A radical re-think is needed in preventive health that addresses the root causes of ill-health and takes a holistic, collaborative, systems approach to improving health and wellbeing.

The following is a summary of the SNRC (Sugar Nutrition Resource Centre) submission to the consultation paper on the development of a National Preventive Health Strategy for Australia. The consultation paper asked a series of questions to guide feedback from submitters.

Vision of the strategy

The SNRC believes the vision adequately describes why an evidence based preventative health strategy is needed, and how multifactorial activity (activities that address the multiple determinants of health) can lead to longer and healthier lives for Australians. The vision could be further strengthened by presenting a positive message for what it is hoping to achieve, instead of what it aims to prevent. Framing health messages in a ‘gain’ context may enhance adoption and encourage partners to participate.

Aims and targets

Given the complexity of issues surrounding preventive health, a holistic strategy is required. It is our view that activities addressing the wider determinants of health should be a priority, be based on scientific evidence and take a system-wide approach.

We support new research by the Australian Partnership Prevention Centre that encourages the broadening of scope of prevention activity and urges a systems approach to address the dynamic nature of chronic disease risk factors.

Agreement with principles

Our comments are in relation to selected principles: collaboration, community and evidence.

Collaborative cross-sectoral initiatives are needed to support preventative health. A Government led commitment to address health prevention, where partnerships, collaboration across all sectors and shared responsibility should be a priority. Given the food industry operates within the complexity of the health environment, we believe we play a key role in enabling solutions to prevent health problems. All stakeholders should have a role in taking responsibility for meaningful action. We look forward to the opportunity to work in a true and meaningful partnership with other stakeholders on this strategy in the future.

Key elements from research that should be considered in order to ensure long term success are:

• Identifying key stakeholders for early participation.
• Strong leadership and engagement of partners who are actively engaged, rather than a single main driving force (Bagnall et al 2019).
• Good governance and shared values that result in better participation, policy-making and intersectional action, as per the WHO European Healthy Cities Network (de Leeuw et al 2014, Goumans & Springett, 1997).
• Relationships, trust and capacity building which is allowed time to develop and a strong relationship between stakeholders (Bagnall et al 2019).
• Partnerships that create sustainable and multilevel change (Public Health England, 2014 & 2019).

We support a focus on evidence-based activity that considers overall dietary patterns and total energy consumption rather than a focus on any single nutrient.  There is a need for the examination and consideration of research that is specific for the Australian population in this regard. Regarding sugars intake, overweight and obesity, the emerging evidence in recent years challenges common misconceptions. For example:

• A systematic review on the effects of sugars on body weight show their effect is mediated via changes in energy intake and is not specific to sugars per se (Te Morenga et al 2012);
• Free sugars intake is not associated with BMI z-score in Australian children and adolescents (Wong 2018);
• There is no significant difference in micronutrient intake between children and adolescents meeting the WHO 10% free sugars guideline and those that don’t (Wong 2019);
• Micronutrient intakes in Australian adults are not compromised at the current average population consumption of free sugars.

There should also be regular monitoring of dietary trends and associated research. The most recent data available on population intakes is now 5 years old and the data was collected in the years prior. If setting nutrition related targets, we must have data on which to base it on.

System enablers

In the context of the latest research, the enablers that have been indicated are lacking a range of important elements for success.

Research has highlighted 9 key enablers that correspond to successful initiatives for addressing complex public health problems:

1. Strong leadership and full engagement of all partners who are genuinely involved, rather than one single leading force;
2. Engaging the local community so they can identify their needs and actively participate in local solutions, allowing them to build their own capacity to address local issues;
3. Investing time and effort to build good working relationships that result in mutual trust;
4. Shared vision, value and an explicit commitment to good governance;
5. Build an appropriate network of partnerships, to create sustainable multi-level environmental change. Engaging non-traditional partners will expand reach;
6. Consistency of language used across organisations to unify the approach, while reflecting each organisation’s own beliefs and structures;
7. Integrate initiatives so they have broader policy context, and not just seen as additional to the mainstream;
8. Local evaluations to show effectiveness of local initiatives from the outset;
9. Funding support and resources.

Targets for focus areas

It’s not clear why there is heavy reliance on the Australian Dietary Guidelines as they provide guidance but no targets, and dietary surveys show there is an ongoing lack of adherence to the Guidelines.  Rather than continuing more of the same or similar activity, with a likely similar result, we suggest taking a fresh look at the myriad of factors that can favour healthy diet. Taking a holistic systems-based approach is a new way of thinking for prevention activity.  

