Would such a move be useful and welcomed in Australia? Read on…

Associate Professor Tim Gill, Institute of Obesity, Nutrition and Exercise, University of Sydney:

“Requiring calories counts to be placed on menu boards in restaurant chains is a good thing but as Jane Martin points out, it is unlikely to have a profound effect on food choice by itself.

It is akin to putting up speed advisory signs at dangerous bends in the road. They are useful if you understand and are accepting of the benefits of such advice; recognise your own limitations and the need to be cautious of road conditions; are not distracted by other issues and thus fail to acknowledge such advisory signs; or over-ride the advice because of your perceived lack of time to slow down.

Unfortunately with both calorie counts and speed advisory signs they are often ignored.

This is not a reason to avoid instituting such measures because they will be of benefit to those who are in a receptive state and can effectively process and act on the information.

Rather it is a reminder that such measures need to be instituted in combination with a variety of other strategies to encourage and support people to be more receptive to these signals.

Of course the preferred method of dealing with dangerous bends in the road is not to encourage people to slow down but rather to take that responsibility away from them by remaking the road at great expense to remove the bend.

Funny, no one ever suggests that this is a nanny-state approach to road safety.”

***

David Gillespie, author of Sweet Poison, Why Sugar Makes us Fat:

“Would you feed your kids a glass of milk or a glass of Coke for breakfast?  Yep, I’d go with the milk too.

How about if you know that the milk has 168 Calories but the Coke has only 108.  Would you switch to the Coke then?  No? You’ve just explained to yourself why Calorie labelling is a pointless waste of time.

You’ve also explained to yourself why Big Sugar is particularly keen on Calorie labelling.  They know a few things which most nutritionist have either forgotten or didn’t know in the first place.

Fat serves up 9 Calories per gram whereas everything else (including sugar) is only 4 Calories.  Calorie labelling is therefore really just fat labelling by another name.  The reason the milk has more Calories than the coke is because it contains fat and the Coke doesn’t.

The study referred to by Dr Russell tells us that it doesn’t really matter anyway.  Just over a quarter of the respondents noticed the Calorie information and it didn’t influence their choices anyway.

Big Sugar knows that no-one knows or cares what a Calorie label means and even if they did, sugary products would come out looking good by comparison.  Do we really want people being steered towards high sugar, low fat foods by Calorie labels?

Ignorance of the number of Calories in food has nothing to do with why we are all fat. We are fat because our food supply is laced with sugar.  Sugar has been proven to significantly interfere with our body’s internal Calorie counter (by making us resistant to the hormones which tell us when are full).

When our appetite control system is working, we eat exactly the number of Calories we need.  If they come from fat, we eat less of everything else.  If they come from protein or carbohydrate, we eat more.

We are fat because our fuel gauge is broken.  We are not fat because we don’t know how much fat is in what we are eating.  We don’t need Calorie counts on menus, we need our built in Calorie counters to start working again.  And the way to do that is eliminate sugar from the food supply.

But don’t fret too much about lobbying for Calorie counts, Big Sugar will implement them voluntarily soon enough.”

****

Stephen Leeder,  Professor of Public Health and Community Medicine at the University of Sydney and Director of the Menzies Centre for Health Policy:

“My personal view is that the more nutritional information that consumers can be given access to, the better.  The work that Tom Friedan, former chief health officer of New York City and now boss of CDC, in getting restaurants to label their menus is part of a larger enterprise to raise community and commercial awareness of nutritional responsibility. He did the same with tobacco control to good effect.

People DO take an interest in food labelling. Come with me one weekend to Coles in Katoomba – hardly the socioeconomic pinnacle of NSW society – and observe how often customers stop and read and compare food labels.

Many would argue, with evidence, that colour coding of foods with red, orange and green to indicate the safety levels of key components such as saturated fat, calorie density and whatever else.

The food industry presents elaborate objections to the ‘traffic light’ labelling. But in the meantime, until this is resolved, clear nutritional labelling makes sense. I think one of the craziest moves ever was the move away from the calorie, which many people understood, to kilojoules, which people don’t understand.

Food labelling is very political and much engagement with the food industry by action oriented politicians (and not all are) makes great sense.”

***

Boyd Swinburn, Professor of Population Health, and Director, WHO Collaborating Center for Obesity Prevention Deakin University:

“I am just travelling at the moment but have discussed this people here in the US.  It started in New York City where to got in regulations to include the calorie content next to the price on the menu boards of chain restaurants.  They also had an anchor that about 2000 kcal is what was needed for a typical day for a typical adult.

Several other cities/states started following suit and expending the provisions. The industry could foresee an escalating situation and called for federal regulations which require the calorie information but prevent local authorities for pushing it further.

I definitely think the Australia should follow suit and all the arguments that it is not possible have evaporated. Our use of kJ will add complexity however.”

Croakey’s North American correspondent, Dr Lesley Russell, has been investigating the history of calorie-counting menus, while a local obesity policy expert, Jane Martin, looks at whether such an option might be useful in Australia.

Lesley Russell writes:

“In 2006, in a controversial move in response to rising obesity rates, New York City’s Health Department amended the city health code to  require the posting of calorie counts by chain restaurants on menus,
menu boards, and item tags.

