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STANDING COMMITTEE ON HEALTH AND AGEING
26/11/2008
Obesity in Australia

CHAIR (Mr Georganas) —Welcome.

Ms Pezzullo —Thank you for having me here today. It is an honour, and I hope I can give you some background to the report that we did on obesity, which I understand is my brief today—to explain why it was commissioned and what we did and then to answer some questions from you. I am a South Australian, so it is great to see the overrepresentation of South Australia on the committee!

The report was commissioned by Diabetes Australia. We worked with them initially in producing a report in 2006, which was for the year 2005, to estimate the economic impact of obesity. We have done a lot of cost-of-illness analyses over the years—I think I counted 37 different therapeutic areas—and we do cost-of-illness studies in five continents. We are currently doing ones in the UK, Japan and Canada and we have done a number in New Zealand. We have refined the methodology over the years since 2001 when we first started developing a methodology to accurately estimate the costs of disease in Australia to start with.

The 2006 report for Diabetes Australia was designed to estimate the prevalence as well as the financial costs of obesity. We also were asked to try to estimate the disability burden and to place a dollar value on that disability burden. The burden of disease, you may be aware, has two particular components. One is the YLD component, the years of life lost due to disability, and one is the YLL component, the years of life lost due to premature death. I will reflect a bit more on that methodology when we get to that part of the costing.

Risk factors are a bit different from diseases that have ICD-10 codings. Risk factors are obviously contributors to disease, so what we needed to do was to map the attributable fractions—how much obesity contributes to particular conditions. While it contributes to a number of conditions that we did not include, we did include what we thought were the major ones, and those were type 2 diabetes, various types of cardiovascular disease, four different types of cancer, and osteoarthritis. I will not go through the clinical pathways there, but I am sure you would be familiar with that if you have been doing this process for a year.

The 2006 report, just to give you some context, was quite conservative in its projections of obesity prevalence and in its attributable fractions, and particularly conservative in relation to diabetes attributable fractions, so Diabetes Australia asked us to revisit our 2006 study in 2008 and to utilise the new data that had come out subsequently in relation to prevalence in particular and the revised data that had come out from the Australian Institute of Health and Welfare in relation to attributable fractions.

The 2006 costing that we did was based on prevalence in the year 2005, and the prevalence rates there were based on Australian measured anthropomorphic data from the AusDiab study, which I imagine you are familiar with, the national nutrition study of 1995 and the New South Wales Schools Physical Activity and Nutrition Survey, which is commonly known as the SPANS 2004 study and is a study of children. Based on those definitions and data we estimated that there were 3.24 million Australians, 15.9 per cent of the population, who were obese in the year 2005.

Since then, the new data that became available were the Bettering the evaluation and care of health 2006-07 report by Helena Britt—and I imagine that you are familiar with the BEACH data on this. There was also the National Blood Pressure Screening Day, the NBPSD, report titled Australia’s future ‘Fat Bomb’ by Stewart et al 2008. Both the BEACH and the NBPSD data suggested that obesity prevalence rates in Australia were higher than modelled in our 2006 report. However we did not incorporate anything from the NBPSD because we felt that there was potential for selection bias in that study and that its results were in fact overestimates. The BEACH data for adults aligned closely with the historical data on measured BMI, body mass index, so we used those. We thought that they were quite robust and we used those to estimate the prevalence. If you have a copy of the report in front of you, you can see both the prevalence estimates in the chart that we used and also—

Mrs IRWIN —What page?

Ms Pezzullo —The very first page on the executive summary. It is titled ‘Trends and obesity prevalence of adults from 1980 to 2007’. You can see there the male and female measured BMI estimates that we presented previously in the 2006 work and you can then see the BEACH data for males and females going through from the year 1999 to 2007. So there was a fairly robust trend extrapolation in those data.

You can see the data themselves if you just flip over the page to the prevalence table. Those are the prevalence rates that we used by age group in order to estimate the total number of Australians who were obese. People familiar with prevalence rates can just multiply them by the demographic groupings and in that way you can estimate the numbers of people who have a particular condition. That was 3.71 million when you do that sum product, and that is 1.76 million males, 16.5 per cent of all males, and 1.95 million females, which is 18.5 per cent of all females. We also found that the 55- to 59-year-old age group contained the largest number of obese people for both men—183,200—and women, which was 231,600. Also there were over 290,000 young Australians aged five to 19 years whom we found to be obese using that method. So the total estimate is about 14.5 per cent higher than our 2005 estimate, using those higher prevalence rates driving that result.

