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| Journal of the New Zealand Medical Association,
28-January-2005, Vol 118 No 1208
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Regarding ‘Preventing diabetes—time is running
out’
Congratulations on the 17 December 2004 issue of the
Journal—devoted to the important
issues of diabetes, obesity, nutrition, and physical activity. The papers
contribute to our understanding of these conditions, provide evidence to support
the planning and funding of both public and personal health services, and
identify important issues for further research.
Unfortunately, the negative tone of Robert Scragg’s
editorial1 did not do justice to either the
accompanying papers or the current policy environment, and some of the
statements were truly puzzling. The assertion that “a degree of apathy and
indifference appears to prevail among influential circles in the Ministry of
Health and District Health Boards [DHBs]” regarding diabetes could not be
further from the truth, and at the Ministry we are unable to understand how this
conclusion was reached.
The effort to tackle chronic disease is spread across
several different parts of the Ministry and across DHBs, PHOs, and other health
providers. Thus, it is not as easy to quantify as work on more specific issues
such as immunisation or cancer screening. However, this should not lead to the
impression that this work is not being done.
The prevention and management of chronic disease has been a
top priority for both the Ministry and DHBs for several years. Diabetes and
cardiovascular disease are top priorities in
The New Zealand Health
Strategy2—as are reducing obesity,
improving nutrition, and increasing physical activity.
The Primary Health Care
Strategy3 aims to build capability in
primary care to address chronic diseases (specifically diabetes and
cardiovascular disease). Considerable additional funding—NZ$1.7 billion by
July 2007—is going into this. Primary health organisations (PHOs) are
expected to address chronic diseases through improved access, taking a
population health approach, closer links with communities, developing multi
disciplinary team approaches and more ongoing (rather than episodic) patient
care.
Health Eating: Healthy
Action (HEHA)4,5 provides a clear
framework for preventative action both across and beyond the health sector. As
important causes of diabetes and other chronic diseases are outside the health
sector, it is arguable that the most important interventions are there also.
Government funding for the Sport and Recreation Council (SPARC), and elements of
transport, education, and conservation, inter alia, are all highly relevant. The
Ministry has a role in coordinating and leading this activity, and is doing this
through HEHA. The Ministry is also leading intergovernmental work to promote
healthy eating and healthy activity as one of five “critical social issues
for sustained interagency action” identified in the recent Government
report entitled Opportunity for All New
Zealanders.6
This high priority in policy work is also reflected in the
funding and delivery of services. Professor Scragg himself points to (and
commends) the “Get checked” programme, now in its third year. The
Ministry continues to require all DHBs to provide “Get checked” as
part of their funding arrangements with the Crown, and to report on diabetes and
cardiovascular disease in their annual plans. Existing public health funding to
improve nutrition and increase physical activity totals NZ$12 million, and
new initiatives under HEHA are likely to boost this.
Likewise, chronic disease prevention is demonstrably a
priority for DHBs. Work in Waikato (Te Wai O Rona), Counties Manukau
(Let’s Beat Diabetes), and Tairawhiti (Ngati and Healthy) are just a few
examples of many great DHB and PHO initiatives in this area.
Finally, we concur with the conclusion by Mann et al in the
companion editorial, that perhaps the greatest issue remaining to be solved is
how to persuade at-risk individuals and populations to make the necessary
changes.7 This is a huge challenge, and we need
to work cooperatively with each other as health sector practitioners, providers
and policy makers, and with other sectors, to achieve the goal of reducing the
impact and incidence of diabetes and cardiovascular disease.
Don Matheson
Deputy Director-General, Public Health Colin Feek
Deputy Director-General, Clinical Services Ministry of Health
References:
ResponseThe response by Don Matheson and
Colin Feek to my comments1 about the study
showing a high prevalence of insulin resistance among East Coast
Maori,2 confirms my statement that apathy
towards diabetes prevention appears to prevail among influential circles in the
Ministry of Health. I am surprised they have focused on the ‘negative
tone’ of my statements instead of being concerned about the very high
prevalence of insulin resistance found among East Coast Maori. How can a report
of an insulin resistance prevalence of 37%, on top of a diabetes and impaired
glucose prevalence of 16%, have a ‘positive tone’ when we know only
too well the smoke of insulin resistance precedes the fire of
diabetes?
