An alarming trend has occurred over the last 25 years; with the number of Australian children who are overweight doubling (NSW Ministry of Health, 2017). The most recent data from the Australian Bureau of Statistics (ABS), showing more than a quarter of Australia’s children are overweight or obese (NSW Ministry of Health, 2017). The World Health Organization (WHO), considers the dramatic rise in childhood obesity over the last three decades as; “one of the most serious public health challenges of the 21st century” (World Health Organization, 2018).
Being overweight, especially obese puts significant strain on our bodies and increases the risk of developing noncommunicable diseases (NCDs)/chronic disease. The main types being “cardiovascular diseases, cancers, chronic respiratory diseases and type 2 diabetes mellitus” (World Health Organization, 2017b). These diseases “kill 40 million people every year, equivalent to 70% of all deaths globally” (World Health Organization, 2017b).
It is recognised that childhood obesity is complex; with a number of social determinants of health playing a part in its development. Apart from genetics, environmental factors, lifestyle choices, and cultural practices all play a part in childhood obesity. It has been found that “obesity becomes more entrenched throughout early childhood and possibly less reversible by the middle school year” (Australian Institute of Health and Welfare, 2012). This is supported by evidence suggesting that obesity can occur later in life as a result of factors in early childhood. Some of these factors include; “poor foetal nutrition, low birth weight, maternal diet and absence of breastfeeding as well as levels of physical activity and diet in childhood” (Department of Health, 2009).
Research by the WHO (2012) suggests that overweight and obese children are more likely to develop noncommunicable diseases at a younger age; resulting in premature death, along with an increased risk of low self-esteem, issues with body-image and social isolation.
Overweight and obesity, as well as related diseases, are to a great extent preventable, hence why prevention of childhood obesity is a high priority (World Health Organization, 2012).
Research also shows that there are inequalities in overweight and obesity which originate from people’s social determinants of health (World Health Organization. Regional Office for the Western Pacific, 2017). Children from lower socioeconomic groups, children living in a one-parent household, or Aboriginal and Torres Strait Islander (ATSI) children are all more likely to be overweight or obese (Australian Institute of Health and Welfare, 2016).
Food preferences and dietary habits are firmly established early in life, making the best time for intervention in early childhood (Birch, 1999). Research in Australia shows that a child’s weight status, food intake and food preferences are influenced by their parents through different preferences, their food intake and any physical activity they undertake. This suggests that childhood obesity prevention needs to include parenting strategies (World Health Organization, 2012).
The WHO (2016) has noted that many children are growing up in environments that encourage weight gain and obesity and “the marketing of unhealthy foods and non-alcoholic beverages” (World Health Organization, 2016) has been identified as a major risk factor in the increase of children being overweight and obese.
Overweight and obesity has considerable negative impacts on the Australian health care system and society through the direct and indirect costs it generates. Reports showing the cost of obesity in Australia show that in 2008 alone; obesity cost an estimated $58 billion, “including $8.3 billion in financial costs and $49.9 billion in the cost of lost wellbeing” (Access Economics, 2008).
The Council of Australian Governments (COAG) has aligned itself with the WHO; identifying “obesity prevention as a national priority (Australian Healthcare and Hospitals Association, 2016). Preventative health is an essential approach to reduce future demand on the Australian health care system while concurrently “improving quality of life for all Australians” (Australian Healthcare and Hospitals Association, 2016). With all levels of government facing budget pressure due to rising health costs, not only does a preventive health approach address such pressure, it can also delay onset and reduce “severity of any conditions” (Australian Healthcare and Hospitals Association, 2016).
Overweight and obesity was initially identified as a growing health concern in the 1990’s by the WHO; resulting in the introduction of public awareness campaigns warning “policy-makers, private sector partners, medical professionals and the public at large” (Department of Nutrition for Health and Development (NHD) World Health Organization, 2000) .
In 2004 the World Health Assembly (WHA) endorsed the “Global Strategy on Diet, Physical Activity and Health” (World Health Organization, 2012). The strategy addresses the growing prevalence and burden of non-communicable diseases globally; particularly “diet and physical activity patterns” (World Health Organization, 2012). Consequently, WHO provided Member States of the WHA with a framework to support monitoring and evaluation of implementation. The framework recommends “governments demonstrate leadership and facilitate collaborative action” (World Health Organization, 2012) through the promotion of “supportive environments for health” (World Health Organization, 2012); facilitating “positive change in diet and physical activity behaviours, with related health, social, environmental and economic outcomes” (World Health Organization, 2012).
