Obesity & Food

An overview in Victoria

We have a problem with obesity.
How can we make it easier to eat better?

Preface

As a Citizen Juror you will be asked your opinion on how to deal with the problem of obesity in relation to food and what we eat. This means you will need to become familiar with some of the key issues surrounding obesity, like healthy eating and what influences food choices. Here is some information that will help you as you form your view on what can be done to make it easier to eat better.

The problem

Australian adults and children are experiencing high rates of overweight and obesity. [1]

• Almost two thirds of Australian adults are overweight or obese.

• Around one in four Australian children aged 2–17 years are overweight or obese.

• In Victoria, one in four adults are now obese. [2]

Being overweight or obese contributes to many diseases including diabetes, cancer, and cardiovascular health.

<span style="line-height: 23.1111011505127px;">BMI ranges by weight classifications in adults</span>

BMI ranges by weight classifications in adults

Obesity - Future Predictions

Current predictions suggest that by 2025, 72% of adults will be overweight and obese, with 34% obese.

This would result in a total of 16.9 million Australians who are overweight and obese, having risen from 10.2 million in 2005.

Current estimates predict that one third of children will be overweight or obese by 2025. [3]

Source: Obesity Australia 2014, Obesity A national epidemic and its impact on Australia [4]

Source: Obesity Australia 2014, Obesity A national epidemic and its impact on Australia [4]

Overweight and obesity in Australia and across Victoria

Overweight and obesity are not evenly distributed across our population.

• The number of adults who are obese is higher for those living in areas of more disadvantage.

• In almost every age group, the rate of overweight and obesity for Aboriginal and Torres Strait Islander adults is significantly higher than non-Indigenous adults, with nearly four in every ten (39.8%) being obese. [5] Aboriginal and Torres Strait Islander adults who are obese are seven times more likely to have diabetes than those who are at a normal weight or underweight.

• Rates of obesity differ according to country of birth and ethnicity. Of those born in North Africa and the Middle East, Southern and Eastern Europe, and Oceania, approximately one in three are obese. [6]

• Adults living in inner regional, outer regional and remote areas of Australia are more likely to be overweight or obese compared to adults living in major cities. [7]

• The risk of obesity is 20 to 40% higher in individuals who live in a household that ran out of food in the last 12 months and could not afford to buy more (food insecurity). [8] Around 1 in 20 (4.6%) Victorians live in a household with food insecurity. [9]

Photo credit - Marko Mikkonen

Counting the health care costs of obesity

• Each one percentage increase in obesity in the Australia population costs about $4 billion a year. [10]

• Of the Australian Health budget, less than $1 in every $50 is spent on public health and measures to prevent ill health. [11]

• The increase in obesity has been followed by a dramatic rise in costly weight loss surgeries. [12]

• As many as 85 Australians a week are having lower limb amputations due to diabetes, a consequence of our increasing levels of obesity. [13]

• Estimating the cost of obesity is complicated, as it involves direct costs incurred by the health-care system, and indirect costs such as lost productivity and carer costs. The figure opposite estimates that in 2008 the total financial costs at 8.3 billion. [14]

What causes obesity?

Obesity is a complex problem. Simply put, obesity occurs when we take in more energy through eating than we burn through our day to day activities and exercise. There are many other factors that influence body weight such as our biology and genetics and whether our environment makes it easy to be physically active and eat well.

The graph below demonstrates the many factors involved which are difficult and challenging to address.[15] Rather than be overwhelmed we need to look at the factors where we can have an impact. Fundamentally, we are consuming too many kilojoules from poor nutritional sources. We want to think about what we want individuals, the food industry and governments to do to make it easier to eat better.

