Metabolic diseases

A cross-sectional survey of Tasmanian students aged 8–13 years finds that mandatory iodine fortification of bread appears to have achieved the goal of significantly improving iodine status in this population. However, further research is needed to assess the effects of mandatory fortification in pregnant and breastfeeding women.

Kate M DePaoli BSc(Hons)(Diet) · Judy A Seal BAppSci, GradDipDiet, MPH · John R Burgess FRACP, MD, PhD · Roscoe Taylor MB BS, FAFPHM, GradDipEpid

Recent evidence and new guidelines provide impetus to shop for whole foods rather than bad foods fortified with a few selected beneficial nutrients.

Rosemary A Stanton OAM, BSc, PhD(Hon), APD

The results of this 12-month assessment provide a compelling rationale that more needs to be done to improve diet and nutrition in remote communities.

Julie K Brimblecombe GradDipNut · Megan M Ferguson BSc, GradDipNut · Selma C Liberato GradDipNut · Kerin O’Dea BSc, PhD

CorrectionSIncorrect text: In “Australia’s dietary guidelines and the environmental impact of food ‘from paddock to plate’” published in the 21 January 2013 issue of the Journal (Med J Aust 2013; 198: 18-19), there was an error in the third paragraph of the article. The statement “Around half of Australia’s fisheries are overfished” is incorrect. It should read “Forty per cent of Australia’s managed fish stocks have been ...

Linda A Selvey MB BS(Hons), PhD, FAFPHM · Marion G Carey MB BS(Hons), MPH, FAFPHM

Delays in a uniform approach to detecting gestational diabetes mellitus and providing adequate management represent a missed opportunity to improve pregnancy outcomes and maternal health.

H David McIntyre MD, FRACP · Jeremy J N Oats DM, FRCOG, FRANZCOG

Nathan Grills examines unhealthy alliances that highlight corporate social irresponsibilityIndustry sponsorship of charitable causes is increasingly promoted and practised across the corporate sector in Australia and overseas. But should such “corporate social responsibility” be limited in certain circumstances? Apart from tobacco companies, there are currently very few restrictions on which industries are allowed to support which charities. But there is a need to consider whether ...

Nathan J Grills MB BS, DPhil, MPH

To the Editor: In Australia, cancer, heart disease, stroke and diabetes mellitus contribute to 56% of all deaths,1 and have a significant nutrition-related lifestyle component. In 2008, 68% of men and 55% women were classified as overweight or obese,1 and of those in residential aged care, 50% were moderately or severely malnourished.2 Accreditation standards for medical schools (currently under review) specify that medical graduates have ...

Caryl Nowson · Marjo Roshier-Taks · Brendan Crotty

What is in our food should be on the labelTrans fatty acids (TFAs) are produced by the food industry during partial hydrogenation of edible vegetable oils, such as soybean oil, canola oil and cottonseed oil. This industrial process leads to oils that are more solid at room temperature and have better physical properties for food processing, including increased shelf life. Low levels of TFAs are ...

Gunveen Kaur PhD · David Cameron-Smith PhD · Andrew J Sinclair PhD

The prevalence of vitamin D deficiency varies, with the groups at greatest risk including housebound, community-dwelling older and/or disabled people, those in residential care, dark-skinned people (particularly those modestly dressed), and other people who regularly avoid sun exposure or work indoors. Most adults are unlikely to obtain more than 5%–10% of their vitamin D requirement from dietary sources. The main source of vitamin D ...

Caryl A Nowson PhD, DipNutDiet · John J McGrath AM, MB BS, MD, PhD · Peter R Ebeling MB BS, MD · Anjali Haikerwal BSc, MB BS, MPH · Robin M Daly PhD · Kerrie M Sanders BSc, GradDipDiet, PhD · Markus J Seibel MD, PhD · Rebecca S Mason MB BS, PhD

Objective: To determine the nutrient intakes and status of preschool children from a representative population sample in Adelaide.Design, setting and participants: Cross-sectional survey of children aged 1–5 years, using a stratified random sampling method and a doorknocking strategy, between September 2005 and July 2007.Main outcome measures: Dietary intake, assessed using a 3-day weighed-food diary; anthropometrics, biomarkers of iron, zinc and vitamin ...