This move was based on the following key facts:

*nearly one-third of Americans report that they are trying to lose weight;

*people are unaware of the calorie content of food, and when asked to
estimate the number of calories in food, they greatly underestimate
them; and

*consumers who were provided calorie information were much less likely
to choose the higher-calorie items.

Many fast-food chains make nutrition information available, but not in places or at times when consumers can easily use it when they buy their food. Most often, the information is available for download on Web sites.

According to the company, McDonald’s Web site nutrition page receives approximately 2,000 visitors per day, but since McDonald’s serves more than fifty million people per day, this suggests that only about one in 25,000 customers obtain nutritional information from the Internet.

The law was finally implemented, after a series of tough legal battles with the restaurant industry, in July 2008.  The system has since  become a model for similar rules intended to combat obesity and  promote good nutrition being implemented in California, other parts of  New York state, the cities of Seattle and Portland, and elsewhere.

Now some of the early findings about the success or otherwise of the New York initiative are available, in a paper (sub or pay per view only) published recently in Health Affairs.

The study compared patrons of fast-food restaurants in low-income, minority New York City communities with those in nearby Newark, NJ, a city which had not introduced menu labeling. About half of the New York respondents reported noticing calorie information, but only a  quarter of these reported that the information influenced their food  choices. However the study found that even those who indicated that  the calorie information influenced their food choices did not actually purchase fewer calories.

Last week New York City health officials delivered a more upbeat  assessment of their own, saying that New Yorkers ordered fewer calories at four chains – Au Bon Pain, KFC, McDonald’s and Starbucks – after the law went into effect. There was a significant increase in calories ordered at Subway, which researchers attributed to a continuing $5 special on foot-long sandwiches which has tripled demand for them.

The results are good enough to cause policy-makers to think that calorie labeling might be one component of a multi-faceted plan to  tackle obesity.  Certainly that’s what US lawmakers think.

Tucked away in the 1990-page health care reform bill that passed the  House of Representatives last Saturday night is a provision that will require anyone who operates chain restaurants with more than 20 locations to provide a calorie count for each standard menu item.  In addition, anyone who owns or operates 20 or more vending machines would have to provide a sign in close proximity to each item of food or the selection button that includes a clear statement about the number of calories the item contains.

The National Restaurant Association supports the labeling  requirements; the National Automatic Merchandising Association is less enthusiastic.  We assume that the Republicans, still complaining about  the size of the bill, did not read it and therefore don’t know about  this provision, otherwise we would surely have heard.”

• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies  Center for Health Policy, University of Sydney/ Australian National  University and a Research Associate at the US Studies Centre, University of Sydney.  She is currently a Visiting Fellow at the Center for American Progress in Washington DC.

Should Australia require calorie-counting menus? Jane Martin, a Senior Policy Adviser to the Obesity Policy Coalition, writes:

“This is something the Obesity Policy Coalition supports. This is yet another study showing, like restrictions on junk food advertising, that an initiative with a modest effect can have a large impact on a population.

This study is an excellent assessment of the situation.  Currently in Australia, even if there is information given about meals in chain restaurants, it is on websites or on the packaging of the meal that you order (McDonald’s), therefore people are not making informed decisions at the point of purchase.  If there was a system such as in New York, together with an education campaign, the potential impacts could be large.

This is definitely something that should be on the table here, as part of a comprehensive approach.”

But the real food war to watch is underway in the US, and you can read more about it in this investigation, “The Food Lobby’s War on a Soda Tax”, jointly undertaken by the Centre for Public Integrity and the Huffington Post Investigative Fund.

The investigation reports that:

Washington lobbyists have been enjoying a multi-million-dollar sugar rush from the food industry. Soft drink makers, supermarket companies, agriculture and the fast-food business have poured millions into campaigning against what they fear could be a burgeoning national movement to raise money for health care reform by taxing sweetened beverages.

During the first nine months of 2009, the industry groups stepped up their lobbying in Congress. They have spent more than $24 million on the issue of a national excise tax on sweetened beverages and on other legislative and regulatory issues, according to an examination of lobbying reports filed with the Senate Office of Public Records. The review shows that 21 companies and organizations reported that they lobbied specifically on the proposed tax on sugar-sweetened beverages — which among other things would include sodas, juice drinks and chocolate milk.

About $5 million of the money was spent on a national advertising campaign aimed at Capitol Hill lawmakers and promoting a newly formed coalition called Americans Against Food Taxes. The group bills itself on its website as a coalition of “responsible individuals, financially-strapped families, [and] small and large businesses” but its 400-plus membership list is dominated by industry heavyweights such as Burger King Corporation, Coca Cola, PepsiCo and Domino’s Pizza.

The heavyweight lobbying and spending is not so surprising, given what’s at stake for the industry.

In California yesterday, legislators were hearing arguments in favour of a soft drinks tax, including from Professor Kelly Brownell, who was the lead author on this landmark article in the New England Journal of Medicine arguing that there are “compelling” reasons for taxing sugar-sweetened beverages.

According to this LA Times report, one senator told the hearing that he wants “to end the Pepsi Generation,” and compared the marketing of soft drinks to cigarette marketing.

Brownell told the hearing that the landscape for the soda industry is not unlike what it was for the tobacco industry when governments began to increase taxes on cigarettes as a strategy to get people to stop smoking.

