommended daily intake of various components per serve. Currently many food items are so labelled, but are commonly dismissed as unreadable/impossible to understand: constructive proposals in this area would be inexpensive, and helpful if introduced. Traffic lights other than red are contentious: green lights on carbonated sweetened soft drinks for salt and fat may act as a palliative for the red light for sugar. If red lights (equivalent to a reverse tick) are to be implemented this would require the introduction of detailed regulations, which are likely to be bitterly opposed by industry. 20. Taxes proved to be a useful driver of behavioural change in terms of tobacco use: the food/drink area is very much more complex. The short lived Danish measure has not helped this issue. A pilot program taxing carbonated sugar sweetened (as opposed to non-calorie sweeteners) soft drinks might be both simple and evidence of governmental commitment, with proceeds going directly to obesity. 21. Bans on advertising are currently voluntary during gazetted hours of childrens peak television viewing: critics claim that these do not represent the hours that children watch TV, and that a complete ban on so-called junk food is called for, similar to that for tobacco. This may raise definitional problems of what constitutes junk food/high sugar drinks, and issues of sport sponsorship at all levels. Again, a piecemeal approach may be necessary, i.e. banning not particular producers but particular products e.g. calorie rich carbonated drinks rather than diet versions, energy dense fast food but not choose four fillings subway rolls. 22. The current state of weight loss medication, and in particular weight loss maintenance medication, to be used in conjunction with a very low calorie diet, have proven effective for weight loss, but less so once a maintenance phase is required. Weight loss maintenance has been reported for diabetes medications, but to date their use would be off-label. The FDA appears to demand long studies on possible side-effects of candidate medications, but judges their efficacy (or otherwise) on weight loss, rather than weight loss maintenance. Patent issues will probably make successful weight loss maintenance medications expensive for the first 20 years of their life, even for combinations of existing drugs, representing a cost to the PBS when listed. 23. Bariatric surgery is part of bariatric medicine, in that both pre-surgery and postsurgery patients require follow up, the latter on a continuing basis. Bariatric surgery

is the potentially life-changing option for the markedly obese, or the less obese with associated disorders. Currently there are relatively few bariatric surgery operations in the public sphere, with wide state-by-state variation, and thus the majority are part-supported by private health funds for those with insurance. What makes bariatric medicine the success it is in Australia is that the continuing follow-up visits post surgery attracts Medicare funding; whether this continues to be the case is currently under scrutiny. One feature of the Obesity area is that the community, media and policy makers hear a variety of voices, each focussing on a particular facet of the issue, and often advocating specific means to address it. What needs to be done is too bring these voices together, so that the whole is greater than the sum of the parts, and together address the community, media and policy makers on the wide range of issues on which there is consensus 24. That obesity is rife (25% of adults), and overweight the new norm (40%); 25. That obesity results from a complex interplay of genes and environment; 26. That the medical and productivity costs of obesity are very substantial; 27. That as well as a personal issue obesity is thus a societal issue, appropriate for effective government leadership and intervention; 28. That government interventions need to be redirected as a matter of urgency; 29. That there is broad community agreement for government intervention. On the basis of a united voice we then need to present the options outlined above for consideration: the current problem is not that the policy makers do not know the answers, but in the main that they are slow to recognize the extent of the problem. The answers parental guidelines, school programs, urban planning, health literacy, weight loss maintenance programs, food/drink labelling, tax measures, TV advertising, bariatric medicine/surgery - need to be presented to the community, the media and the policy makers. We need to present them as investments not only in population health but importantly in national productivity; they need to be recognized as having radically different time-lines in terms of their impacts; they need to be costed and prioritized on estimated cost-benefit ratios; they are not competing, but together form whole cloth. The outcome of the Summit is that we need to join together to make this happen.