We estimated that, if there were no further changes in age-gender prevalence rates, then by 2025 there would be a total of 4.6 million Australians—in other words, the raw prevalence rate would increase to 18.3 per cent of the population. That is a result of demographic ageing, and I have to emphasise the importance of that ceteris paribus assumption—ceteris paribus being Latin for ‘all things being equal’—so we are assuming that nothing else changes in that assumption. If prevalence rates stay just as they are in each age-gender group, then demographic ageing alone will increase prevalence of obesity in Australia. Of course there are a whole lot of things that could cause obesity rates to change in any direction so it is a projection; it is not a forecast.

Looking at the attributable fractions that we used, they were based on the AIHW, the Australian Institute of Health and Welfare’s attributable fractions for obesity and overweight. Again, I am assuming that you are familiar with the work by Begg et al at the Australian Institute of Health and Welfare. They do burden-of-disease analysis—

Mrs IRWIN —No, I am not—

Ms Pezzullo —They estimated the burden of disease in Australia in the year 1999 for the first time. That publication was by Colin Mathers, Theo Vos and Chris Stevenson of the AIHW, and they estimated the burden of disease with a disability and mortality component for a large range of diseases. Their method was based on the same methods that were used in the global burden-of-disease study which was done by the World Health Organisation, the World Bank and Harvard University in the 1990s.

In fact, the new World Health Organisation burden-of-disease study is being done right now. I am an expert panel member for that particular global study. The Australian work has now been updated, and that was this new work, which is the 2007 update. It is actually for the calendar year 2003, so we have had to do some extrapolations between 2003 and 2008, but the attributable fractions are unlikely to change in a small period like five years.

The attributable fractions were 23.8 per cent for type 2 diabetes, 21.3 per cent for cardiovascular disease—and the underlying conditions there were hypertension, coronary heart disease and stroke—24.5 per cent for osteoarthritis and 20.5 per cent for colorectal, breast, uterine and kidney cancer. So all those attributable fractions were higher than in our 2006 work.

What they mean is that, for example, 20.5 per cent of all bowel cancer is attributable to obesity. That is what that attributable fraction means. It means that, with conditions, you can allocate how much of them are due to particular factors, whether it is physical inactivity, overweight, obesity or high blood pressure. Obviously bowel cancer may be due to other problems as well—for example, red meat has been one of the risk factors that have been postulated for bowel cancer.

The attributable fractions suggest that in the year 2008 there were 242,033 Australians who had type 2 diabetes as a result of being obese, there were 644,843 Australians who had cardiovascular disease as a result of being obese, there were 422,274 Australians who had osteoarthritis as a result of being obese and there were roughly 30,000 Australians who had the various cancers as a result of being obese. That led to a total of around 197,000 disability adjusted life years, or DALY, associated with obesity, which was up from around 114,000 in 2005.

I will quickly run through the costs. We estimated those from the 2006 work and we inflated them. We inflated the direct health system costs using the AIHW health inflation indices. We inflated productivity losses and carer costs using the ABS wage-price index and we inflated other financial costs based on the consumer price index. We based our value of a statistical life year on a meta-analysis that we had done for the Department of Education, Employment and Workplace Relations, which is actually on their website and part of their showcase publications this year as an example of best practice research. The publication is called The health of nations: the value of a statistical life. It is a meta-analysis of 244 studies, and from those we can estimate how much people value the addition of an incremental year of healthy life. It uses willingness-to-pay methodology, and the meta-analysis uses mixed meta-analysis techniques.

Using all those inputs, we estimated the new obesity costs in 2008 as $8.283 million. Of that, the productivity costs were about $3.6 billion, or 44 per cent, which is quite high. The health system costs were about $2 billion, or 24 per cent, and carer costs were about $1.9 billion. We also estimated the deadweight losses from transfers. Deadweight losses are efficiency losses that are caused by raising taxation or by having to pay welfare payments. The transfers themselves are not economic costs—they are just moving money around the economy—but the deadweight losses that are associated with those transfers are real economic costs, so we include those efficiency losses and we estimate them based on the Productivity Commission method. The net cost of the lost wellbeing was valued at a further $49.9 billion, which brought the total cost of obesity to $58.2 billion.