Meanwhile, Kellogg has announced that it will withdraw the IMMUNITY claim on Cocoa and other Rice Krispies cereals. The withdrawal follows this report in USA Today, citing concerns held by the San Francisco city attorney and prominent public health experts (including Kelly Brownell).

A collector's item...

On related matters, the SMH is  reporting on a project by the International Consortium of Investigative Journalists examining the climate lobby in eight countries including the US, Canada, Australia, India, Japan, China, Belgium and Brazil. The conclusion is that “big greenhouse polluting companies around the world, employing thousands of lobbyists, are exerting heavy pressure on governments to weaken climate change laws at home and slow progress on an international climate agreement in Copenhagen”.

It all starts to sound so familiar doesn’t it….

Boyd Swinburn, Professor of Population Health, and Director of the WHO Collaborating Center for Obesity Prevention at Deakin University, writes:

“Stephen Leeder makes a well argued plea for people to quit blasting the food industry with moral indignation and to work with them to find solutions to the food over-supply and over-promotion which are important drivers of our current obesity epidemic.

Indeed, there are many, many nutritionists, food technologists, dietitians and researchers working with the food industry helping them to re-formulate and market their products.   This is largely positive but that is not the role of everyone.

Public health is politics and effective public health gains have always had as a driving force the combination of passion and science being brought to the political debate. The passion, which I like to think comes from a strong ethical basis rather than a quasi-religious moralistic basis, is an essential ingredient to progress and I would be interested in the rationale or evidence that it is making things worse.

If the passionate advocates, like Rosemary Stanton, had not continually spoken out about the ways that the food industry has been contributing to the obesity problem and has been white-anting the solutions, we would have made very little progress.

It is an unfortunate fact of politics that Rosemary’s approach  will more likely catalyse the ‘banging heads’ meeting of the PM and the industry CEOs that Stephen talks about than will the cooperative approach of the embedded nutritionist or the industry-funded scientist.

But both are important for progress.”

However, Stephen Leeder, Professor of Public Health at the University of Sydney, argues that the public health community needs to move beyond moral indignation to effective engagement with industry.

He writes:

“The recent Croakey conversation about obesity and the soft drink industry is imbued with strong moral concerns, as is the public health community more generally – many members march at the front of the platoon that seeks to secure equitable access to health care, even, indeed, equal health outcomes from care or equality of health status.

No great problem there: this moral concern has motivated deep inquiry into the social determinants of health and action to tackle maternal and child survival, extreme poverty, the humane care of people with AIDS and Indigenous health.  It is in sympathy with international movements that promote human rights generally and those pertaining to health specifically.

While this moral concern has generated power in the grid of modern public health action – including the battles fought and partially won with tobacco companies – paradoxically it may inhibit progress in achieving better health for people who suffer because of the negative effects of global economic expansion, city building and food manufacture.  Illnesses caused by these changes now dominate the lists of global mortality and morbidity.

Why may our moral indignation in public health be a problem?  Before answering that question we need to hear a word from the philosopher John Rawls.

As Denver ethicist Jack Donnelly wrote recently in a monograph on concepts of human dignity, Rawls distinguishes notions of justice that derive from religious and philosophical doctrines such as Islam and Marxism from “political conceptions of justice”.

These, in Donnelly’s words, “address the political structure of society, defined (as far as possible) independent of any particular comprehensive doctrine. Adherents of different comprehensive doctrines may be able to reach an overlapping consensus on a political conception of justice.”

What Donnelly is getting is that while the foundational motivations and ideology of different people will vary, and sometimes radically so, it remains possible “to achieve an overlapping consensus [that is] partial rather than complete.  It is political rather than moral or religious.”

Many of the solutions to our current health woes undoubtedly sit outside the health sector, and will involve stakeholders with sometimes very different values and objectives and different concepts of morality.  Finding the points of ‘overlapping consensus’ is key for us to move forward towards  health gain.

Recently in Sydney we listened to two points of view – from Derek Yach and Rosemary Stanton – about nutrition and how it might be altered in favour of a slimmer society.  Derek works with PepsiCo and Rosemary definitely does not!  Both are people of impeccable public health credentials and they deliberated about how we might enter an age where obesity and its dark consequences did not dominate our thinking.

It has generated lively debate but I do not see how we can make progress until such time as we accept that a solution to this problem will be based on a political conception of social justice, to use Donnelly’s term – at the school, local government, state and federal levels.  It will be a political and pragmatic rather than ideological notion of justice that will motivate action.

Instead of allowing ourselves the indulgence of shouting from the moral high ground about the motivations of industry, perhaps we should seek a consensus around what a social conception of justice in regard to food means.

We need as public health people to get over our shock and horror at food companies being primarily motivated by profit.  We need to move beyond saying, “Their good will is just PR!”  A mutual understanding of each other’s values and goals is essential to merit a seat at the table, a table of policy and politics.

This applies to many public health policy problems.  Recognising a problem, and even understanding it is different to choosing the most effective course of action, knowing how to speak in terms that industry will take seriously, being pragmatic and knowing how to go about getting things done when success more often than not requires people to negotiate the politics.