In 2014 the WHO established the “Commission on Ending Childhood Obesity (ECHO)” (World Health Organization, 2016) to review, build on and address gaps in existing directives and strategies; after noting “progress in tackling childhood obesity slow and inconsistent” (World Health Organization, 2016). The following year, the WHO identified “prevention and control of noncommunicable diseases as core priorities” (World Health Organization, 2016). Specifying that implementation of “effective and culturally appropriate population-based childhood obesity prevention programmes” (World Health Organization, 2012) need to “occur across the whole population, in a variety of settings, and through multiple strategies” (World Health Organization, 2012).
Historically, the Australian federal government identified overweight and obesity as a “priority area for action” (National Preventative Health Taskforce, 2009); giving the Australian National Preventative Health Agency the task of developing a National Preventative Health Strategy. However, with a change in governments, this was abolished.
The “National Strategic Framework for Chronic Conditions (the Framework)” (Australian Health Ministers’ Advisory Council, 2017) was introduced in 2016 by the current federal government; to support Australia’s international commitments through the provision of support in the development of policies, strategies, and services. This framework is not a strategy and there is currently no coordinated national approach to addressing Australia’s obesity problem. The current federal government instead, focusing their attention on the promotion of physical activity and education programs, without a strategy in place, due to their search for the definition of obesity.
The state government, on the other hand, has two strategies aimed at addressing increasing rates of childhood obesity; the “NSW Healthy Eating and Active Living Strategy: Preventing overweight and obesity in New South Wales” (NSW Ministry of Health, 2013) and the “Healthy School Canteen Strategy” (NSW Government, 2017) which has been revised and is in the process of being rolled out.
There is evidence to suggest “childhood obesity rates appear to be plateauing in high-income countries” (World Health Organization, 2017a); however, this is at high levels. This is also “supported data from the NSW School Physical Activity and Nutrition Surveys (NSW SPANS)” (Australian National Preventive Health Agency, 2014a). In general, there are more children overweight across most age groups. However, within that, both national and state data shows obesity has risen in younger boys and fallen in older boys, with “no consistent pattern in girls” (Australian National Preventive Health Agency, 2014a). While overweight and obesity trends vary state to state, national patterns suggest obesity is going to continue to increase (Australian National Preventive Health Agency, 2014a).
The “NSW Healthy Eating and Active Living (HEAL) Strategy: preventing overweight and obesity in New South Wales 2013-2018” (NSW Ministry of Health, 2013) targets adults and children. The aim, to encourage healthy lifestyle choices with support through “health-focused planning, built environment and transport initiatives” (NSW Ministry of Health, 2013), and improving “access to healthier foods and improved food labeling” (NSW Ministry of Health, 2013).
The HEAL strategy has four strategic areas of focus; built environment, support programs, advice through service delivery and education to “enable informed health choices” (NSW Ministry of Health, 2013). A key action of the HEAL Strategy is improving the accessibility of healthy food and drink options across a variety of settings; including schools, and implementing the Australian Dietary Guidelines within all nutrition initiatives (NSW Ministry of Health, 2013).
In 2015, the “NSW Schools Physical Activity and Nutrition Survey (SPANS)” (NSW Ministry of Health, 2017) found that approximately 4 in 5 children in NSW met their recommended daily intake of 2 serves of fruit; however less than 1 in 10 met their recommended daily intake of 5 serves of vegetables (NSW Ministry of Health, 2017). Other key finding included the low rates of physical activity, high consumption of high sugar foods and drinks and takeaway food, low vegetable intake and too much ‘screen time’; on phones, laptops and TV’s amongst children (Hector et al., 2012).
An initiative under the HEAL Strategy, which encourages the promotion of nutritious food and drinks to school children between the ages of 5 and 16, is the “NSW Healthy School Canteens Strategy” (NSW Department of Education, 2016). The hope is to increase children’s fruit and vegetable intake and encourage them to drink water over sugary drinks. The idea is that by increasing the availability of healthy options in school canteens, it will be easier for children to make healthier choices (NSW Government, 2017).
The NSW Ministry of Health commissioned a body of research to assist with a review of the strategy from 2014 – 2015. Information was “gathered from a range of sources including literature reviews, qualitative and quantitative research, and stakeholder consultation” (NSW Department of Education, 2016); which allowed the Ministry of Health to understand what barriers and enablers there were to the implementation of the Healthy School Canteen Strategy.