I have to emphasise that the estimate of the value of the burden of disease, that large component of $50 billion, is not something that you can compare with GDP. It is not a financial cost; we do not include the value of wellbeing in our estimate of GDP. So, even though it is a big number and tends to get lots of headlines, the best number to look at is the $8.283 billion, the financial cost measure. But we think it is important to include an estimate of the value of the loss of human life because, after all, that is why we do what we do in health. We actually do it not to make financial savings, although financial savings are nice; we make health investments in order to purchase years of quality healthy life and longevity. We place a value on that so that people can see the order of magnitude of the value of a healthy life relative to the order of magnitude of the financial costs or potential savings.

We also did some state and territory estimates. They are fairly straight-line estimates. They are basically just working out the prevalence in each state and territory and dividing the costs based on the prevalence, so it is a per capita extrapolation. There are much more sophisticated techniques that you could use to more accurately estimate the state and territory costs, because they may vary state by state, but there was not the budget or the time to do that in this particular analysis so it is a fairly straightforward estimate of the state and territory costs. I will not go into details because you have got them in the report and it would just be a whole lot more numbers for you to try to absorb. But I hope that has been a useful summary, and I am very happy to take your questions.

CHAIR —It has been, thank you very much, and if anyone wants facts and figures I am sure they are all in here. I will start by asking for a couple of clarifications. On page (iii) there are graphs on the prevalence of obesity, by age group and by male and female. From the age of zero to four it seems to be zero, but when we were at Westmead Hospital recently we saw cases where that was not the case. Did you just not include those four-year-olds?

Ms Pezzullo —That is correct. We could not get robust estimates for the zero-to-four group. There is a fair degree of diversity as to what those estimates might be and we take a very conservative approach if we cannot get a robust estimate. Also, we did not think it would have an enormous impact on the total in terms of a costing, and we really only estimate prevalence in order to estimate costs—that was our brief—so we just excluded that particular value.

CHAIR —At the point showing age 25 to 34 and below, it is usually the males that have a greater prevalence of obesity, then from that point it changes and it is the females. Are there any studies showing why that happens at that point? I suppose you were looking at the economic side of it.

Ms Pezzullo —Yes. I am not an epidemiologist so I could offer some possible reasons but it is probably better to ask an epidemiologist.

CHAIR —Yes. It is just interesting that at that point it changes. Your figure of $49.9 billion for wellbeing: can you describe how you arrived at that figure? We can understand productivity and all those other things, but how do you put a dollar on wellbeing?

Ms Pezzullo —On healthy life? It is the most frequently asked question and it has a very complex answer, I am afraid. If you will bear with me I will try to do it step by step. Going back to the burden of disease analysis, we can estimate the DALYs, the disability adjusted life years, that are due to a condition. That is quite a common metric; it is used around the world. We use it in health evaluation where we estimate the dollars that are invested in any intervention or prevention program in order to purchase a certain number of DALYs. That is how we estimate cost effectiveness when we are evaluating the national bowel screening program or the breast screening evaluation.

CHAIR —Can you explain the DALYs again?

Ms Pezzullo —The DALYs are a measure of the loss of healthy life that is attributable to disease or injury. It goes back to that global burden of disease report, where the DALYs methodology was developed. It has the two components: the YLD component and the YLL component.

Mr BRIGGS —Preventable disease?

Ms Pezzullo —It is disease and injury. You can prevent some of it, and we are preventing some of it, fortunately. What is good to see is how our burden of disease pattern changed between the first Australian study that was done in relation to the year 1996 and the second Australian study that was done in relation to the year 2003. But what the change shows is that we are reducing our mortality burden—we are reducing the YLL component proportionately—but we are increasing our disability component. So we are living longer but with more disability. I am digressing a little.

CHAIR —That is an interesting point.