This viewpoint is reinforced by my previous experience.  Two years ago I participated in a Canberra meeting hosted by Senator Guy Barnett about obesity.  I chaired a small working group that included representatives from the food industry, academic nutrition, advertising, media and urban designers.  Naturally we sparred about traffic light food labeling, advertising on children’s TV and other contentious topics, but we all stayed till the going home bell sounded.  The conversation was prickly but OK.

Just before we went, one of the participants turned to me and said, “You know, professor, you have the wrong people at this forum.  We’re middle managers. You need the CEOs. If they say something is going to change, it will.”

I was pondering the good sense of this suggestion – and others were nodding affirmatively, when my colleague added, “And you’re the wrong person to be chairing it.  We should have the PM and a few of his ministers without their bureaucrats at the table.  He could say to them all, ‘We have a problem and we are all going to contribute to its solution, so before you leave today I want to hear what you are going to do to help!’”

Besides revising our attachment to moral indignation, the other thing we need is a clear view of how long it has taken us to get into a situation where nearly half of all Australian adults and close to three in every 10 Australian children are overweight or obese, a mess that has disturbing similarities to global warming.  Decades: so it will probably take decades to get out.

The history of public health progress is nearly always of incremental change with many people taking many different actions.  Even the apocryphal wrenching removal of the Broad Street water pump handle has a richer context than we commonly recognize.

That is why public health is accurately perceived as a community movement and public health research workers as social scientists.  There are times when aggressive advocacy and the force of the law are necessary.  At other times they are not.  Then, as Churchill put it, we need jaw-jaw and not war-war.

The rise and rise of obesity is complex.  Recruiting the food industry – or a bit of it anyway – to our cause, while being true in our policy discussions with them to a “political conception of justice,” strikes me as a good move.

I am not at all convinced that confrontation and moral indignation do anything in this context other than make things worse.   This does not mean that we should be silent if we find abuse and hypocrisy but rather in conversation we should define those interests that are common and where, if a consensus is struck – by the PM if not by us – we can inch forward.”

Obesity control expert Professor Boyd Swinburn has sent in his observations while travelling in the US. He writes:

“I am currently in Boston and read with interest the comments about Derek Yach and Pepsi’s PR mission to Australia.

The TV in the US is currently carrying a series of advertisements about a regular Mom complaining that the government is thinking about raising taxes on foods and drinks (actually the talk is only about taxes on sugar-sweetened sodas).

“They say its only going to be pennies, and it may not matter to those people in Washington but it matters to me when I am struggling to feed my family”. Who is behind the ads: an outfit called Americans Against Food Taxes.

And who is behind this front group: Pepsi Co and all the other usual suspects.

One of the most powerful influences big food has is in undermining public health initiatives. Pretending to be the good guy at the same time gives it an even greater influence over government as we have recently seen with the softly, softly Preventative Health Taskforce report.

Derek used to speak  for the benefit of public health, now he speaks for the benefit of food giants.”

• Boyd Swinburn is Professor of Population Health, and Director, WHO Collaborating Center for Obesity Prevention

He writes:

“The pity is that Melissa clearly did not absorb the objective data I offered re modest but important examples of change across food companies (from 60% less calories sold in schools in the USA; to tons of less salt in many products in the UK; to 90& reductions in certain ads to kids across Europe; to 30 000 products reformulated for many nutrients; to real impacts of portion sizes on total calories consumed)…all the data being measured and mostly independently audited!

Many of these changes do not come with increased profits in the short term and are part of deep structural changes underway across industry. They include responding to the World Health Organization’s call for support of the Global Strategy on Diet and Physical Activity; developing coordinated approaches across many multinationals to tackle a variety of nutrition issues; and stepping up investments in innovation.

Further, to call addressing hunger a distraction is the very worst type of cynicism. I attach our CEO’s speech from last week at the World Food Prize on this. Some might call it a giant distraction–most I work with regard it as an imperative we cannot and must not avoid tackling!

Melissa would do well to relisten to the debate and take note of the above points as well as many impediments to progress in tackling obesity that require more effective actions by governments, NGOs and individuals. For Australia this includes fully supporting the new Preventative Task Force recommendations.”

The paper says that 46 per cent of the state’s secondary students have registered for the Maths Online tutoring program. Nationally, more than a third of Australia’s 1.46 million secondary students have registered for the program since March this year.

When students open the program on computers they see the McDonald’s logo and the words: “Proudly provided by your local McDonald’s restaurant.”

Federal Education Minister Julia Gillard has reportedly commended the firm. And she’s a former Opposition health spokeswoman!

It really makes you wonder whether all the talk about cross government action to tackle obesity is just that. Talk. And pretty insincere talk at that.

So what do the public health crowd think?

Nutritionist Dr Rosemary Stanton writes:

“Parents have a right to know why the education of their children has passed from the government to vested interests.

McDonald’s haven’t sponsored this (and other) programs out of the goodness of their hearts. They want customers. Their sponsorship of this program also means that teachers won’t feel free to criticise McDonald’s, their products and even their marketing methods.

It’s also unlikely that governments who are now obligated to McDonald’s will do anything to bite the hand that feeds them. And our young trusting children will also think McD’s are good guys – or their teachers and parents wouldn’t endorse their products.

