Metabolic diseases

The reluctance of Australian policy makers to take evidence-based action on childhood obesity is unacceptable

Michael J Moore · Martin McKee · Aimee L Brownbill

A 58-year-old woman was admitted with chronic lower limb ulcers

Alicia R Jones · Kavita Kumareswaran

To the Editor:The Editorial by Harvey and Diug1 on the value of food fortification as a public health intervention was prompted by demonstration of the effectiveness of mandatory iodine fortification in reducing iodine deficiency.2 Mandatory fortification of wheat flour for bread making was introduced in Australia at the same time to prevent neural tube defects. Harvey and Diug state that the two are conceptually different, as the former addresses a population iodine deficiency, whereas folic acid fortification is to compensate a presumed genetic defect that cannot be individually recognised, thus raising ethical questions about exposing the many for the benefit of the few. However, this is the case in almost all public health interventions. Using an example of Harvey and Diug, we expose the whole population to the mandatory fortification of flour with thiamine to prevent Wernicke–Korsakoff syndrome, a condition largely confined to people with a chronic alcohol problem. The concern they raise about mandatory folic acid fortification1 is exposure to unmetabolised folic acid, proposed as possibly increasing adverse effects, but which have not been clearly or conclusively shown. They refer to an Irish study reporting that seven of the 68 children in the study had detectable levels of unmetabolised folic acid in their blood.3 Ireland does not have mandatory folic acid fortification; the main sources of folic acid were voluntarily fortified breakfast cereals and fortified milk — products that are fortified with relatively high levels of folic acid. In Australia, breakfast cereals and other food products are also permitted to be fortified voluntarily — breakfast cereals often contain around 200–300 μg of added folic acid per 100 g (or about 100 μg per serve). This compares with mandatory fortification of flour of 200–300 μg per 100 g flour, or about 40 μg folic acid per slice of bread. While either source could lead to circulating unmetabolised folic acid, the higher doses in voluntarily fortified products are more likely to do so. With the introduction of mandatory fortification, there was a reduction in neural tube defects.4 Importantly, there has been a 68% reduction in previously higher rates of neural tube defects in Indigenous people.5 Mandatory fortification provides a more equitable, consistent and cheaper source of folic acid to the population than voluntary fortification. Let’s leave mandatory folic acid fortification preventing neural tube defects in our population.

Carol Bower · Fiona J Stanley · Mike Daube

To the Editor:We congratulate Cheney and colleagues1 for throwing light on the contributions of overweight and obesity on adverse birth outcomes by analysing data from a teaching hospital in central Sydney.1 Around 16% of the women presenting between 2010 and 2014 were overweight, while 7% were obese. Furthermore, despite obesity being an important risk factor for adverse pregnancy outcomes, their study showed a lack of recording of body mass index (BMI) in patients’ records. Adverse pregnancy outcomes are more common among Indigenous Australian women than non-Indigenous women;2 obesity levels are high in pre-conception and in pregnancy, and the subsequent adverse impact on increased metabolic health in offspring is likely contributing to early onset of diabetes and chronic disease in Indigenous Australians. Hence, we want to extend the debate to report on what is happening in primary health care (PHC) settings for Indigenous women. We have analysed continuous quality improvement data from audits of adherence to evidence-based guidelines for maternal care in 65 Indigenous PHC centres (1091 patient records) across Australia during 2012–2014.3 The majority of women at most PHC centres had the first trimester weight recorded (mean, 90%; range, 60–100%), but there was wide variation in recording of BMI (mean, ∼ 60%; range, 0–100%) (Box). This indicates that most barriers to BMI recording are more to do with clinicians’ understanding of the value of and ability to calculate BMI than around women’s willingness to be weighed. For women with an abnormal BMI (mean, ∼ 30%; range, 0–100%), there was wide variation in documented BMI management plans (mean, ∼ 40%; range, 0–100%). Dealing with these generally low levels of recording and wide variation in recording between PHC centres is a vital early step in limiting the contribution of obesity to adverse pregnancy outcomes and improving long term health outcomes for the mother and baby. Women attending PHCs that had participated in continuous quality improvement activities were more likely to receive recommended pregnancy care related to screening and brief interventions for modifiable lifestyle-related risk factors, such as obesity.4,5 These findings support the incorporation of continuous quality improvement activities into the delivery of maternal care. Box – Record of scheduled maternal care services received by Indigenous women at Indigenous primary health care centres, 2012–2014* BMI = body mass index. * More information on how to interpret box plots is available in Gibson-Helm et al,3 page 21.

Jodie Bailie · Jacqueline A Boyle · Ross S Bailie

To the Editor:We fully support Colagiuri’s appeal to implement comprehensive, regulatory action to reduce sugar-sweetened beverage consumption.1 Excessive sugar-sweetened soft drink consumption is associated with weight gain, diabetes and dental caries.2 Strikingly, sugary drinks are the single largest contributor of added sugars in the diet of Australians aged 14–50 years.3 In recognition that environmental changes can support healthier consumer choices, the New South Wales government has pledged to remove sugary drinks for sale from all its health facilities by December 2017.4 This follows the lead of 13 health services in Victoria that have also adopted this health-promoting policy. Media coverage of these measures has been positive,4 as communities look to health centres to be leaders in supporting and protecting public health. In contrast, Australian university campuses, including those with medical schools responsible for developing future health leaders, remain saturated in soft drink promotions and sales. Detractors of policy-based approaches suggest that education efforts and offering healthy choices are preferable to “nanny state” restrictions. Health education campaigns that advise people to restrict their consumption of sugary drinks must battle against the ubiquitous advertising and availability of these products. In the United States, it is well documented that the university food environment is shaped by purveyors of unhealthy food and drink.5 “Free choice” arguments ignore the realities of sales contracts that include exclusively selling certain brands and products. Similarly, in Australia, exclusive sales contracts offered to suppliers may restrict the choices of staff and students on campus. The real issue appears to be the unfounded fear that banning the sale of soft drinks on campuses may have negative revenue implications. This fails to acknowledge that replacement beverages that are not sugar-sweetened could still be sold. Australian university campuses have readily banned smoking and the sale of tobacco without experiencing financial hardship as a consequence. Universities, especially those training future health professionals, need to flex their collective muscle and be part of the momentum towards creating healthy environments. Initiating healthy beverage policies is a significant step forward.

Becky Freeman · Kieron Rooney · Eloise Howse