Shao J Zhou PhD · Robert A Gibson BSc, PhD · Rosalind S Gibson PhD · Maria Makrides BSc, PhD

To the Editor: Your focus on obesity in the 20 February 2012 issue of the Journal expresses the frustration of many of us working in this area. After 25 years, it is clear that we have achieved little in reducing the problem at the population level and that the existing model for dealing with obesity, based on personal ...

Garry J Egger

Robert MacMahon AM, MB BS, MS, FRCS, although publicly renowned as a paediatric surgeon, was far more — teacher, innovator, a family man with a delightful sense of humour, and founding governor of the Make-A-Wish Foundation Bob was born in the Sydney suburb of Eastwood on 22 April 1931. He studied medicine at the University of Sydney, graduating in 1954. He undertook 4 years of training at the Royal Newcastle Hospital, and spent his spare time in the surf and on the rugby field for the Newcastle Wanderers. He then studied in the United Kingdom, where he decided to become a paediatric surgeon. After obtaining a Master of Science from the University of Colorado Denver, he returned to Sydney in 1965, to become the first James Fairfax Surgical Research Fellow at the Children’s Medical Research Foundation. In 1967, he was appointed inaugural Head of the Department of Paediatric Surgery at the Queen Victoria Medical Centre (later Monash Medical Centre), Melbourne. In 1970, he became Associate Professor of Paediatric Surgery at Monash University. At Monash, he developed his interest in the nutrition of premature infants, running a research program in amino acid and mineral metabolism. Between 1970 and 1975, through intravenous feeding, he increased premature infant survival from 18% to 71%. In 1974, Bob founded the Australasian Society for Parenteral and Enteral Nutrition and was its inaugural President. He served on the Monash University Human Research Ethics Committee for 40 years, and was its Chair from 1999 to 2009. He was President of the Australian and New Zealand Association of Paediatric Surgeons from 1991 to 1993. He performed the first human fetal operation in Australia and the first in-utero repair of a diaphragmatic hernia. He also pioneered in-utero laser vesicostomy and helped create the Fetal Diagnostic Unit at Monash Medical Centre. Throughout his career, Bob contributed to 10 textbooks and authored more than 60 research articles. In 2010, he was made a Member of the Order of Australia. After he retired from medicine, he enjoyed camping in the bush, surfing and golf. Bob died on 1 April 2011 from prostate cancer, and is survived by his wife Bessie and four daughters. He will be remembered for his personal integrity, enthusiasm, achievements, intellect and judgement, and his wonderful sense of humour.

Robert J Stunden

To the Editor: The prevalence of obesity in Australia is increasing, with a quarter of Australians currently obese and two-thirds overweight.1 The fast-food industry is particularly implicated in this, because it offers cheap, high-calorie and low-nutrient food and employs branding that can alter taste preferences.2 Despite considerable lobbying from health groups, Australian governments have not elected to regulate the fast-food industry, instead leaving it to self-regulate. Predictably, a recent industry self-regulatory initiative aiming to decrease advertising to children failed.3 Suggested methods of regulating the fast-food industry have included taxing unhealthy foods, limiting advertising to children, and mandatory nutritional labelling. However, recent research has suggested a more creative solution. Instead of restricting the industry, perhaps the effective branding strategies of fast-food companies could be used for health promotion. It has been shown that children prefer food in McDonalds-branded wrapping over the identical item in plain wrapping.2 Even typically healthy items, like milk and carrots, are preferred when given McDonalds branding. New research has taken this idea a step further and shown that the branding of a fun, health-themed television show can be used to make healthy foods more appealing.4 These findings may motivate a new population-level strategy to reduce obesity. Established fast-food brands could be given incentives to apply their branding to healthy items. This would allow the fast-food industry to contribute to a healthier food environment, while avoiding the market restriction of taxation. Another option is to establish a government-funded enterprise that uses fast-food marketing to sell healthy items. Costs of such ventures may be outweighed by future reductions in health spending. With regard to obesity, perhaps it is time we started looking on the outside of the box for the solution.