Are our education departments really so thick that they can’t see through this? And are we happy for sell our children to McDonalds?”

***

Jane Martin, a Senior Policy Adviser to the Obesity Policy Coalition and Professor Elizabeth Waters from the University of Melbourne, write:

“The Maths Online tutoring program is ostensibly supported by local McDonald’s stores, however it is likely McDonald’s funded the website and its development, and paid for expensive advertisements on prime time television – adding value to their positioning around corporate social responsibility.

Obesity prevention groups are concerned about this development because McDonald’s is in the business is selling burgers and fries, not education. This is a backdoor way to ensure that their branding reaches children, under the guise of education.

If the company was truly serious about providing tutoring to children, they should do this without using the distinctive McDonald’s branding.

The reach of the program, outlined in the press today, illustrates what good value this is for McDonald’s – particularly to target secondary school children.

This is a group who have more independence with their food choices as they are less likely to be under the control of parents and beginning to make independent decisions about what they eat, and how they spend their money, when they are out with their friends.

The recommendations of the recently released Preventative Health Taskforce strategy have acknowledged the importance of protecting children from the promotion of unhealthy food.  This example illustrates how the internet and educational programs are being utilized by fast food companies to reach and influence young people. This is an underhanded way to create and build a relationship with young people and the McDonald’s brand.

This is a situation which is more common in the United States, but likely to be something that we see more of if restrictions are phased in on junk food marketing to children through commercial television.”

PostScript: Jane Martin and Elizabeth Waters have sent in this additional comment:

“There is also evidence that migrant families new to Australia, and those with low literacy, may think that these sponsored programs mean that schools and governments support McDonalds and implies that McDonalds products are healthy.  This “halo” effect is similar to when McDonalds is placed in children’s hospitals – people think that the franchise provides financial support to the hospital, that the food is healthier and its presence means they are also more liklely to purchase the fast food.

Many schools, including those in NSW, have introduced policies and programs in these settings to ensure consistency in the approach around the promotion of healthy lifestyles.  This is undertaken by ensuring a healthy food supply in schools, through the curriculum and within broader school community.  The relationship with McDonalds and the educational curriculum creates inconsistency and undermines these policies and messages.”

But there are other players whose role we don’t often hear much about when it comes to the fight against fat. Employers and workplace managers could be making a useful contribution to their employees’ health, suggests a new systematic review published in the American Journal of Preventive Medicine. It was conducted for the Task Force on Community Preventive Services at the Centers from Disease Control and Prevention.

The review is summarised by the CDC’s Community Guide here.

It analysed 47 studies examining the impact of education, behavioural and social strategies such as individual or group behavioural counselling, and policy or environmental approaches such as improving access to healthy foods in vending machines and providing on-site exercise facilities.

In nine studies, participating employees lost an average of 1.3 kgs after 12 months, compared with control groups.

The review concluded that no one focus, diet or physical activity, or combination of both appeared to be better than others in terms of its effect on weight loss.

Most of the studies involved a white collar workforce that included some employees with overweight or other chronic disease risk conditions.

The range of cost-effectiveness estimates from three studies (two involving weight-loss competitions and one involving a physical fitness program) varied from $US 1.44 to $4.16 per pound of loss in body weight (one pound being 0.45 kg for those not old enough to remember…)

If employers want a fit, healthy workforce into the future, they may need to start stepping up to the plate, so to speak, and accepting that they have some role – along with everyone else – in obesity control.

Here at Croakey, we thought we’d do our bit to save the public purse by asking some relevant experts for their views about one particular recommendation, and the challenges surrounding its implementation.

This recommendation states (p97):

There should be a common national approach to evaluating all health interventions, with consistent evaluation of medical care, pharmaceuticals, prevention and population health interventions, medical devices and prostheses, allied health and complementary medicine. To use an example this might allow comparison of the relative efficacy of a medical intervention (gastric bypass), a pharmaceutical intervention (an anti-obesity drug), an allied health intervention (a structured program of exercises and diet management) and a population health intervention (a community walking program) in reducing obesity.

Of the experts contacted by Croakey, most liked the general thrust of the recommendation, although several cautions were sounded, and multiple barriers were identified.

Some of the cautions:

Jon Wardle (Qld Uni): The recommendation is certainly good in theory and worth pursuing – though is fraught in many practical ways. I see a well-intentioned measure heading for disaster.

Ben Harris-Roxas (University of NSW), when asked whether the recommendation should be progressed, gave “an emphatic ‘maybe’.” It sounds intuitively appealing but there will be substantial practical and methodological challenges.

Glenn Salkeld, School of Public Health, University of Sydney: It is worth agreeing upon a common set of principles for the evaluation of interventions and then consider the task of how best to evaluate the options. Without a clear articulation of the objectives of resource allocation (which must include the distributional consequences of resource allocation) we run the risk of measuring precisely the wrong thing in an evaluation.

***

Below, in no particular order, are the full responses to our informal survey:

1. Jon Wardle, School of Population Health, University of Queensland

What issues would need to be addressed to enable implementation? There are many barriers. The first is that there seems to be an underlying assumption that the generic nature of reactive pharmaceutical intervention for disease can immediately be transferred to the proactive/preventive treatment of disease. This casually ignores the many socio-cultural or other ‘non-health’ factors that affect the outcome of preventive health measures far more than acute treatments.