Ms Pezzullo —This whole DALY metric is based on the amount of deaths that there are attributable to particular diseases. That underlies the YLL component. The disability component is underscored by disability weights. The disability weights are measures which are based on epidemiology and also on expert opinion. That is a little bit controversial, because people ask how we can estimate the proportion of a life year, which is what a disability weight is, that is lost when you have a particular condition. The disability weights range from zero, which is perfect health, to one, which is death. The highest disability weights are about 0.94 in the burden of disease analysis. That relates to terminal stage cancer for example. People estimate that if you have terminal stage cancer you really are only experiencing six per cent of the quality of life that you would have relative to if you were in perfect health.

These are very carefully deliberated relativities between different conditions. They are based on very extensive literature on how to measure health quality of life. There are a variety of ways of doing that, such as using standard gambles and other different trade-off mechanisms. We ask things like: ‘How would you feel if you lost a leg relative to if you had diabetes? Which of those two options would you prefer?’ People have to rate their choices. That is one of the methods that are used. There are revealed preference methods. Those are the two primary methods: stated preference methods and revealed preference methods. You can extrapolate those into monetary terms as well. You can ask people what dollar value they would place on particular health states relative to other states. There is an enormous amount of literature on this.

There is also an enormous amount of literature on the revealed preference methods. You can look at the trade-offs that people actually make to purchase a healthy life. A typical one is how much they invest in safety devices—how much they are willing pay to put smoke detectors in their homes. There have been studies on all sorts of things that have some cost but that improve safety—the wearing of seatbelts, for example. By far the most literature in that field is in relation to wage-risk trade-offs what level of risk people will accept in order to get a higher wage premium in a factory, for example. They might choose to work in a mine where the risk of death is one in a thousand higher than it was working safely back in their Perth office. But in doing that they might receive an extra $500 a year. So you can use all these—

CHAIR —The risk factors.

Ms Pezzullo —risk factors and estimate from those what the value of a statistical life is. I can commend to you the report that I mentioned earlier, The health of nations: the value of a statistical life which goes through all the literature on the willingness to pay and presents the meta-analysis of all those studies, in which we came to the conclusion that the value of a statistical life year is about $260,000. That is the value that we place on having a year of perfectly healthy life currently in Australia at the margins. We can purchase bits of life incrementally, and that is the price that we put on them incrementally. I emphasise that in economics the average price is not the same as the marginal price. If you were to purchase large chunks of healthy life you probably would not be paying $260,000 for each year. We also put a huge range of sensitivity around that. The sensitivity analysis is robust, as you can read in the report. The sensitivity analysis was around the dollar value. In the various cost of illness reports that we do, we use lower and upper bounds as well.

Mr COULTON —While you are on that, I have got a question—and I do not think I can hold it for much longer! You are talking about the risk factor for quality of life. One of the things we talked about was the fact that a lot of risks are removed from children, with the removal of park playgrounds and the banning of what were considered unsafe practices that were actually healthy. You can compare the risk of injury with the risk of obesity through lack of activity. Have you done any work on that?

Ms Pezzullo —We have not, but as a mother of four children I really hear what you are saying. When I was a child, I walked to kindergarten in Adelaide and I rode my bike to school. In kindergarten, I was four years old and I walked a kilometre to kindergarten and back again. And that was in the days of the Beaumont children, so I do not know what my mother was thinking! I also rode my bike from Myrtle Bank, which is in the foothills of Adelaide, down to Glenelg, Novar Gardens, where I went to school, which is a fairly nice ride down—

CHAIR —A beautiful ride.

Ms Pezzullo —but it is a pretty steep ride home again. And I ran in the foothills of the Adelaide Hills. That is what I did as a child.

CHAIR —Mount Lofty and Waterfall Gully.

Ms Pezzullo —Yes. My four children struggle to ride their bikes 2.9 kilometres to school. They say it is too hard, that riding home up the hill is too hard. I think children have a different expectation now. That is my personal observation.

Mr BIDGOOD —I agree. It is the same with my kids.

Mr BRIGGS —But look at the food we ate at that age as well. Most of the food I remember was cooked in fat—all the food we ate.

Mrs MAY —But we did not have all that take-away stuff either.

Mr IRONS —I can remember seeing vats of lard in the fridge, and we used to eat—

Mr COULTON —Back to my question—

Mrs IRWIN —I want to hear about the lard in the fridge! You are still looking healthy, Steve.