Photo Credit - Mosman Council

Adapted from: Public Health England 2015, Causes of obesity, http://www.noo.org.uk/NOO_about_obesity/causes [15]

Adapted from: Public Health England 2015, Causes of obesity, http://www.noo.org.uk/NOO_about_obesity/causes [15]

Why eating better is important

A healthy diet is vital for optimal growth, development and health throughout life, starting with breastfeeding. Eating well contributes to physical vitality, mental health and, social well-being. The importance of combining regular physical activity with nutritious foods to help maintain a healthy weight is well known. While there are many aspects to a healthy lifestyle including being active, the focus for Victoria’s Citizens’ Jury on Obesity is limited to one of the most influential factors on obesity – what we eat. We will focus on how our food consumption habits and our food environments contribute to obesity and what can be done to change them.

The Australian Dietary Guidelines use the best available scientific evidence to provide information on the type of foods and dietary patterns which promote health and wellbeing and reduce the risk of diet-related diseases across all ages. [16]

Eating a healthy diet that includes adequate fruit, vegetables and wholegrains rather than too many processed foods, sugary drinks and salt, reduces the risk of chronic diseases. [17]

The five food groups in the Australian Guide to Healthy Eating make up all the nutrients needed for good health. The recommended amount of food across the five food groups varies according to age, life stage and gender. [18]

<i>Source: Australian Guide to Healthy Eating, 2015</i>

Source: Australian Guide to Healthy Eating, 2015

What are Australians eating?

As a population, we are not eating a healthy diet. A lack of healthy food and drinks, combined with eating too many unhealthy foods that are high in energy (kilojoules), sugar and salt is having a negative effect on the health of Victorians. What we eat is contributing to the alarming rates of overweight and obesity among both adults and children, across Australia and many other countries.

What are the main issues?

The first annual Shape of Victoria Survey 2015 [19] found:

• Almost half regularly snacked on biscuits and chocolate

• One in four ate fast food at least every second day

• One in three skip breakfast - a routine associated with overeating later in the day

This highlights the key issues: a lack of fruit and vegetables and too many processed foods. On top of this, almost 50% of those surveyed said they didn’t realise how much they ate in a day and up to 45% admit to overeating when they’re stressed or upset.

This underlines that there are social, psychological and environmental factors that encourage us to eat.

Fruit and vegetables

• Eating the recommended amounts of both fruits and vegetables has protective effects against weight gain, certain types of cancers, and heart disease. [20]

• Less than one in 10 adults meet the recommended daily intake of vegetables [21] (see figure below).

• Only around half meet the recommended daily intake of fruit. [22]

• Among Victorians, only 1 in 20 adults (5.2%) meet both the fruit and vegetable dietary guidelines. [23]

Proportion of Australians eating the recommended serves of vegetables [24]<sup id="cite_ref-1" class="reference" style="line-height: 1; font-size: 11.1999998092651px; unicode-bidi: -webkit-isolate; color: rgb(37, 37, 37); font-family: sans-serif; text-align: start;"></sup><br/><br><br/><i>Source: Australian Bureau of statistics (ABS)&nbsp;</i><br/><i>Australian Population Health Survey 2011-2013</i>

Proportion of Australians eating the recommended serves of vegetables [24]


Source: Australian Bureau of statistics (ABS) 
Australian Population Health Survey 2011-2013

Discretionary foods

Discretionary foods are food and drink which are not necessary to provide the nutrients the body needs for good health and are high in energy, saturated fat, added sugar and salt. [26] The Australian Guide to Healthy Eating recommends that these foods should only be eaten sometimes and in small amounts. [27]

• Over one third of the total daily energy intake of Australians comes from discretionary processed foods which are energy dense and nutrient poor. At the same time our fruit and vegetable intake is too low. [28]

• Sugary drinks, which include soft drinks, sports drinks, cordial and fruit juices/drinks are the largest source of added sugars in the Australian diet. [29]

Reducing intake of ‘discretionary foods’ such as sugary drinks among both adults and children can lead to reduced energy intake and the health risks associated with overweight and obesity. Small changes maintained over time can have a significant impact. For example, swapping a can of soft drink (675 kilojoules) for water every day for a year would reduce individual energy consumption by around 250,000 kilojoules (60,000 calories).