Dugal B S Smith

Non-surgical intervention has many benefits. A recent article published in the Journal1 was widely reported in the popular press, with statements such as the following being quoted: public health messages encouraging people to eat healthy food and to exercise are unlikely to have long-term impact on their weight....

Daniel J Green PhD · Andrew J Maiorana PhD

Objectives: To examine the prevalence of overweight and obesity in Australian secondary school students and identify factors associated with excess adiposity....

on behalf of the NaSSDA Study Team*

Despite having spent many a rapturous hour staring at the back of cereal packets, I tried not to take it personally when I heard Professor Bruce Neal from the George Institute saying, on ABC Radio, that anyone who reads and understands an Australian nutritional panel is a weirdo....

Ruth M Armstrong

What can we do to avoid discrimination against the obese? A few years ago I had the pleasure of tutoring groups of medical students in their communication course. One topic on the syllabus was discrimination — an opportunity for the students to reflect on their own potential biases. During these sessions I discovered that most students could overcome racism, homophobia and religious prejudice quite readily, but had considerable difficulty in being non-judgemental about Australia’s most prevalent health condition: obesity. In an effort to help my students, I would recount the following anecdote. In the 1980s, I worked in a small endoscopy facility that employed some nurses who were significantly obese. One of these nurses, whom I shall call Janet, was not normally especially friendly to patients. One day I was struck by a particular encounter. A patient was wheeled in, on an extra wide trolley — a patient with morbid obesity. Janet started to stroke the patient’s forehead and call her “dear” and “darling” in the gentlest tone of voice. I had never seen Janet so compassionate before. This made me realise that Janet herself must have experienced negative attitudes from health professionals. My students have now graduated and will be fine non-judgemental doctors, I hope. But discrimination against obese people in health care settings is still common. Take this example from a blog written by “Midlife Midwife” in the United States: I have to admit. I have a hard time emotionally with severely overweight people ... I have to really work at not being judgmental of them. I get a sinking feeling in my stomach and frustration bubbles up into my chest when I see a patient’s weight is over 250 pounds. I have to really work to put on my smile and be as kind as possible.1 Midlife Midwife goes on to discuss the technical difficulties of doing a Pap smear, including lack of appropriate specula, in obese women. The negative attitudes held by Midlife Midwife have been shown to be held by a large percentage of doctors, students, nurses and others.2 Overweight people suffer inferior care, negativity and even ridicule, and they become reluctant to access health care. They are then at risk of further deterioration in health. Critical attitudes and stigmatisation of obesity do not make weight reduction more likely — in fact the reverse is true. Discrimination has been shown to lead to worsening of unhealthy eating patterns. Conversely, it has been shown that empathy enhances weight reduction. Overweight people are now claiming the moral high ground. There is a fat acceptance movement, which has spawned various societies, such as the International Size Acceptance Association. However, critics of the fat acceptance movement aver that societal acceptance of obesity will reduce the aspirations of the community to lose weight. If I were tutoring medical students today, they might ask: what do we do? Do we treat obesity as a disease or simply a physical attribute? If we overcome our prejudices and show empathy, are we normalising obesity? To help in my answer, I might reflect further on my own practice. Over the years I have seen many patients with non-alcoholic fatty liver disease, and so counselling on weight reduction has become part of my bread and butter (thin scrape only!). I think I have been able to empathise with the patient without normalising obesity — obesity is a chronic medical condition. Fat acts as a huge metabolic organ, producing cytokines that cause symptomatic bad health. I have learned that if you add a few E-verbs to a good spoonful of Empathy you will help your patient achieve weight loss. The mix should include some Empathising, some Evoking of the patient’s reasons to change, a good helping of Enabling (with simple strategies such as a daily walk), some Educating and some Empowering the patient to take control, all while Enjoying the collaboration. If you work with your patient as a team — acting as an ally and an Equal (the final E-word) — you will have a great recipe for success. Midlife Midwife may have learned a thing or two from one of the responses to his or her blog: Maybe speculums should be made to fit the people who need them. And maybe fat people are human enough to KNOW that you don’t like them and that you automatically think less of them, and that’s why many would rather go for years without medical care than subject themselves to a snotty, superior attitude and knowing that they’ll be snickered at behind their backs. Oh, and my husband has no trouble finding where to put the “speculum” in, and I’m 350 lbs. And I regularly walk 5 miles for the hell of it. Put that in your pipe and smoke it.1 Yes, a daily walk is good for everyone — but the most important walk for doctors is the walk in our patients’ shoes.