Mr COULTON —Up until 10 years ago I did not eat anything that I had not killed myself. This obviously is a very complicated issue that we are grappling with. We have to be careful that we do not come up with simple answers to a complicated issue. How can you ever justify putting a little bit of risk back into life on the premise that it is going to enhance your quality of life?

Ms Pezzullo —You could do an analysis. You could look at the fantastic reduction in deaths from motor vehicle accidents among children, which is a great achievement and has really enhanced quality of life in that age group. You could compare those risks by doing a detailed analysis, but we have not done that work. On the other hand, you could try to make policies that were both safe and encouraged healthy living. Those things, I think, are what tend to be recommended—the bike paths that are away from the roads, so you can hopefully achieve both and end up with a win-win. There will be the safety factor, including from wearing a helmet—although it does not really protect you against magpie attacks, my children say!—and you will also get the exercise in. But there is a complex array of different factors there—about urban design, how we do what we do and expectations of mothers. I feel that there is an expectation that you are a ‘bad’ mother unless you do the door-to-door drop-off of your children in the car to the school car park. Again, that is a perception and a personal thing. I have not got any evidence to back that up, but I want to emphasise from personal experience that those things come into play in the decisions that we make about how we parent our children as well.

Mrs MAY —I would like to ask something along the same sorts of lines. When you look at the stats in here about the burden of disease on budgets and the cost to our country, is there any relationship to—and this is going back to when we were all growing up—

Mr COULTON —Some of us longer ago than others.

Mrs MAY —Is there any relationship to the wealth of our country growing compared to when we were kids? We had to ride our bikes to school—we lived out in the country anyway. Is there a relationship with the wealth that we have in this country now? Is that having an impact on our healthy lifestyle, or lack of healthy lifestyle? It seems incredible to me. I think there is a relationship. I just wonder if you have looked at that.

Ms Pezzullo —There is interesting literature on the relationship between obesity and socioeconomic status. It is a difficult question and I certainly would not want to try to answer it here. There is an argument and quite some evidence to support the fact that in any low socioeconomic groups there is higher obesity—

Mrs MAY —Yes, I find that hard—

Ms Pezzullo —Junk food is cheaper and easier—

Mrs MAY —You see, I don’t buy that one. I don’t know about the rest of you, but if you have Chinese takeaway for two you are looking at 40 bucks.

Mr BRIGGS —But McDonald’s for two is quite filling and it is not nearly as expensive.

Mrs MAY —But it is still not cheap.

Ms HALL —But all literature and all the evidence we have received on this committee supports that people who are in lower socioeconomic groups have got a higher rate of obesity. It is not only in Australia; it is worldwide. There is absolutely no substantive evidence that has been collected that supports anything other than that.

Mrs MAY —But, Jill, I would argue too that I do not think that it is just a case of buying cheap takeaway. I think this comes back to education and the life skill of how to cook. You cannot tell me that a bag of apples is more expensive than a few McDonald’s hamburgers—I just do not buy it. I think that sometimes it is a lack of education and a lack of life skills.

Ms Pezzullo —You are both right. There is a substantive body of evidence that shows that calorie-for-dollar you get more bang for your buck from having those sorts of high-calorie but fatty meals, but nutrient-for-dollar you do not. There is also a complex array of risk factors that complicate that whole analysis. There can be clusters of risk factors in lower socioeconomic groups that mean that there might be all sorts of other social reasons why people are less well-off and disadvantaged and why they also would not eat well or not exercise much, so it is a complex social situation.

CHAIR —I think that what Margaret said is very valid as well. Education has a big role to do with it. If you do not know how to cook a nutritional meal, and you can cook nutritional meals very cheaply because there are plenty of products around, it is far easier to go and buy a cheap hamburger, because it is there and available, or a cheap pizza, two-for-one—

Mrs MAY —But it is going back to our schools too and what we saw in Victoria of teaching kids what a nutritional meal is and how to cook it. When I was at school you had to do home economics and you learned how to cook and you had your Commonsense Cookery Book.