Eating Out and Takeaway Foods

Victoria, like other Australian states, has a high number of restaurants and takeaway food outlets. Spending on fast food and eating out has grown by 50% (ABS) in the past six years. [32]

Currently, Australians spend nearly a third of their weekly household food budget on dining out and fast foods. [33] Unfortunately much of this food is laden with saturated fats, added sugars and salt, and loaded with kilojoules - all of which contribute to obesity.

What can be done to address the complex problem of obesity?

Food Supply

The type of food which is available and accessible – the food supply - plays an important role in health, particularly among groups who experience higher rates of disadvantage. [34]

Certain communities are more susceptible to food insecurity where healthy food and drink options are unavailable, inaccessible and/or unaffordable, including the unemployed, single parent households, low income earners, rental households, young people, Indigenous and culturally and linguistically diverse communities, and socially isolated people. [35]

Our current food supply is contributing to the problem of overweight and obesity. An increased supply of cheap, tasty, energy-dense foods, which makes food much more accessible and convenient; along with more persuasive and pervasive food marketing, is contributing to the problem of obesity. [36] Therefore food supply policies are important, particularly to assist disadvantaged populations to have affordable access to healthier food options. [37]

Food prices affect food selection, and over time, the cost of healthy food has increased more than less healthy items. [38]

The four dimensions of food security [39]

The four dimensions of food security [39]

What can be done to make it easier to eat better?

To stop the rise in diabetes and obesity by 2025, international experts from the World Health Organization (WHO) recommend key changes by communities, government and industry all needed to come together to create a healthier food supply. [40]

The World Health Organization recommends healthy eating policies and strategies that focus on breastfeeding; food and beverage marketing; food production; supply and retail; food provision within institutions; pricing and agricultural incentives public information campaigns; supportive healthy eating environments; and nutrition labelling for pre-packaged food. [41]

World Health Organisation 2013, WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013 - 2020

These can be summarised into three broad categories:

  1. The food environment

  2. The food system

  3. Behaviour change and communication strategies

________________________________

1. The food environment

As outlined above, the food environment involves a number of groups. Below are some examples of what can be done and who would be responsible for these changes.

2. The food system

The food system is made up of links between food producers, processors, distributors and the community. Developing an understanding of a community’s current food system can identify how these aspects interact, and where interventions would be most effective to promote food security and healthy diets.

THE NEED FOR A MULTI-SECTORAL APPROACH

A multi sectoral approach involves many organisations, groups and representative bodies working in the same area.

Due to the need for many sectors to be involved in obesity prevention, coordination and commitment across government structures and government departments at a national and state level is required.

Often the impact of programs on a population level may be small. However when combined with a cross government approach they can still make a significant impact.

Previous Victorian Government approaches include the Healthy Together Victoria initiative,[43] which used a systems-based prevention approach to support local settings and community leaders to map their local systems, and identify the relevant interventions that promoted healthy food and physical activity environments and behaviours.

The Healthy Food Connect model[44] is used to assist local government to address local food system change, with interventions ranging from creating local food hubs, community-supported agriculture, fresh food recovery programs, and food charters.

Another option is a Health in All Policies (HiAP) approach,[45] where health is an outcome of all policies, with a focus on health equity. Health is everyone's business and requires coordinated action from all government departments such as transport, housing, education, nutrition, water and sanitation.

Examples of the application of HiAP include the following:

• The protection and promotion of health and sustainable food security declared as overriding priorities in food policy development

• The protection and promotion of health ensured in trade agreements and agricultural and food fiscal policies (e.g. subsidies, taxes, import tariffs, quotas)

• Taxation and social policies support the reduction of socioeconomic inequalities which contribute to health inequalities

3. Behaviour change and communication strategies

Government and the food industry have an important role to play in influencing our food environments. Individuals also have responsibility for their own behaviour with regards to diet.