It also over-simplifies the methodological challenges in measuring the outcomes of interventions. Some may require a ‘whole-practice’ approach and not have readily identifiable markers of effect (I know of many menopausal interventions that have lower effect on single measures, but are superior on multi-factoral measures like ‘menopause scores’), or some may have patient-centred outcomes that may not be readily identifiable or comparable to clinical scores – but equally important in many aspects (for example the qualitative study of rheumatoid arthritis patients in Bristol that for the first time identified that fatigue associated with the condition, not pain, was the factor that most impacted their life – ‘clinical’ research had not previously explored this area). Of course people are individuals – some may respond better to diet than drugs, some vice versa.

Would a crude comparison make the intervention most effect for that individual unavailable as most other people did not see an effect? I would also suggest that it is not just health interventions that are measured. After all one of the most significant public health initiatives was seat belts – and that had bugger all to do with the health system!

The society in which we live predisposes the population to poor health outcomes (ie social isolation of suburbia; car-focused non-active transport; liquor licensing laws that encourage ‘super-pubs’ and subsequent binge drinking and violence over smaller, more social venues; urban planning that has reduced access to greengrocers, markets or other healthy and cheaper food choices in low SES areas; food safety laws that promote unhealthy options over fresher ones – for example national or processed over local or artisanal foods).

What impact might it have if it was implemented? The potential exists to stifle innovation in the development of health programs if the process is over-centralised or doesn’t deem it fit to focus on a number of similar interventions (ie why is the one ‘diet program’ chosen over another?). The bureaucracy of running it all may actually divert precious resources in the first place!

Do you think that it has any chance of being implemented? What might be some of the barriers? The barriers are too numerous to mention, and many of them involve internal politics, for example it assumes that one groups ‘walking program’ is the gold-standard, or which allied health profession will be chosen? Who will choose? In a sense this is being done already through broad health research funding agencies such as the NHMRC. A more prudent way to achieve this may be to develop research capacity in this new field through special funding rounds and later allow research to be funded on its merit. Although I would love to see the government fund research into each of those interventions my experience of grant rejection (we’ve all been there) makes me a little cynical and think there simply won’t be enough resources to do so.

Are you aware of any other countries that are already doing this? There are many attempts at doing similar things (NICE in the UK) but they are also share as many differences as they do similarities. Collaborations already compare such data already and we may be re-inventing the wheel.

Any other general issues that are worth raising? There are many factors that can affect health, in areas as disparate as transport or retail competition policy (for example it is pointless promoting to eat more vegetables if current retail policy competition means that the duopoly restricts access and affordability to nutritious foods – sorry a shameless plug for an article of mine coming up in ANZJPH). Many of the health issues of the future are particularly susceptible to the implementation of non-health policy and focus on this issue was sorely lacking. Some nations (including New Zealand) are investigating the role of “Health Impact Assessments” on new projects (such as housing estates) or policy and this is an area that should be explored further.

***

2. Chris Del Mar, Dean, Faculty Health Sciences and Medicine, Bond University

This recommendation is a worthy objective. In particular some treatments are currently measured with quite different standards (esp complementary and alternative medicines, where ‘traditional use’ which can be recent, is considered an OK to licence, while other drugs need endless costly evaluation)

What are some of the issues that will need to be addressed to enable implementation? We need to facilitate randomised controlled trials more easily. Currently these are difficult to get done. Multiple ethics committees etc. In fact an RCT needs a higher standard of care than ordinary treatment (even if unproved!)

What impact might it have if it was implemented? People (patients and their doctors) should be encouraged to partner more in RCT evaluation of novel treatments. Currently this is seen as a ‘predator-prey’ relationship, which the trial funders are trying to make a buck for the shareholders, which is OK sometimes, but often there is a value to society by the RCT taking place and we all benefiting for the knowledge.

Do you think that it has any chance of being implemented? Yes, if we can change attitudes here.

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3. Michele Kosky, Health Consumers Council WA

Great idea, let’s have treatment based on best evidence and most cost effective for patient and the funder. I think it would reduce the competing interests and the territory wars between the tribes of health professionals that we often witness and it could be graded so that the gastric banding, for example, becomes treatment of last resort with all its inherent risks. I think that the industry groups in health and the pharmaceutical industry will ensure this proposal does not happen.

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4. Carol Bennett, Consumers Health Forum of Australia

Is this recommendation worth pursuing? Yes, although it is obviously a goal or stretch target rather than something that can be quickly or easily achieved.

What are some of the issues that will need to be addressed? For common measures of efficacy, there will need to be common measures of patient outcomes which will need to include the experience of care – i.e. the degree to which health consumers felt the treatment matched their health needs rather than the degree to which the service provided matched some rigid standard of procedure.

What impact might it have if it was implemented? If health consumers were properly informed about likely outcomes from the full range of health interventions available, it would allow consumers to have greater control and ownership of their own health and well being. Obviously this would lead to a much more healthy community. At present, whichever procedural specialist you see, whether they be a surgeon or a gym instructor, they will be bias towards the efficacy of the services they provide.