I think I did not explain properly though about the wealth of the country and whether we are too time poor. I would suggest that obesity is evenly spread across all socioeconomic levels. When you look at the incidence of diabetes and cancer, that is not just in the low socioeconomic areas or people; that is spread right across. Educated people too are still obviously making wrong choices about lifestyle and suffering diseases that are obviously preventable according to this.

Ms Pezzullo —Yes, good point, and there is evidence too that obesity is a disease of the rich countries and the rich countries are the ones that have these growing problems of obese and overweight populations. If you do not have enough food on the table in India or in Ethiopia, then, clearly, your risk is actually under-nutrition rather than obesity. So it is a product of our success in some ways.

Mr BIDGOOD —Following on from the discussion, I want to refer back to what you recommended in that we read the Health of nations report. I have not read it, and obviously you have. We are making certain assumptions here, saying, okay, we have got this diabetes problem coming down the road like a truck that is going to cost us billions of dollars. Fine, I accept that assumption. Do you have global evidence either from that report or anywhere else that the rates of diabetes in a nation have gone down and there by association the cost of health care has gone down? Is there any evidence of that?

CHAIR —There was a study done in Nauru.

Mr BIDGOOD —I should say ‘obesity’ not ‘diabetes’.

Ms Pezzullo —I am unaware if there are such studies. There may be, but I have not heard of any.

Mr BIDGOOD —The way we are talking here is that obesity is going to cost us billions of dollars, we have got to stop obesity and thereby we will save money. Okay, fine. But is there any evidence of where obesity has gone down and healthcare costs have also gone down? That is the correlation.

Ms Pezzullo —It is.

Mr BIDGOOD —So I would really like to know that to prove the point.

Ms Pezzullo —Again, I am not aware of such studies because, unfortunately, the trend is the other way. What we can see and deduce is that the costs are associated with prevalence of the condition and it follows that if they increase as the prevalence of the risk factor increases then they will decrease as the risk factor does.

CHAIR —Just for James’s information, when we were in Jill Hall’s electorate someone gave us evidence on a study done in Nauru, so it would be good to read the transcript if you get the chance.

Mr BIDGOOD —Yes. Obviously the report has been done with a global aspect, looking at the health of nations—

Ms Pezzullo —Yes.

Mr BIDGOOD —so I just wondered if there was anything there.

Ms Pezzullo —That report is really about estimating the value of a statistical life year. That goes to the question that Steve Georganas asked initially.

Mr BIDGOOD —I have not researched it but, just off the top of my head, the Second World War went for five years and I know they say about the health of the population in European countries that people are in their 80s—my mother is 88 and going well—because wartime rationing meant everybody was very lean. It would be interesting to look at that period of life. There is evidence now that that generation is going to outlive some of this generation because of those health issues. I am just throwing that up as something to look at.

Ms Pezzullo —Sure. While I say that I do not know of any studies at a whole-of-population level in countries, there are certainly numerous studies that show in subgroup populations that you can have an impact and that, indeed, you can save costs. Some of those studies are presented in our first report, the one we did in 2006. In fact, there is a whole chapter in that first report on cost-effective interventions.

We made some recommendations on the basis of that research. We could not find a lot of evidence to support taxation options like putting a tax on soft drinks. The reality is that soft drink currently has a much higher cost than water but people still drink soft drinks rather than water, so you need to change the thinking behind the behaviour rather than just whacking a tax on. There was not a whole lot of evidence that regulatory options were particularly effective either. What we did find were effective and cost effective were activity based programs, particular for children, that had an emphasis on good exercise and developing good exercise patterns and also things that had an emphasis on good food and creating good diet patterns. It came back to developing an understanding, doing things as simple as bringing the food into schools—for example, showing kids what a leek is and how to cook it—

CHAIR —Education.

Ms Pezzullo —Yes—and growing fresh vegetables, because a lot of children do not see how vegetables grow anymore. There were also interventionist options: for people with chronic obesity, pharmacological options and bariatric surgery have been shown to be cost effective in certain populations.

CHAIR —Evidence has been given to us that points that out quite clearly, especially with regard to bariatric surgery.

Ms HALL —In the comparisons between the 2006 and 2008 studies, I noticed that you have updated prevalence estimates on the people who will be suffering from diabetes, the various forms of cancer and osteoarthritis. Have you tracked or seen whether in reality these prevalence estimates are coming to fruition?