Some people think that overweight and obesity is an individual's problem. However, many experts agree that interventions focused on encouraging individuals to change eating behaviours need to work together with broader population-level change.

Population-level initiatives have the advantage of impacting on far greater numbers than could ever benefit from individual interventions. This is important as it helps to address disadvantage far more than individual behaviour change.

Our food environment has altered so dramatically in the past thirty years, and it is becoming increasingly difficult to eat healthy and be active.

To have a tangible impact on obesity, we need to focus on the factors that can be changed. Genetics or deeper socioeconomic factors such as disadvantage and unemployment can be difficult to change. Experience tells us that ‘just being told’ is not enough to change our behaviour. However, activities such as those listed below can help to have an impact.[46]

• Social marketing campaigns in the form of media advertising

• Communication about healthy lunchboxes, reducing intakes of energy-dense (high kilojoule), nutrient poor foods and drinks at and away from home

• Promoting family mealtimes for families to eat together

• Teaching cooking and food preparation skills

• Lifestyle behaviour change programs which can be effective for weight loss, dietary change and management of chronic disease.

• Promoting and supporting breastfeeding and healthy infant feeding including the appropriate introduction of first foods.

Summary

Photo credit - Tony Fernandez

Photo credit - Tony Fernandez

Obesity is a complex problem which requires multiple strategies from numerous groups working towards a clear common goal of prevention. Urgent action is needed if we are to halt the rise of obesity and related chronic disease. Current thinking is that there is a reciprocal relationship between personal choice and the influence of the environment in which we live, play and work.

There is a vicious cycle at play where unhealthy food environments reinforce unhealthy food choices, making it more difficult to eat well. To turn the tide on obesity, change needs to happen at a population level to have the impact required. A consolidated effort is needed where government, the food industry, communities and individuals work together to promote and implement changes to our food environment that prevent rising rates of overweight and obesity.

• Governments have a role to play in legislation, statutory regulation, setting voluntary standards, guidelines and targets, and through direct action with the food industry.

• The food industry has a role to play in the supply and manufacturing of food including reformulation of food to healthier options. There are also opportunities to address food labelling and advertising.

• The community and non government organisations can play a role in advocating for change in the food environment, supporting education in nutrition, and developing new approaches to help us eat better and prevent obesity.

We need to look toward innovative solutions to solve the problem, such as Victoria’s Citizens’ Jury on Obesity. Your role as a juror will help us address this health crisis.

________________________________

This paper has been compiled from a range of evidence and best practice in obesity research, including an evidence review commissioned from the WHO Collaborating Centre for Obesity Prevention, Deakin University. This paper is intended to provide the jurors with an overview of the problem of overweight and obesity, with a particular emphasis on food. Distilling this complex subject into a short document which can be easily understood by the general public, means that not all aspects of the problem can be covered in depth here. For further understanding about some of the areas introduced in this paper and to get a range of perspectives, we encourage the jurors to read the submissions.

APPENDICES

• Glossary

• Obesity FAQs

• The Australian Dietary Guidelines and the Australian Guide to Healthy Eating

• How to calculate Body Mass Index (BMI)

Glossary

Body mass index
Body mass index (BMI) is a person’s body weight in kilograms divided by the square of their height in metres (kg/m2)

Discretionary foods
Discretionary foods are foods that aren’t necessary for a healthy diet and are typically high in energy, sugar, saturated fats and salt. Examples include sugary drinks, chocolate bars, and fast food.

Energy
When we eat food we take in energy and when we move around we burn energy. The unit we use to measure this energy is the kilojoule (kJ).

Food environment
Our food environment consists of our surrounding physical and social environments where the cost and availability of foods influence what we eat. Our homes, schools, supermarkets, food outlets and community gardens are some of the settings that make up our food environment.

