A passion to address maternal and child obesity

Gretchen Miller: Hello there. Welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre. I’m Gretchen Miller, and our focus is chronic disease, the many different fields of research that contribute to fighting it. Today, two heavy hitter researchers with a shared passion for tackling maternal and child obesity. Helena Teede is an endocrinologist and professor at Monash Centre for Health and Research, Director of Monash Centre for Health Research Implementation, and Executive Director of the Monash Partners Academic Health Sciences Centre.

Helena Teede: If we ask the Australian community what they would prefer to do, “Would you rather have a small investment in prevention or wait until you’re very unwell with the complications of this,” where would we choose as a community to invest? Almost unequivocally, they will say, “Help us in prevention”. That’s a discussion we have not had, and I would very much be passionate about going back to the Australian people. It is their taxpayers’ dollars that we are spending in our healthcare and in our research, and saying, “What do you value most? What is most important to you?”

Gretchen Miller: Louise Baur is a paediatrician and professor and Head of Child and Adolescent Health at the University of Sydney. She’s also a consultant paediatrician of Weight Management Services at The Children’s Hospital at Westmead.

Louise Baur: If we look at school-age children, then about one in four have overweight or obesity. If we look specifically at obesity, then about six to eight  per cent of school-age children are affected. If we look at children just at the time of school entry, four to five years of age, then overweight and obesity affects one in five children. So it’s already quite a lot of the problem is established at the time of school entry.

Gretchen Miller: Now both Helena and Louise have brought their careers’ worth of research to new projects at the Prevention Centre, and both are concerned about how ill-equipped GPs and frontline medical services feel to speak to patients about their unhealthy weight. But to start, some sobering figures from Helena Teede.

Helena Teede: So what we know is that around the world, about half or more than half of women going into pregnancy are at an unhealthy weight. Our rates are even higher than one in two women, who go into pregnancy in an unhealthy weight, and that has quite significant impacts for their own health, but also for the health of their children, their own risks of diabetes and metabolic ill health long-term and that of their children.

Gretchen Miller: Louise, I’m wondering then what the relationship is between these two things. Maternal antenatal obesity and child obesity.

Helena Teede: There’s quite good evidence now, which I’ll hand over to Louise to highlight, that the mother’s weight or unhealthy weight at the time of conception, so this is not just about pregnancy, at the time of conception has quite a profound and predictive effect on the health of the child long-term. Then the mother’s weight gain during pregnancy – which over half of our mums, 60 per cent, put on more than recommended – compounds that and makes that more significant.

Louise Baur: We think there are a range of factors that influence that. Clearly there are strong genetic predisposition. There’s a shared environment, but there’s also the epigenetic effects. So the environmental influences on gene expression at the time of conception from both father and mother can influence a child’s future risk of both obesity, but also the ill health effects, the metabolic effects, long-term. Hence, healthy weight, healthy metabolic health at the time of conception or just beforehand is really important for future generations’ health.

Gretchen Miller: That’s a big burden to carry, actually. As a woman, I’m suddenly feeling a little overwhelmed. I wonder if you could explain what that means practically speaking. What are the implications for that baby in terms of specifics?

Helena Teede: I think it’s really important that we move away from the guilt frame, and emphasize being as healthy as you can when you come into pregnancy and beyond. It’s really unhelpful to simply lay the burden at the feet of women. There are many social and environmental factors that contribute to obesity, and it’s not isolated with women. But, more importantly, we need to start back in adolescence. It’s our girls from 14 to 17 that become quite sedentary, start to put on weight, sit down and study for VCE. We’ve got much higher participation in tertiary education and less physical activity, and very rapid weight gain. The problem starts back then, but really we know that the most effective strategy here is prevention of weight gain. If I can give you an analogy, if Australia were to cut out the equivalent of a small biscuit at morning tea or reduce their glass of orange juice to half a glass a day, we would prevent further weight gain and stall our movement towards obesity.

Because the body doesn’t adjust metabolically when we make small changes. But if we are quite in the unhealthy weight range and we want to reduce our weight to be healthy for pregnancy, it’s very hard to do. It’s very hard to do because the moment you cut back your intake of food and increase your exercise, your body becomes more efficient. That’s not to say we shouldn’t do it, it’s really important to get as healthy a weight as you can, but if your body becomes more efficient, it fights you in that challenge. The first thing we always do in working with mums or people who wish to get pregnant is say, “Number one, be aware being healthy when you get pregnant is important. So plan, ’cause at the moment, half the women in Australia don’t plan their pregnancy. Be as healthy as you can be. That may involve losing a bit of weight beforehand, but if not, it does involve preventing putting on more weight and changing to healthier lifestyle habits that we can all do with the support of your partner. Sometimes your partner’s your mother-in-law, because in many cultures, that’s important.

Sometimes it’s your husband, sometimes it’s a friend. But whoever you choose to partner with, be as healthy and plan as much as you can. Focus on that prevention first, and if you need to achieve a bit more weight loss, then you need to do that with your doctor and your expert, ’cause too much weight loss is also not great right before you get pregnant. Leave the guilt behind. Do what you can. Work on simple preventative strategies, and we’ll all be in a much better place.

Gretchen Miller: So practically speaking, to get to the question of if I am overweight and I get pregnant, what are the ongoing actual impacts on children? What are some of the health impacts that we might see?

