The price of free choice

With guidelines removed by the National Government, school tuck shops and bakeries are free to offer what they like. Photo / Bay of Plenty Times

When National's Tony Ryall took over as Health Minister he promised no major structural changes.

He has kept that promise. District health boards and universal subsidies for primary health care are intact.

National has also fulfilled another, less-obvious commitment - to rewrite anti-obesity policy.

It has shaved more than 10 per cent off anti-obesity funding, taken the state's nose out of school lunches, and rejected Labour's bid for potential Government control of the composition, shelf placement in supermarkets and advertising of any food.

And now National has opted for a delay and rethink on forcing the addition of folic acid to bread - because of bakers' lobbying and after former National MP Katherine Rich, a leading campaigner for the food industry, publicly reminded Food Safety Minister Kate Wilkinson of her vigorous campaign to rid New Zealand of the "nanny state".

The phrase crops up a lot in National rhetoric and found resonance with some, in the way the taunt "political correctness gone mad" used to.

Public health specialists, some of whom are aghast at National's dismantling of anti-obesity policies, have taken to mocking the Government's language.

"This 'nanny state' issue is a total furphy [fictitious story]," says Professor Boyd Swinburn, former medical director of the National Heart Foundation.

"We are descending into being a 'ninny state', where we have got the food industry controlling the politicians and end up with stupid policies," says Swinburn, who advised MPs on the health select committee's obesity inquiry and is the director of the World Health Organisation Collaborating Centre for Obesity Prevention at Deakin University in Melbourne.

When the Herald asked before last year's election how National would fight obesity, Ryall thought it an odd question for an article on health policy. He wanted to focus on reducing the shortages of healthworkers, the delays for treatment and the health bureaucracy.

In unedited statements published in the paper, the Green Party said it wanted to ban TV ads for unhealthy food before 8.30pm, introduce gardening and cooking at school, and greatly encourage cycle- and pedestrian-friendly cities. Labour intended to continue its policies to educate people on the benefits of healthy eating and exercise.

Mr Ryall said: "Changing attitudes towards food and exercise require information and support rather than top-down Government instruction."

These three responses encapsulate what Swinburn defines as a spectrum from "hard paternalism" to "soft paternalism" in obesity policy.

Hard equals legislation, regulation: force. Soft equals encouragement, education, promotion.

Hard policies limit choice, removing less-healthy options from shop shelves or introduce tax differentials. Soft policies assume faulty beliefs are at the root of why 26.5 per cent of New Zealand adults are obese, the third-highest rate among developed nations.

National is at the soft end. This is evidenced by its reversal in February of the rule banning daily school sales of unhealthy foods like high-fat, high-salt pies - Labour's uneasy entry into hard obesity policies.

The Government has also:

Scrapped the target Labour set for district health boards of increasing the population's intake of fruit and vegetables, and

Cut health sector spending on nutrition and physical activity to $58 million, from $65 million last year, although Labour's flagship Healthy Eating/Healthy Action (HEHA) programme remains and Ryall promises a significant investment in children's physical activity to be announced next month.

"We want more HA and less HE," Ryall quipped.

Tasman Bay Food Group, a major supplier to school canteens which invested heavily in reformulating products to fit the Ministry of Health's healthy-food guidelines, has noted a drift back to tuckshops selling cheaper, "untested" pies from local bakeries.

"There had been a lot of progress made in the last five years switching to healthier-choice foods," says general manager Martyn Barlow. "The decision [in February] has seen a drift back for a number of food types that weren't being sold in schools. It has turned the clock back a number of years."

While National's obesity policies did not feature strongly in the election campaign, its philosophy of individual choice is explicit. It wrote dissenting reports after the obesity inquiry and after the select committee considered the Public Health Bill.

"Basic attitudes to food have to change before the tide of overweight and obesity will begin to reverse," National said. "Interventions that eliminate choice and rely on control will not achieve the required attitudinal changes."

Swinburn says it was clear at committee hearings that Ryall "was not buying any of the information coming out from the public health side of the argument. It was very clear that he wanted to go down a personal choice, industry-led approach".