Food industry
The food industry consists of those involved with the production, manufacture and retailing of food.

Food marketing
Food marketing includes a number of different methods used by food manufacturers and retailers to promote purchase and consumption. This includes advertising on television and radio as well as sponsorship of sports team and promotions in supermarkets and storefronts.

Food security
Food security is when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life. It is often defined as having four pillars: food availability - sufficient quantities of food; food access - sufficient resources to access food; food utilisation - skills, abilities and safety to use the food; and food stability - that these conditions are reliably maintained over time (WHO 2015)

Food system
Include all processes and infrastructure involved in feeding a population: producing, harvesting, processing, packaging, distribution and transport; eating and food waste.

Kilojoules
Kilojoules is how we measure the energy that is in our food, similar to the way we use kilograms to measure weight. Another way to measure this energy is calories, much like weight can be measured in pounds as well as kilograms. 4 kilojoules equals approximately 1 calorie.

Multi- sectoral approach
A multi sectoral approach involves many organisations, groups and representative bodies working in the same area.

In the example of addressing obesity, a multi sectoral approach will include a number of organisations with a role to play in reducing obesity such as the food industry, government, consumers and retailers.

Nutritional labelling
The labelling on food packages that includes information on the amount of nutrients contained such as energy, fat, protein, carbohydrates and other nutrients contained

Overweight and obesity
Overweight and obesity are defined as excessive fat accumulation that may impair health. A Body Mass Index (BMI) of between 25 and 29.9 is considered overweight, while a BMI greater or equal to 30 is considered obese.

Processed foods
Processed foods are those that have been altered from their natural state, either to alter the taste of food, make it more convenient to consume or prolong shelf-life. Examples of processed foods include cereals, bread, cheese, prepackaged meals, certain meat products and many beverages such as milk and soft drinks. Not all processed foods are unhealthy, although many have added sugars, salt and unhealthy fats.

Obesity FAQs

What is the difference between being overweight and being obese?
Determining whether someone is overweight or obese is often determined by assessing a person's body mass index (BMI), which is a ratio between weight and height. If your BMI falls between 25 and 29.9, you are overweight. If your BMI is 30 or higher, you are considered obese. BMI is a standardised population measure and may not be relevant for groups like elite athletes.

What is the main cause of obesity?
Though genetics and cultural factors can lead to obesity, the main cause is eating too much and/or not getting enough exercise.

Can physical activity help?
Physical activity brings a variety of health benefits. It takes a relatively large amount of effort to burn a modest number of calories. When focusing on overweight and obesity we should focus both on reducing kilojoule intake and increasing physical activity.

Does dieting work?
Diets such as fad diets which cut out whole food groups and promise fast weight loss can be dangerous to health and usually only encourage short term changes rather than ongoing eating habits that can be sustained long term. Some studies even show that those who are trying to overly control what they eat actually end up eating more as a result

The Australian Dietary Guidelines

The Australian Dietary Guidelines address these dietary risks, providing consistent messages about food patterns to promote health and wellbeing and reduce the risk of diet-related chronic disease.

The Australian Dietary Guidelines feature five key recommendations, with each considered to be equally important in terms of public health outcomes26.

Guideline 1: To achieve and maintain a healthy weight, be physically active and choose amounts of nutritious food and drinks to meet your energy needs
Children and adolescents should eat sufficient nutritious foods to grow and develop normally. They should be physically active every day and their growth should be checked regularly.

Older people should eat nutritious foods and keep physically active to help maintain muscle strength and a healthy weight.

Guideline 2: Enjoy a wide variety of nutritious foods from these five groups every day:

Plenty of vegetables, including different types and colours, and legumes/beans

Fruit

Grain (cereal) foods, mostly wholegrain and/or high cereal fibre varieties, such as breads, cereals, rice, pasta, noodles, polenta, couscous, oats, quinoa and barley

Lean meats and poultry, fish, eggs, tofu, nuts and seeds, and legumes/beans

Milk, yoghurt, cheese and/or their alternatives, mostly reduced fat (reduced fat milks are not suitable for children under the age of 2 years)

And drink plenty of water.