For example, a novel study from the UK highlights how health policy continues to target the same interventions over time, while ignoring the growing evidence of the complex and multi-system nature of obesity (Nobles et al 2021). Preventative health policy has failed to keep pace with the evidence in this case. It has failed to recognise the complexity of the issue and the opportunities to enact population level change. The researchers conclude that policymakers need to be more attuned to the complexity of the system. The policy target should be helping the system to change, rather than a specific outcome per se.

Using the lens of the ‘wider determinants of health’, a greater variety of targets are needed for this Strategy to achieve progress on the issue of access and consumption of a healthy diet.

Regarding the free sugars target, the use of ‘free sugars’ is not appropriate for Australians. The Australian Dietary Guidelines refer to added sugars, while other policy initiatives including the Health Star Rating system inform consumers on total sugars. Free sugars and added sugars are not, by definition, the same. And in the context of the WHO 10% energy as free sugars target, we are already close to achieving it; Australian average free sugars intakes are 10.9% of total energy (Australian Bureau of Statistics 2016). Median intake is 11% energy in New Zealand.

A core principle of healthy eating is to choose whole foods, and not take a single nutrient approach. The Australian dietary guidelines note the importance of overall dietary patterns and advise against singling out or completely avoiding any specific food or drinks. This strategy presents the opportunity to focus on consumption of positive nutrients and foods, rather than avoiding the apparent ‘at risk’ nutrients such as free sugars. 

Framework for action

The framework for action appears to provide a sensible foundation for activity, however, in the context of the latest research, it is lacking a range of important elements for success.

A more holistic strategy is required, that is based on the latest scientific evidence. For example, a ‘whole system approach’ (WSA) which applies systems science and is gaining increasing focus globally for application for obesity and other complex health issues. Public Health England are rolling out an evidence based Whole System Approach for obesity prevention, and they provide practical demonstration and implementation guidelines.

Systems thinking is a framework to look at factors involved in a problem, the relations between these factors and changes over time (Howse et al 2020). Activity is integrated across political, social, cultural, economic and scientific areas. A system approach takes into account the interactions between the factors involved and includes adaption and feedback to drive activity.  

There are 10 areas of activity which are recommended to be considered as part of a ‘systems approach’ (Bagnall et al 2019):

1. Identifying the public health system, interacting elements, bodies and boundaries;
2. Capacity building to support the various stakeholders;
3. Creativity and innovation to address health and social problems;
4. Activity to develop and maintain relationships of stakeholders involved;
5. Support to engage local community in program delivery;
6. Mechanisms to support communications amongst stakeholders;
7. Health improvement policies;
8. Strategies to resource policies and staff;
9. Strong strategic leadership;
10. Monitoring and evaluation to enhance effectiveness and acceptability.

The value of cross-sectoral programs is encouraged as part of the WHO’s Global Action Plan for the Prevention and Control of Non-communicable diseases. Governments, organisations and individuals need to work together to address the problem in a dynamic and flexible way. A systems approach would create this environment and help Australians lead longer healthier lives.

REFERENCES

• Australian Bureau of Statistics. (2016). Australian Health Survey: consumption of added sugars, 2011-12. \Dietary energy from free sugars.
• Bagnall AM, Radley D, Jones R, et al. (2019). Whole systems approaches to obesity and other complex public health challenges: a systematic review. BMC Public Health, 19(1): 8.
• de Leeuw E, Tsouros AD, Dyakova M, Green G (2014). Healthy cities: promoting health and equity: evidence for local policy and practice. Copenhagen: WHO Regional Office for Europe.
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• Howse et al. (2020). What does the future hold for chronic disease prevention research? Australian and New Zealand Journal of Public Health, 31 August 2020. doi: 10.1111/1753-6405.13028
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• Public Health England. (2014). Paths to public health and wellbeing: examples of local authority action in the South-West. London: Public Health England.
• Te Morenga, et al. (2012). Dietary sugars and body weight: a systematic review and meta-analysis of randomised clinical trials and cohort studies. BMJ, 345:e7492
• Wong THT, Louie JCY. (2018). The direct and indirect associations of usual free sugar intake on BMI z-scores of Australian children and adolescents. Eur J Clin Nutr, 72(7): 1058-1060.
• Wong THT, Mok A, Ahmad R, Rangan A, Louie JCY. (2019). Intake of free sugar and micronutrient dilution in Australian children and adolescents. Eur J Nutr, 58(6): 2485-2495.