Ms Pezzullo —The update on prevalence of those conditions was a direct product of the modelling. So if you have a higher attributable fraction then your estimate of the number of cases that are caused by a risk factor increases. So it is a mathematical identity.

Ms HALL —Maybe I should go back to the 2006 report.

Ms Pezzullo —We were very conservative.

Ms HALL —Were the estimates there reflected in reality?

Ms Pezzullo —That there were that many people who had the condition as a result of obesity?

Ms HALL —Yes.

Ms Pezzullo —Well, again, I get back to how you prove that. Do you do a lot of studies and show that in a particular population who are not obese—

Ms HALL —Do you look at the data that relates to those diseases?

Ms Pezzullo —That is right. And the studies that we have used in order to estimate those prevalences are studies that show that people who are obese or overweight have a higher prevalence of all of those conditions. From that you can estimate what is called a ‘relative risk ratio’ or an ‘odds ratio’ and you can control for a whole range of other factors—age, gender, socioeconomic status and ethnicity—and you can work out the relative risk of having the disease because—

Ms HALL —I understand that. I was just wondering if you have done any comparison between your predictions and reality. It sounds like it has not happened. I am not doubting or questioning that your estimates would be correct. I am just wondering if it was just simply a matter of whether or not there has been a comparison between actuality and the prevalence figures that you put forward.

You were just saying that studies have shown that the best types of interventions are increased activities with young people. Then there is regulation, taxing and labelling—does labelling work or tend not to work? But activities tend to work. Could you point us in a direction where we can look at some of the studies that have been done on that and look at some of the data that we can consider when we are putting together our report and looking at it from an evaluation point of view?

Ms Pezzullo —Yes, absolutely. Again, I would refer you to the 2006 study, which has a chapter on cost-effective interventions. There really is just a dipping of fingers in the water because our brief was not to provide a comprehensive literature review and summary of all cost-effective interventions. That would be a huge task. I think it is something that we really need to do—to start to develop some league tables of what works and what does not.

Ms HALL —I think you are right.

Ms Pezzullo —I am actually sure that a lot of people have started to do that. There is a great website called the CEA registry that shows the cost effectiveness of interventions across many countries, and that is very useful.

CHAIR —The interventions would I suppose be in education—

Ms Pezzullo —Yes.

CHAIR —in regulation—

Ms Pezzullo —Yes.

CHAIR —and other areas. I suppose you could see which ones have the most impact, with the studies that have been done.

Ms Pezzullo —Yes.

Ms HALL —That is directly what we are interested in.

Ms Pezzullo —Yes. We divided them in that report into different categories: the taxation ones, which are based on trying to change the relative prices of foods and drinks; and the regulatory suite of packages, which is everything from labelling, to banning, to advertising on television during certain hours and so on.

CHAIR —And the cost effectiveness?

Ms Pezzullo —And the cost effectiveness of each of those.

Ms HALL —We need to see that.

Ms Pezzullo —The third set of options were the psycho-social or behavioural interventions, which are actually directed towards changing behaviours, primarily through information provision and education. There are other triggers that can help people to activate behavioural change. My sister is a GP in Adelaide and she finds that just checking up on her patients—asking them in a proactive but nice way—is very effective with her patients. Again, it is a very small sample size and not a clinical trial, but it is anecdotal evidence. Having people and mentors encouraging you has, in her case, proven to be quite effective in helping some of her very overweight patients lose weight. Then there is the pharmacological suite, which is the fourth set of packages and the fifth set of packages are the surgical interventions.

CHAIR —When was this study or report done?

Ms Pezzullo —That was done in 2006 in relation to the year 2005.

Ms HALL —You were talking about the The health of nations report. Is that the 2006 report?

Ms Pezzullo —That is a January 2008 report that we did. Prior to that, the value of a statistical life year that we used had been based on a fairly small sample of studies. The Office of the Australian Safety and Compensation Council, as it formerly was, commissioned us to try to do a much more comprehensive and extensive study that could give a better indication of the value of a statistical life year and the weaknesses and strengths in different methodologies for estimating it and how to apply it in a policy setting. That is what that report is about.

Ms HALL —I am interested in getting a copy of that. How do I do that?