Guideline 3: Limit intake of foods containing saturated fat, added salt, added sugars and alcohol

Limit intake of foods high in saturated fat such as many biscuits, cakes, pastries,pies, processed meats, commercial burgers, pizza, fried foods, potato chips,crisps and other savoury snacks.

Replace high fat foods which contain predominantly saturated fats such as butter, cream, cooking margarine, coconut and palm oil with foods which contain predominantly polyunsaturated and monounsaturated fats such as oils, spreads, nut butters/pastes and avocado.

Low fat diets are not suitable for children under the age of 2 years.

Limit intake of foods and drinks containing added salt.

Read labels to choose lower sodium options among similar foods.

Do not add salt to foods in cooking or at the table.

Limit intake of foods and drinks containing added sugars such as confectionary, sugar-sweetened soft drinks and cordials, fruit drinks, vitamin waters, energy and sports drinks.

If you choose to drink alcohol, limit intake. For women who are pregnant, planning a pregnancy or breastfeeding, not drinking alcohol is the safest option.

Guideline 4: Encourage, support and promote breastfeeding

Guideline 5: Care for your food; prepare and store it safely

Table: Recommended average daily number of serves from core food groups – children & adolescents

Table: Recommended average daily number of serves from core food groups – children &amp; adolscents

Table: Recommended average daily number of serves from core food groups – adults

Table: Recommended average daily number of serves from core food groups – adults

How to calculate Body Mass Index (BMI)

Body Mass Index (BMI) provides a measure of body weight in relation to height that can be used to estimate levels of unhealthy weight in a population. It is calculated as weight in kilograms divided by the square of the height in meters (kg/m2). Individuals with a BMI over 25kg/m2 are classified as overweight and those with a BMI of over 30kg/m2 are classified as obese.

Click here to calculate your BMI

REFERENCES

[1] Australian Bureau of Statistics (ABS) 2013, Australian Health Survey: Updated Results, 2011-2012 (4364.0.55.003)

[2] Victorian Department of Health 2014, Victorian Population Health Survey 2011-2012

[3] Obesity Australia 2014, Obesity: A national epidemic and its impact on Australia

[4] Obesity Australia 2014, Obesity: A national epidemic and its impact on Australia

[5] ABS 2013, Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Australia, 2012-13 (4727.0.55.001)

[6] ABS 2013, Australian Health Survey: Updated Results, 2011-2012 (4364.0.55.003)

[7] Walls, H et al. 2012, Projected progression of the prevalence of obesity in Australia. Obesity 20: 872-878

[8] Burns, C et al. 2004, A review of the literature describing the link between poverty, food insecurity and obesity with specific reference to Australia, VicHealth

[9] Victorian Department of Health 2014, Victorian Population Health Survey 2011-2012

[10] Lateral Economics 2011, The Herald/Age - Lateral Economics Index of Australia’s Wellbeing,http://lateraleconomics.com.au/wp-content/uploads/2014/02/Fairfax-Lateral-Economics-Index-of-Australias-Wellbeing-Final-Report.pdf

[11] Australian National Preventive Health Agency (ANPHA) 2013, State of Preventive Health 2013, Canberra

[12] AIHW 2010 Weight loss surgery in Australia. Cat.no. HSE 91. Canberra.