Katrina J R Watson MB BS, FRACP, MPH

To the Editor: The recent article by Hebden and colleagues on the frequency and content of fast-food advertising on Australian television concluded that the industry self-regulatory initiatives currently in place are ineffective in reducing children’s exposure to advertising of non-core foods.1 As the managers of these self-regulatory initiatives, we consider this conclusion to be misleading to your readers. The Australian food and beverage industry recognises the level of community concern in relation to food and beverage advertising to children. There are currently two self-regulatory initiatives in place to moderate advertising of non-core foods and beverages to children: the Responsible Children’s Marketing Initiative, that covers products found in retail outlets; and the Australian Quick Service Restaurant Industry Initiative for Responsible Advertising and Marketing to Children, that covers foods sold in quick-service restaurants. These initiatives are designed to restrict advertisements aimed at children by means of the nature of the advertisement and/or the medium by which it is delivered. Hebden et al base their conclusion on a broad definition of “advertising to children” that captures all advertisements screened between 5.30 pm and 10.30 pm on weekdays, and between 7.30 am and 11 am and 4.30 pm and 11 pm on weekends. Specific time periods are not, in fact, covered in the industry initiatives as these periods capture programs that are watched primarily by adults. If children are watching these programs, they are likely to be doing so accompanied by an adult who can provide guidance on appropriate food consumption. However, industry does recognise that times when children are watching television alone and advertisements that are designed particularly to target children are a different matter, and that it must act responsibly in these areas. The success of the initiatives should not be measured by advertising frequencies during certain time periods, as implied by Hebden and colleagues. Nevertheless, the data presented by Hebden et al actually suggest a significant reduction in the frequency of non-core-food advertisements (excluding fast food) in just the first year of operation of the initiatives, which, in terms of what the authors perceive to be “advertising to children”, should be viewed as a positive finding. The Australian Food and Grocery Council is committed to monitoring the self-regulatory initiatives and makes the results available to all stakeholders to help evaluate the effectiveness of what the initiatives set out to achieve.

Peta E Craig · Geoffrey Annison

In reply: Children’s exposure to advertising of unhealthy foods is of concern because children are exposed to a large volume of such advertisements. The World Health Organization has clearly stated that any efforts to address this issue must reduce children’s exposure to unhealthy food advertising.1 Our research article2 was based on such measures. The viewing times applied in our research were specifically those when the highest numbers of children aged 5–12 years watch commercial television, according to Australian audience data for Sydney commercial television stations, and thus are exposed to advertising. Craig and Annison refer to a decrease in the relative proportion of advertisements for unhealthy fast foods over the first year of the industry initiatives. However, readers should be aware that our research showed that the total amount of fast-food advertising increased over this period, so that the frequency of unhealthy fast-food advertisements that children were exposed to remained the same. To make meaningful changes to what advertising children see, time-based restrictions would form a more responsible approach for regulation than the current industry specifications.

Lana Hebden · Lesley King · Anne Grunseit · Bridget Kelly · Kathy Chapman