It is misleading to mention additional funding of NZ$1.7
billion by July for primary healthcare when most of this funding will go towards
the provision of health services, for the treatment of a range of diseases
besides diabetes, rather than specifically for diabetes prevention.
I agree with both doctors that the Ministry of Health has
put considerable effort into preparing reports about obesity. But a closer look
at the ones cited in their letter,3,4 including
the 2001 to 2003 reports implementing the NZ Health Strategy, contain only
summary statements about the extent of the obesity epidemic, not the solutions.
A few case examples are cited of individual initiatives by a small number of
DHBs trying to do something about the obesity epidemic, but overall this creates
the impression of an uncoordinated and ad-hoc approach to try and quell a
mounting epidemic of national importance. It does not show the coordinated
effort, lead by central Government, that is so urgently needed.
Dr Matheson and Dr Feek state the Ministry of Health plans
to use Healthy Eating: Health Action
(HEHA)5 as a framework for preventive action,
and further, that the Ministry of Health will lead and coordinate the HEHA
implementation plan with other Government agencies. This will be great if it
happens. I agree that the 2004-2010
Implementation Plan contains many options related to obesity
prevention.6 But it also includes many
unrelated to obesity prevention, and my worry is that so many options are
listed, often in very general terms, that I can’t see how the Ministry
will start implementing concrete initiatives without a dedicated group focused
on obesity prevention.
I am concerned by their statement that the ‘greatest
issue remaining to be solved is how to persuade at-risk individuals and
populations to make necessary changes.’ It suggests that senior Ministry
officials believe the focus of obesity prevention should remain on getting
individuals to change their behaviour, rather than also considering legislation
and policy which will change our ‘obesogenic’ environment. A
dedicated committee working on obesity prevention within the Ministry of Health
needs to look seriously at all options. Legislation is likely to be very
cost-effective. For example, the evidence linking increased consumption of soft
drinks with childhood obesity is so compelling a case can be made for taxing
soft drinks by their level of sugar concentration, to decrease purchasing, since
soft drinks are price elastic.7 (Mechanisms are
already in place for alcoholic drinks to do this).
In addition, the evidence linking TV watching with childhood
obesity is very convincing, and a case can also be made for banning advertising
of unhealthy foods on TV, especially during after-school viewing hours. The
latter action may appear radical to some readers and to the Ministry, but the
example of tobacco shows how public opinion will change on important health
issues—it was only 30 years ago that smoking was allowed in airplanes and
tobacco advertising on TV.
Ultimately, the commitment of the Ministry towards obesity
prevention will be measured by the scale of its funding. Given that the Ministry
of Health estimates that obesity costs NZ$303 million per annum (based on World
Health Organization estimates of 2%–7% of the annual health budget), it
would be reasonable initially to spend 5% of that amount on research and
development to prevent diabetes—about NZ$15 million per annum.
Drs Matheson and Feek do not mention the amount of funding
available for the current obesity and diabetes prevention activities by DHBs,
such as those they cite in Waikato, Counties Manukau, and Tairawhiti, but I
would guess it is nowhere near NZ$12 million of public health money already
being spent on all nutrition and physical activity programmes related to HEHA.
Not all of these relate to obesity prevention, but I am very happy to be proved
wrong on this.
Hopefully, my concerns are unfounded, and that the Ministry
of Health will provide leadership and funds towards preventing an epidemic that
currently causes the deaths of over 3000 New Zealanders each
year.8 Otherwise the grand statements of intent
in the latest implementation plan6 will
continue to be viewed as a public relations gesture.
Robert Scragg
Associate Professor in Epidemiology University of Auckland, Auckland References:
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