Do you think that it has any chance of being implemented? What might be some of the barriers? This has very little chance of being implemented in the short to medium term primarily because existing health providers generally like to measure their performance against the efficacy of their agreed procedures rather than comparing real health outcomes for consumers. We need to make health outcomes for consumers the focus of evaluation, not the procedures that are currently used. A good model in the general practice setting is the Collaboratives program which focusses on health outcomes.

Are you aware of any other countries that are already doing this? Increasingly countries like the UK are looking to health consumer outcomes as the primary reference point for efficacy of any procedure or health intervention, but it still has a long way to go before it becomes a realised ambition as outlined in the recommendation of the NHHRC.

Any other general issues that are worth raising? While the goal may be a long way away, any step to provide better information to health consumers about the outcome of a range of possible interventions is to be encouraged and supported.

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5. Public health physician George Rubin

What are some of the issues that will need to be addressed? National mechanism/s for conducting the reviews – a network of organisations under the auspices of NHMRC; methods agreed and developed …perhaps along the line of the evolution of systematic reviews

What impact might it have if it was implemented? Gradual shift of practice towards interventions of demonstrated effectiveness; hopefully a mechanism for ongoing assessment of interventions for which there is little or no evidence; reduction of interventions proven ineffective

Do you think that it has any chance of being implemented? What might be some of the barriers? Little chance. It will take a major organisational effort, will need a substantial budget (which could be saved by a successful program) and will involve substantial politics around what potentially gets dropped. More realistic to develop a program of comparative effectiveness measurement. Are you aware of any other countries that are already doing this? Health technology assessment organisations in NZ, Canada, US etc but unaware of comparative assessment programs

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6. Michael Moore, Public Health Association

I think that there is some merit in pursuing the recommendation. However, I do have some reservations about how the comparative research might be conducted and the prism through which such research might be constructed. Over the last decades preventive and public health has been the poor cousin in research because it is not simply about a gold standard double blind study with all confounding factors eliminated.

The medical and the pharmaceutical research methodology is likely to be more easily understood and therefore carry a favourable bias. I am not sure how these concerns might be met. A sensible study that wrestled and dealt with those issues has the potential to provide some serious insights into the most effective methods of dealing with obesity providing opportunity for governments to determine the most effective allocation of resources.

Implementation will be difficult as I suspect the funding of broad ranging research across different disciplines as this will demand is likely to be very expensive. However, it is possible and could be achieved by letting a tender to a consortium capable of crossing the barriers.

The complexity of obesity, the structural issues that drive it and the role of junk foods is probably a higher priority for research funds.

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7. Ben Harris-Roxas, Research Fellow, Healthy Public Policy Program, University of NSW

At time when we face increasingly complex health issues that are caused by multiple factors such as the way we live, work and take care of ourselves this may lead us further down the path to simple answers.

Also it’s unclear what methods might actually be used to compare interventions, e.g. cost-effectiveness studies, health technology assessment, etc. It’s not like issues of effectiveness will be examined independent of cost, so we should really be calling it what it is – a discussion about which intervention(s) should be funded based on their comparative cost effectiveness.

What impact might it have if it was implemented? I think it would tend to concentrate preventive activities even further on simple, well tested interventions that are closely tied to health outcomes, i.e. not complicated by other factors. This is not a bad thing in of itself, but it could stifle innovation and may only address the underlying issues at the margins.

Do you think that it has any chance of being implemented? What might be some of the barriers? It depends what the purpose of the “national approach” is. Will it be to ensure that only effective interventions get used or to decide that only a limited number of the most cost-effective interventions will be funded? Getting the states and the Commonwealth to agree on a common approach to this will be a minor miracle. The other issue is that the capacity to do health economic analysis is exceedingly weak at the state level and quite patchy at the Commonwealth level. The ability of drug manufacturers to demonstrate their products’ cost effectiveness is beter developed than, say, people developing population-based interventions, partly due to the nature of the interventions and outcomes but also because they are already doing cost-effectiveness studies for the PBAC/MSAC. The other problem is that it will favour one or two interventions as being the most cost-effective, when much of the emphasis in population health research is shifting to using complex interventions for complex problems.

Are you aware of any other countries that are already doing this? The UK’s National Institute for Health and Clinical Excellence (NICE) do this to a certain extent and the conventional wisdom is that they will only recommend that a drug or procedure gets funded if it costs less than £30,000/QALY.

If the “national approach” is only to set a minimum benchmark for cost effectiveness of interventions we may encounter a situation where

• costs grow rapidly (as currently occurs once drugs are apporved by PBAC or procedures by MSAC),

• there are increased inequalities in the health outcomes, and

• there will be concern about funding more and more interventions, suggesting that the benchmark threshold will have to be revised regularly.

A broader discussion is required about how much we are willing to pay as a nation and society for our health and how much we’re willing to invest in an average individuals’ health, but that’s too politically sensitive to contemplate in the forseeable future. If the purpose of the “national approach” is to ration services, and it would have to be at some level, this debate will have to occur.

Any other general issues that are worth raising? Transparency of the process will be important. Also, how do we circumscribe our consideration of effective interventions for health. For example, a recent meta-analysis of the lifetime effects of education on quality of life made a conservative cost estimate of between €98,000 and €168,000 for every QALY gained [Furnee CA, Groot W, van den Brink HM. The Health Effects of Education: A meta-analysis. European Journal of Public Health 2008;18(4):417-21.], and this didn’t quantify the effects such as the impact of education on mortality.