Poor nutrition is estimated to cause more than 8000 deaths a year, and lack of exercise more than 2000. Labour took heart from statistics last year which showed child obesity had stabilised at 8 to 9 per cent and the rate of increase had slowed in adult obesity.

But Greens health spokeswoman Sue Kedgley says National's cuts in obesity policy are foolish because of the risk of obesity and type 2 diabetes overwhelming the health system.

Swinburn characterises the obesity epidemic as "probably the single biggest threat to the health of Australian and New Zealand children".

Former health minister Pete Hodgson warned, when launching Labour's obesity policies, that New Zealand faced "the very real possibility that the current generation of New Zealand children will be the first to die younger than their parents".

Swinburn says Labour put New Zealand ahead of the average among developed countries in child-obesity policy, but the country had now slipped toward the bottom of the rankings.

"Conservative governments tend not to like the hard policies so they tend to go for health-promotion-type options rather than enforceable policies or taxes. The New Zealand Government is taking the approach that childhood obesity is an issue for parents and for the food industry to sort out and government doesn't really have any role in it. That's a recipe for increasing childhood obesity."

He notes governments have not shied away from legislating on behaviour where public health threats are high - like banning smoking at work, outlawing illicit drugs and requiring seatbelts to be worn. But he expects governments are unlikely ever to stipulate what people can eat or what physical activity they must do, which would go beyond the hard policies he advocates.

Ryall says National is concerned about "unhealthy weights in the community", but wants "more emphasis on sport and the physical activity side of the equation ... We got a very clear message from the public that they want a balanced approach on this issue."

You are never going to address the issue of unhealthy weights with a single focus on food and denying choices. We have to change people's behaviour. The best way to do that is by information and a balanced approach."

Our view on the school tuckshop issue is that these decisions are best left with school boards of trustees and parents."

Diabetes specialist Dr Robyn Toomath, of the group Fight the Obesity Epidemic, accuses Ryall of "inventing evidence" over his assertion the public want a morebalanced nutrition/physical activity policy.

She says surveys have shown what most want: a ban on junk-food advertising on TV during the hours when children typically are watching; and protection of the school food environment.

Labour, despite introducing hard policies, disappointed some in the public health community by not taking a harder stand on food advertising and the food industry.

It negotiated a Food Industry Accord in 2004, under which the industry has voluntarily changed to healthier ingredients in some products and reduced the portion sizes of some confectionary and drinks.

The Food Industry Group, representing food manufacturers, distributors, advertisers and media, lists changes which have removed large amounts of salt, saturated fat, trans fats and sugar from the diet of New Zealanders. These include Fonterra Brands' 10 per cent reduction of added sugar in Primo flavoured milks; Goodman Fielders' reduction of the proportion of fat in its flavoured milk, from 2 per cent, to 1.7 per cent - removing about 26 tonnes of fat a year; and Kellogg's introduction of a version of Coco Pops breakfast cereal that has 16 per cent less sugar.

Perhaps the leading food-supply improvement is bakers' voluntary removal of 150 tonnes of salt a year from bread through a Heart Foundation project which, by reducing blood pressure, is expected to help reduce heart attacks and strokes.

Foundation medical director Dr Norman Sharpe considers this scheme, which won last year's supreme Health Innovation Award, to be a good example of the benefits of collaboration between the public health sector and the food industry.

He foresees great benefits for the population's health in building on this success - but he doubts the voluntary code on TV food advertising will sufficiently protect children.

Food Industry Group chairman Jeremy Irwin welcomes National's less-regulated approach to food consumption.

"It's interesting to see this Government has a different approach to the levels of self-responsibility for consumers to buy and consume what they desire, rather than the approach that was looming where people were virtually being told what to eat."

But for Toomath, the change is cause for despair.

Schools, she says, were starting to feel nervous about fast-food sponsorship and the quality of food in their tuckshops.

"Now they're being told to go for it. What we've got ahead of us is a huge increase in obesity in kids and a lot more obesity-related illness. People don't get thinner."