Ms Pezzullo —It is on the website. If you google ‘health of nations’, you will find it.

Ms HALL —Thank you.

Mr IRONS —We should get hold of some copies for the committee.

CHAIR —Yes. I was just about to say that we should order some copies.

Ms HALL —It sounds like it is a worthwhile report.

Ms Pezzullo —It is a dense report. It is 200 pages and it goes into a lot of the micro-economics that underlies the theories of willingness to pay.

Ms HALL —And the 2006 report is on your website too?

Ms Pezzullo —It is.

Ms HALL —And I can get chapter 2, which is the chapter that—

Ms Pezzullo —No, it is not chapter 2. I think it is about chapter 4 or 5. It is towards the end of the report.

Ms HALL —That deals with—

Ms Pezzullo —Cost-effective interventions. Again, I emphasise that it is not a comprehensive analysis of interventions.

Ms HALL —But it is a starting point.

Ms Pezzullo —It is just a grab bag. We had a bit of a look and this was our preliminary understanding of things that work and things that do not. We recommend that a lot more research is done in that area.

Mr IRONS —During your inquiry, what was the comparative prevalence of obesity in families?

Ms Pezzullo —It was not a topic of our research. Anecdotally, the people that I have spoken to—some of the experts in this area that we talked with in researching the report—certainly have told me that there is a cluster effect. There tends to be an environmental impact. So, if you have obesity in parents, you have a higher disposition to have obesity in children, over and above the genetic factor.

Mr IRONS —Lifestyle, is it?

Ms Pezzullo —Yes, that is—

Ms HALL —It is very hard to tell whether it is environment or whether it is genetic.

Ms Pezzullo —It is hard to separate. It is very difficult, yes.

Mr IRONS —The only reason I ask is that I did a lot of coaching of junior sport, and you could just about bet that, when an obese child turned up, the parents were going to be obese as well. It was a lifestyle type of thing. I was just asking whether that had showed up in any inquiries. The other thing was, during your inquiry, did you find that smoking had any influence on obesity? Did that show up at all?

Ms Pezzullo —Again, it was not something that we looked at specifically, but anecdotally it comes back to that clustering of risk factors issue. People who tend to be in lower socioeconomic groups or be more disadvantaged tend to have clusters of risk factors, and smoking, obesity, alcohol abuse or drug abuse are all clusters that tend to occur together.

Mrs MAY —Is it too simplistic to just say that we are all overindulging? What you put in your mouth is what you look like. Is it that simple? It is all part of education. I know I have gone to a dietician and gone back to the plate and the fist and how big the meal is. Is it just overconsumption? We have lost our way of eating. James, you talk about the Second World War. I know when I grew up in Fiji we just did not have takeaway food shops and we lived on fruit and fresh vegetables. We just did not have any problems. But the size of our meals—even if you go to a restaurant now, our thinking is, if the plate is not full, we are not getting bang for our buck, we are not getting value for the dollar. Have we got to rethink what we are eating?

Ms Pezzullo —Certainly portion size is something that is in the literature. There is a debate about the contribution of diet versus the contribution of exercise.

Mr IRONS —Input versus output.

Ms Pezzullo —At the end of the day, it is an energy equation. They have got to balance, otherwise there is weight gain.

Mrs MAY —What hits the lips, hits our hips—we know that, as girls.

CHAIR —I have one very last question before we close off.

Mrs MAY —You know that, Julia, as well as I do.

CHAIR —It is a very broad question and you might give us some views. The report was called The growing costs of obesity in 200: three years on. Could you summarise that for me?

Ms Pezzullo —We had estimated the cost of obesity for the year 2005 in our 2006 report, so we were looking at how the costs had changed over the three years. The changes were largely a result of new data—better prevalence estimates, which were higher; new attributable fractions, which were higher.

CHAIR —So everything was higher.

Ms Pezzullo —Everything. We realised that we had been quite conservative—overly conservative—in our 2005 estimate, so we thought it worthwhile putting the less conservative if perhaps less comfortable estimates on the table.

CHAIR —Thank you very much for that. That was very informative. Many things came out of it that we would also like to have more on, and we will see if we can get some more reports and things. We have keen interest in this. Thank you very much.

Committee adjourned at 9.36 am