Education has a number of other positive impacts beyond direct health gains – should we be funding education as a cost effective health intervention?

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8. Wayne Hall, School of Population Health, University of Queensland

What are some of the issues that will need to be addressed if this is to be implemented? Something along the lines of the Pharmaceutical Benefits Advisory Council would need to be set up to evaluate major interventions in fields of high public health priority. Given the demands on expertise and time to do these analyses such an approach would probably have to be phased in.

What impact might it have if it was implemented? It would put the onus of proof on advocates of new approaches to provide evidence not just of their safety and efficacy but their cost-effectiveness compared to other similar interventions directed at the same risk factor or disease. It would make government think more strategically about funding for health care interventions rather than make piecemeal decisions about things one at a time (as we do with drugs with PBAC with limited capacity to revisit past decisions in the light of new interventions)

Do you think that it has any chance of being implemented? What might be some of the barriers? Barriers will be many: special interest groups (e.g. food industry, diet industry, pharmaceutical industry, health professionals with an investment in particular approaches); the economic costs to govt of implementing and scaling up such a system of evaluation; lack of data for economic evaluations etc etc

Are you aware of any other countries that are already doing this? NICE in the UK attempts to do something along these lines in so far as data permit for major areas of public health concern. Rob Carter from Deakin and Theo Vos at UQ are undertaking this sort of project at present for an NHMRC funded grant. Rob has done something along the lines suggested on obesity interventions and Theo something similar on alcohol.

Any other general issues that are worth raising? It’s an idea that needs to be seriously discussed and trialed in a couple of key areas of current public health concern, e.g. obesity

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9. Glenn Salkeld, School of Public Health, University of Sydney

What are some of the issues that will need to be addressed? Common issues – is there a common metric of health outcome that captures what matters? (ie the stated objectives of government health expenditure) Where does the information for the evaluation come from and is it valid and reliable? Who (an independent body or not) and what governs the assessment of the evaluation (is it regulation, legislation?) How does the process manage competing interests (of both buyers and sellers of health interventions/products)? What impact might it have if it was implemented? It would slow things down and allow time for proper debate on the best use of scarce resources. Depending on the responses to questions 1 & 2, it has the potential to shift resource allocation to a more transparent process (and hopefully move resource allocation to a more considered and defensible basis)

Do you think that it has any chance of being implemented? What might be some of the barriers? It will require a good deal of courage. It has worked in the pharmaceutical area because the only way to sustain large public expenditure that benefits the population and the sellers of medicines is to have an evidence-based approach to the selection and reimbursement of drugs. Without the public subsidy both sides lose. With a credible way to allocate money for medicines both sides gain. Are you aware of any other countries that are already doing this? The UK has the National Institute for Clinical Effectiveness (NICE) but that functions in the context of a more planned health service.

Any other general issues that are worth raising? Without a national approach to better resource allocation in health we will struggle to exert any control over who gets what health resources and how much. Doing nothing will only increase health inequalities.

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10. Les Irwig, School of Public Health, University of Sydney

My quick reaction is:

• Great idea!

• will need massive Govt funding to avoid the problem of RCTs being more likely for new pharmaceuticals.

• non-drug interventions used in the trials will need good descriptions – see Paul Glasziou’s recent paper in the BMJ on how poorly they are described currently in the lit

• need better consumer/patient involvement to define what endpoints are meaningful to patients and therefore should be measured in the trials

• pity they didn’t include diagnostic technology, for which far more trials should be done

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11. Lloyd Sansom, Chair, Pharmaceutical Benefits Advisory Committee

The Government is currently undertaking a Health Technology Assessment and one of the issues they are examining is the relationship between the various agencies particularly in regard to hybrid technologies and timeliness . With increasing applications of molecular targeted drugs, drug/device combinations it is important that we examine the situation to improve the efficiency of the process.

The PBAC submission to the review is here.  In view of the current review it would be inappropriate for me to make any other comment other than the submission

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12. Jon Jureidini, Adelaide psychiatrist and member, Healthy Skepticism

It could have a dramatic impact in some areas, but would require significant and often unpopular disinvestment. There would be some practical barriers, but the political ones will be stronger.

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13. Libby Roughead, School of Pharmacy and Medical Sciences, University of SA

Very often in health care we need implementation of a mix of strategies, not just one, so there needs to be a context in which this recommendation is considered. That being said if we only evaluate pharmaceuticals against pharmaceuticals, then we might not understand how that compares with other interventions which may be less or more effective – which I suspect is the issue trying to be raised.

If you look at the US Institute of Medicine’s top 100 priorities for comparative effectiveness, you will see that many of those are about gathering evidence for the mix of health care interventions – although I gather the top 100 priorities were opinion-based supported by a nominal group process rather than based on other data.

It is certainly a good idea to think about how public health dollars and practice and primary health dollars and care may be better integrated and how the evidence may integrate – we will always need both strategies (not just one or the other).

The challenge is creating the incentive for developing the evidence – it is work rarely done and we already have a challenge of evidence just within areas of health care. I suspect the starting point is to create the dialogue about what this means – as Croakey is doing.