Three phases were discernible in the process of policy making that occurred as part of the NSW Childhood Obesity Summit: 1) building and maintaining the momentum 2) summit debate and 3) outcomes and policy formulation.
1) Building and maintaining the momentum
Obesity had been recognised as a longstanding and increasingly important public health problem. Ebbeling et al (2002) pointed to publications decades earlier highlighting the issue and the need for a policy response[24
]. Media interest in the issue of obesity in Australia was stimulated by available data highlighting "the doubling and tripling"
of rates of obesity and concerns around the "second fattest kids in the world" (FGD)
. Obesity was seen as "the new tobacco"
– the public health issue which was being recognised as demanding attention. Articles published in the peer review literature around this time [24
] were triggers for media coverage and interviews with key informants and the focus group with NSW Health staff all emphasised the importance of media coverage in bringing the issue to public and policy attention:
"It [media coverage] was partly driven by data...the MJA [Medical Journal of Australia] also carried some data on childhood obesity and ... reinterpreting existing data sets. ...so that put it on the radar, that doesn't mean you've got [a] Summit happening yet... the data is essential – it is necessary, but not sufficient." (FGD)
"The doubling and tripling was the most used [news] grab everywhere, in every article, and it is still used." (FGD)
Why was NSW Health interested? The issue was shown to be important to the public. It provided the opportunity to divert attention away from other health issues which are considered solely the responsibility of government, for example, health care service provision. NSW Health also wanted to show leadership in an area where there was arguably Federal Government inaction. In New South Wales there was a clear perception that "prior to the Summit there was a national leadership vacuum"
around childhood obesity (FGD)
. An earlier government summit on illicit drugs [26
], had mobilised massive public attention and resources and it was hoped by NSW Health that a childhood obesity summit would draw in funds and resources to address this public health problem. A summit was seen as providing scope to debate interventions in an area where there was no scientific or political clarity at the time:
"there was interest, we were asked to do things, write things, pull things together... there were lots of false starts...we had things in train that were going to take another 5 or 10 years and they said they wanted a solution today... a summit was suggested as a way forward."(FGD)
Table shows the number of media articles by month between April 2002 and December 2002. Within each month the percentage of articles that used Type 1, Type 2 or Type 3 evidence are identified. All the articles drew on more than one type of evidence. Peak months of coverage were July when the Summit was announced (n = 15), September when the Summit was held (n = 40), and December when the Health Minister announced the preliminary government response (n = 19). In the months prior to the announcement of the Summit, childhood obesity was covered 1–2 times per week in the newspapers studied.
Number of media articles and evidence type used
In the lead up to the Summit, most of the articles cited evidence of at least one type concentrating on Type 1 evidence focussed on the magnitude of the problem, backed up by expert opinion (Type 2). In the month before the first announcement by government in December economic data (Type 3), always referring to the cost of obesity to the health care system, were also reported.
Prior to the Summit and throughout the study period, Type 1 evidence was widely reported and largely uncontested, quoting authoritative sources such as the Lancet [24
] and the Medical Journal of Australia [25
] concerning the magnitude of the problem. Media representations drew on such data to present 'sound bites' to stimulate debate. The most commonly reported statistics were that either one in four, or one in 5 children in Australia was overweight or obese and that overweight and obesity had doubled between 1985 and 1995. These data from Magarey et al (2001) [9
] were also contained in the background document prepared for the Summit [27
] and included in the factual preamble to the Summit resolutions [16
]. Once the Summit was underway, Type 2 data were more widely reported and ideas from experts, community members and key stakeholders concerning the way forward, were presented in the media. In putting forward their views, these stakeholders called on common sense understandings, research studies or pointed to a lack of conclusive evidence to support inaction.
Food advertising to children was a case in point. Prior to the Summit, debates about evidence in the media focused on taxing 'high fat foods' and banning food advertising to children. The soft drink industry spoke about the lack of good evidence for the effectiveness of such initiatives and the negative economic impact of a "fat tax". Physical activity and the role of parents as an influence on obesity were highlighted by the advertising and food industries as being the major influences on childhood obesity. Results from Sweden which were stated by the food and advertising industry as showing obesity rising despite an advertising ban were used to demonstrate that "there is no evidence that advertising makes children eat more fatty foods" (The Australian Newspaper, 1 July 2002
]. It became clear from the media coverage during the Summit that a ban on food advertising was the critical concern for industry who were calling a 'clear link' between harmful childhood behaviour and commercials, with editorials suggesting that instead "parents are the dominant influence on food choices" (Daily Telegraph, 12 September 2002)
2) Summit debate
The Summit was held in September 2002 at Parliament House in NSW. An across-government organising committee oversaw delegate selection and sought to ensure balanced representation including: i) children and young people; ii) families, parents and community perspectives; iii) experts; iv) relevant peak bodies; v) special population perspectives, such as the socially disadvantaged, people from culturally and linguistically diverse communities, Aboriginal and Torres Strait Islanders, rural and remote communities, and people with disabilities.