[13] Australasian Podiatry Council 2012 Diabetes: Foot Treatment and Complications Information Sheet

[14] Obesity Australia 2014, Obesity: A national epidemic and its impact on Australia

[15] Adapted from: Public Health England 2015, Causes of obesity, http://www.noo.org.uk/NOO_about_obesity/causeshttp://www.noo.org.uk/NOO_about_obesity/causes

[16] National Health and Medical Research Council (NHMRC)2013, Australian Dietary Guidelines, Canberra

[17] Institute for Health Metrics and Evaluation (IHME) 2013, GBD profile: Australia, http://www.healthdata.org/sites/default/files/files/country_profiles/GBD/ihme_gbd_country_report_australia.pdf

[18] Appendix for more information or go to www.eatforhealth.gov.au

[19] Cancer Council Victoria 2015, Shape of Victoria, http://www.cancervic.org.au/about/media-releases/2015-media-releases/june-2015/new-research-reveals-the-shape-of-victoria.html

[20] NHMRC2013, Australian Dietary Guidelines, Canberra

[21] ABS 2015, Australian Health Survey: Nutrition First Results - Food and Nutrients 2011-2012

[22] ABS 2015, Australian Health Survey: Nutrition First Results - Food and Nutrients 2011-2012

[23] Victorian Department of Health 2014, Victorian Population Health Survey 2011-2012

[24] ABS 2015, Australian Health Survey: Nutrition First Results - Food and Nutrients 2011-2012

[25] NHMRC2013, Australian Dietary Guidelines, Canberra

[26] NHMRC2013, Australian Dietary Guidelines, Canberra

[27] NHMRC2013, Australian Guide to Healthy Eating, Canberra, www.eatforhealth.com

[28] ABS 2015, Australian Health Survey: Nutrition First Results - Food and Nutrients 2011-2012

[29] ABS 2015, Australian Health Survey: Nutrition First Results - Food and Nutrients 2011-2012

[30] ANPHA 2014, Evidence Brief - Sugar-sweetened beverages, obesity and health, http://sydney.edu.au/medicine/public-health/menzies-health-policy/publications/Evidence_Brief_Sugar_sweetened_Beverages_Obesity_Health.PDF

[31] Boden Institute University of Sydney, Australian National Children’s Nutrition and Physical Activity Survey 2007 - analysed by Public Health Nutrition Group

[32] Australian Bureau of Statistics 2009-10 Household Expenditure Survey Australia Summary of Results. 6530.0. 2011 Canberra

[33] Cancer Council NSW Media Release Exposing the truth on fast food restaurants

[34] Swinburn, B et al. 2011, The global pandemic: shaped by global drivers and local environments, Lancet; 378: 804–814

[35] Burns, C et al. 2004, A review of the literature describing the link between poverty, food insecurity and obesity with specific reference to Australia, VicHealth

[36] Barton, H and Grant, M 2006, A health map for the local human habitat, The Journal for the Royal Society for the Promotion of Health, 126 (6): 252-253.

[37] Swinburn, B et al. 2011, The global pandemic: shaped by global drivers and local environments, Lancet; 378: 804–814

[38] Lee, J et al. 2011, Influence of food cost on diet quality and risk factors for chronic disease: A systematic review, Nutrition and Dietetics, 68: 248-261

[39] Australian Institute for Health and Welfare (AIHW) 2012. Australia’s food and nutrition, Cat no. PHE 163, Canberra

[40] Hawkes, C et al. 2013, A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework, Obesity Reviews, 14 (supp 2): 159-168

[41] World Health Organization 2013, WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013-2020

[42] Adapted from: NSW Centre for Public Health Nutrition 2003, Improving food and nutrition in NSW – Food Security Options Paper: A planning framework and menu of options of policy and practice interventions

[43] http://www.health.vic.gov.au/prevention/healthytogether.htm

[44] Department of Health & Human Services, 2014, Healthy Food Connect: A Support Resource https://www2.health.vic.gov.au/getfile//?sc_itemid=%7BDB862F84-2C5B-486E-AB7A-8C82C44C293F%7D

[45] WHO:Health in All Policies - Framework for Country Action 09 May 2013

[46] Commonwealth of Australia 2009 Australia: National Preventative Health Strategy - Overview