The research findings identified that schools were having differing levels of success in implementation of a healthy canteen and that there was “low levels of compliance” (NSW Department of Education, 2016). Barriers identified that were impacting the development and ability to implement the healthy canteen strategy included; policy, environmental influences, canteen practices and attitudes and awareness (NSW Department of Education, 2016).
Policy barriers reported were “lack of enforcement in relation to the implementation of the strategy” (NSW Department of Education, 2016); independent and Catholic schools only being encouraged to participate. The healthy canteen guidelines also appeared to be easier to implement in primary schools opposed to secondary schools (NSW Department of Education, 2016).
Schools reported confusion regarding their requirements and identified that the guidelines were confusing and contradictory. The inflexibility of the strategy making it difficult to respect students’ cultural and religious requirements also caused issues. Schools also felt unsupported to effectively implement and then maintain the strategy and this, in turn, was associated with lower compliance (NSW Department of Education, 2016).
Schools’ undervaluing or not understanding their role in the delivery of healthy foods and parents’ perceptions about school canteens were also barriers. The research findings flagged perceived lack of demand for healthy foods being a significant barrier to implementing the strategy; with rural schools and schools in low socio-economic areas having more unhealthy food in their school canteen (NSW Department of Education, 2016).
Implementations issues reported were due to organisation and food storage issues; that being that fresh produce does not have a long shelf life, lack of storage, not having appropriate facilities to store and prepare food and not enough help in the canteen to prepare healthy food (NSW Department of Education, 2016).
The review also identified that a collaborative approach was an enabler to success for healthy school canteens. A whole school community approach, health promotion, partnerships, students inclusion, “awareness and promotion of healthy foods and having a canteen environment that is conducive to making healthy choices” (NSW Department of Education, 2016); were all enablers to the success of the strategy.
The findings from the state government’s commissioned research is also supported in “qualitative research undertaken with NSW secondary schools, which found building the capacity of the school community through resources and training is a critical success factor” (NSW Department of Education, 2016).
The role of the nurse in relation to the implementation of the NSW Healthy School Canteens Strategy, would most likely be as a school nurse delivering primary health care directed towards health promotion, education and information around healthy eating. It may also include assistance with monitoring, evaluation and reporting to get some evidence to build on.
Healthy eating “regimes can cause conflict and confusion for adolescents under the influence of families who are promoting differing ideas, especially within indigenous communities” (McHugh, 2016). It may be the role of the nurse to bridge the gap between children, their family and the information being provided in the healthy eating strategy. NSW Health’s Healthy Kids for Professionals’ website; is an online resource package which may be able to support the role of the nurse in deciding what input they will have. The website is “designed to help health professionals manage children above a healthy weight, and their families” (Healthy kids for professionals, 2018).
There may be scope for building on the strategy to provide appropriate preventative health care alongside healthy eating. An example of this could include running a metabolic clinic or running a health promotion campaign alongside the strategy.
School nursing roles also engage in health counseling and referral which would run in sync with a healthy eating initiative.
Evidence suggests that a whole of school approach can assist in supporting healthy food message delivery, “resulting in a healthier canteen” (NSW Department of Education, 2016). Harnessing support from a range of school community members, through effective communication strategies has been found to assist in the implementation of a healthy school canteen (Department of Education and Training Melbourne, 2006)
If there was a school canteen committee; there may also be a role for a school nurse to sit on the committee. Having an active role in the planning and implementation stages of the strategy whilst building “awareness and knowledge among the wider school community of the issues associated with canteen policy development” (Department of Education and Training Melbourne, 2006).
Nurses are well placed to identify and consider the health needs and well-being of children and families and apply nursing knowledge and skills in their care (NSW Department of Health, 2015). The role of the nurse could include assisting the school to engage and involve parents in the life of the school community; like volunteering in the school canteen to assist in the logistics of the strategy. The nurse may also be the best person among staff to assist the school in building relationships with external stakeholders that also support the implementation of the health school canteen initiative.
The rise in childhood obesity worldwide is one of the greatest public health, social, and economic challenges of this century. Strong contribution and input are required from schools. The potential ‘ripple effect’ that school health promotion can have via families and communities can also be utilised in this role; impacting more than just the child and school community.