The Summit provided an opportunity for delegates to present their case for action during plenary sessions. During the Summit, nine working groups (WGs) were convened: i) Early Childhood, ii) Family and Community, iii) School Education, iv) Health, v) Sport, Recreation & Fitness, vi) Local Government, vii) Commercial Food Industry, viii) Media, and ix) Transport and Planning.
The WGs were requested to put forward 10–15 resolutions for the Communiqué to be presented to government. The importance of evidence for the resolutions was made clear by the NSW Premier on the first day of the summit when he referred to the NSW Drug Summit [26
], which had been held in May 1999.
"The Drug Summit emphasised looking at evidence, basing policies on evidence ... I would like that to be your guide too." (NSW Premier, Day 1 pg 33)
The case for action to tackle childhood obesity was uncontested from the outset. In opening the Summit the NSW Minister for Health referred to strong empirical evidence of the magnitude of childhood obesity:
"In Australia the level of combined overweight and obesity between 1985 and 1995 has more than doubled... Today in New South Wales one in five children aged between seven and 15 are classified as being either overweight or obese." (NSW Minister for Health, Day 1, pg 5)
Experts from government departments, academic institutions and the health service put forward similar statistics that highlighted the magnitude of obesity. Many outlined the consequences of overweight and obesity for type 2 diabetes in particular. The use of simple statistical concepts such as "doubling in rates" and "one in five of our children" were commonplace. Economic evidence highlighted the cost of the "obesity epidemic" to society – "it costs us a community $830 million a year" (Minister for Health, Day 1, pg 7) and individuals – "in one year the personal cost to individuals who are obese is $19 billion" (expert, Day 1 pg 16). Such data were uncritically and widely accepted during the Summit.
On the opening day, experts, parents, community groups and industry talked anecdotally about societal changes over decades and their impact on physical activity and food consumption. Statistics and studies were referred to in support of these observations, such as an increased reliance on carbonated sugared drinks, although no actual data were provided. Data from the US concerning changes in levels of physical activity were presented: "most people in my generation walked to school, today less than a third of children in the United States walk to school" (US expert, Day 1, pg 12) and Australian data on sedentary activity: "97% of our adolescents watch television ... between 60 and 80% play computer or video games." (Australian expert, Day 1, pg 16). Anecdotal observations about changing societal behaviours and environments were widely cited and seen as important factors to address despite the lack of reliable trend data and research evidence:
"we do not yet have evidence that any single one of these factors is driving the epidemic" (US expert, Day 1, pg 13)
"we know very little in any, firm solid way about the factors that influence young people to be active or sedentary – all we have to work with over the next three days are some recently informed guesses and some far less well-informed speculations" (Australian expert, Day 1, pg 12)
The views of young people, were an integral part of the Summit process and provided an emotive appeal to take action. Young people's stories were shown on video and they addressed the Summit. However, there appeared to be little attempt to draw these views together, articulate common threads or examine whether and how such views related to other empirical data and expert opinion. A young person opening the Summit stated that "It is genuinely important that our voice be heard"(young person, Day 1, pg 2). The FGD participants saw young people's stories as being powerful in stimulating action:
" we had to have lots of consultation processes that included the voice of the child... engaging the children... it was the most powerful thing." (FGD)
A young person at the Summit, however, expressed frustration about the focus on evidence:
"Unfortunately we have been bombarded with statistics. They have been repeated over and over again ... we are almost scared to put up a decent suggestion." (young person, Day 2, pg 30)
In contrast to the research evidence supporting the magnitude of the problem and the influencing factors, evidence supporting calls for action were mostly opinion and ideas with some reference to overseas efforts. Nonetheless, much was made of the need for evidence-based strategies, with a US expert claiming three strategies that were "defensible, but not conclusive" (US expert, Day 1, pg 13)
: breastfeeding, limiting television viewing and the promotion of physical activity. A Cochrane systematic review [30
] covering 1985–2001 and encompassing 14,000 studies was reported (researcher, Day 1, pg 37). It found 11 studies of a high enough quality to examine the effectiveness of the intervention and it found only small or no effects with those interventions that were most effective focussed on reducing sedentary behaviour. A few delegates questioned the need for evidence from primary prevention trials, pointing to broader experiences that tell us "what works". They highlighted other successful public health campaigns such as in tobacco control as evidence for the success of a range of strategies, including advertising controls and taxes:
"we do need evidence, we do need to work at what has been shown to be the most effective, but that should not inhibit us from acting now. There have been a number of successful public health programs that have been introduced without definitive evidence." (expert, Day 1, pg 39)
The FGD and comments by Summit delegates highlighted the need for action coupled with thorough evaluation:
"There needs to be a recognition of the sense of urgency...that policy won't wait for the data." (FGD)
"This is about promising interventions, we have to just go with promising interventions, make sure they do no harm and just evaluate the heck out of them, and then maybe in ten years time, if they weren't the best things to do, well at least we did something" (FGD)
"we need periodic surveys to tell us how we are doing with respect to implementation of strategies ... we need causal models, that is, longitudinal studies which allow us to link risk factors like change in the food supply with changes in the prevalence of obesity." (US expert, Day 1, pg 13)
"we would like to see a regular – maybe five yearly – national nutrition, physical activity and health survey." (industry, Day 2, pg 2)
"Certainly, we need to take action, but at the same time we need to be doing research. We cannot continue to act in an evidence vacuum." (expert, Day 2, pg 20)
The most contentious issue centred on the role of food advertising to children (see Figure ). The intensity of the debate between food industry representatives and the advocates of a ban on food advertising to children clearly illustrates the way different types of evidence are drawn upon to articulate a particular position or undermine that of opposing perspectives.
Contesting the evidence: food advertising and obesity.
3) Outcomes and policy formulation
The final Communiqué to government was to include a "factual foundation" and recommendations and resolutions for future action. The purpose of this component of the Summit was to: "Frame evidence-based solutions within a community-based 'reality check' perspective."(Day 3, pg1)
Evidence of the magnitude of overweight and obesity was included with little debate. Statements about the influencing factors were carefully worded to reflect agreement on importance and available evidence:
"Although physical activity trend data is lacking, it is apparent that children and adolescents are less physically active" (Day 2, pg 72)
"An increase in television viewing is associated with an increase in obesity in children. An increase in sedentary behaviour is associated with an increase in obesity in children. Experts have advised that television viewing needs to be one of the targets for obesity control efforts" (Day 2, pg 78)
Exposure to advertising messages was included in the factual preamble referring to the range of potential influences on food selection behaviours. The resolutions about food advertising to children generated the most debate concerning the evidence-base for such interventions (see Figure ) and the relationship between food choice and television viewing. This debate illustrates the use of different types of evidence by industry representatives as one means of opposing calls for a ban on food advertising to children.
A resolution to ban food advertising to children was not agreed. In its place agreement was reached to have an independent review by the Federal government of the regulatory arrangements for food advertising "in recognition that food advertising is one of the contributing factors to the prevalence of eating habits that may promote obesity"(Day 3, pg 9) in addition to a review of a voluntary code to be undertaken by industry. Attempts by the Food Industry to have this statement deleted from the Communiqué were not successful. A systematic review of the impact of food advertising on diet, physical activity and childhood obesity was also recommended.
All other resolutions passed with minimal debate, including those addressing physical activity, school education, transport and planning. Most of the resolutions agreed at the Summit and taken up in the subsequent Government Action Plan
] were focused on physical activity and nutrition education. Mandatory guidelines for school canteens also passed as a resolution despite some opposition from industry. Numerous resolutions in the Communiqué [17
] referred to research and a detailed section on surveillance and monitoring proposed a funded collaborative centre of excellence in research, prevention and management.
Limited attention was devoted to the financial and logistical feasibility of the resolutions – this was apparent by the number of resolutions that required intervention at a federal rather than state level. However, the preliminary response from the government in December considered what was feasible in the current financial and political context:
"it wasn't really evidence-based, it was the feasibility of whatever strategy they had suggested..." (FGD)
In the final Summit address by the NSW Health Minister [16
] the two resolutions specifically mentioned and strongly supported were the recommendations on school canteens and a collaborative centre for excellence for overweight and obesity research. These two initiatives were subsequently publicly announced in December as the key response to the Summit by the government [19
]. The advisers to the Minister and NSW Health were concerned to ensure that the Summit resulted in some "announceable"
interventions – and the two chosen seemed "doable"
, of value, and in some respects least contentious (FGD)