Helena Teede: We do know at the moment that the majority of the impact is actually from the mother’s side. The father is very important as a support person and there is some epigenetic effects, but probably because of that shared environment of the nine months in the womb, a lot of this has got to do with the healthiest we can support mothers to be. So the things that we see is if you start at a high weight or you gain more than is recommended, and we’re not eating for two. Very important message. We need 10 per cent more, not 100 per cent more, during your pregnancy. But if we do put on more than the recommended, then what we see is we actually have paradoxically bigger babies. Bigger babies are harder to deliver and there’s a lot more complications along the way, but we also have smaller babies. What happens is the blood supply and the placenta that shares the nutrition between the mum and the baby is not as healthy. We actually have babies that are often smaller than they should be, because they’re not in a healthy environment.

Bigger babies, smaller babies, and both of them have problems. Mum’s much more likely to get diabetes in pregnancy, more likely to get high blood pressure in pregnancy, more likely to have quite severe complications, more likely to need caesareans and induction. The list goes on. Then we hand over to the complications for the baby, which Louise will speak about in a moment, but the message is that all of these you can prevent or reduce by either coming in a bit healthier in the pregnancy, and by gaining the recommended amount of weight. Really important you know what that is, really important that your healthcare provider informs you of what it is, because it is individualised by each woman. Do your best to stay within that healthy range, and don’t stop being active. Our research shows that mums think they need rest or confine, especially some of the women from other cultures. Mother-in-law comes and stays and they really don’t move much for nine months. The physical activity declines dramatically. We need to keep that up.

Helena Teede: So healthy eating, keeping up your physical activity, hitting those recommended targets. All of that’s very doable no matter what weight you come into pregnancy at.

Gretchen Miller: All right. So, Louise, how does this all play out on the ground for you? You’re working as a paediatrician. What do you see coming through your clinic doors in terms of mothers and their kids? Are both usually overweight, for example?

Louise Baur: In our clinical practice where we see children with, or adolescents with, moderate to severe obesity, we certainly see this as a family, whole of family issue. Almost all of the families that we see, both parents are affected, are well above a healthy weight, as well as their child. This is shared genes, shared environment. A really complex issue. We work with the whole family in trying to turn that around. We’ll also often see a strong family history of type 2 diabetes, premature heart disease, obstructive sleep apnoea, and related issues.

Gretchen Miller: This is almost a wicked problem really, isn’t it? Where do you even start with that? If I’m a policy maker sitting here in this room going, “Okay, this is pretty terrible. These are high statistics we’re talking about in terms of the percentage of overweight mothers and children.” What does your research bring to what needs to happen, Helena?

Helena Teede: It’s clear that we need help as a society. It’s not about the individual. The concept of the nanny state and the fact that it’s seen to be an individual’s behavioural issue. All the evidence suggests that’s not the case.

Gretchen Miller: Obviously, as you say, the burden shouldn’t just be on the woman. It’s actually on all of us to create environments in which healthy weight can be easily achievable.

Louise Baur: Of course. We can recognise that whether it’s within the family and home environment. If you’re thinking about children, whether it’s around the school, early childhood centres. Whether it’s around the local neighbourhoods. Can people walk, get to fresh food outlets easily? Or the broader environment. Are people being able to use public transport? Are they able to move freely and safely? Are the children being exposed to inappropriate food marketing? And more, and more. All of these factors influence whether people are able to have healthy food choices and healthy physical activity or not. These are well beyond the capacity of usually a family or even the health sector to influence. It’s all of us as a society that need to advocate for those strategies.

Helena Teede: That’s really important. For example, the Cancer Council has done some really good research showing that 86 per cent of the population actually wants more regulations to help us be fitter, healthier, and not put on more weight. But it takes brave government, and we’ve seen that with smoking, if we follow the history of smoking, Australia led the world in so many ways. We had brave government, but the adage of public health is you educate those for whom it’ll help, you incentivise and support others, and you may need some regulation. What we’ve got still in obesity and health is this focus on, “It’s all about the individual. Make the right choices and the problem’s over,” and really not understanding that we need the support and incentives and the regulations, especially for industry and others to do this. The other thing that’s really important we then need to support the individuals. In our case, it would be about environmental and public health initiatives for children through to young women through to women at reproductive age. Informing and empowering as much as we could with social change in the whole of the sector, addressing the wicked problems.

But importantly, that the really big issue is the community wants it. If you ask them, they want it. They want help and they want support. To regulate around inappropriate food advertising, to look at the sugar tax, to do that’s important. All the experts agree we have a very simple roadmap of 10 top things.

Gretchen Miller: What are some of those 10 top things?

Helena Teede: Inappropriate advertising for children is paramount. The sugar tax. Evidence-based really would make a big difference, and often makes a big difference for perhaps the population that Louise is talking about. The population that often is not necessarily empowered and may struggle to make some of those decisions. We know around the world that it works. We’ve seen others implement these sorts of changes, but we just don’t seem to be making those brave decisions.

Gretchen Miller: Louise.

Louise Baur: I think when you look at strategies like that, you realise that that’s not a nanny state. What you’re doing is empowering families, particularly of children and young people, to be able to take control back. So the parents are able to say, “I don’t want unhealthy food marketing coming to my home. I don’t want a third parent in there telling my child what to do, nor do I want the food marketers telling my child what to eat and what to do in other ways. I want to have a world where it’s easier for me to make healthy choices for my child around eating and physical activity and so on. I think that’s a form of empowering families and also removing barriers to making healthy choices.

Helena Teede: In terms of the research that we’re doing, because obviously that requires brave government and collective input, which we aspire to see moving forward. The research we’re doing with the Prevention Centre is very much about capturing women before they’re possibly going to get pregnant. As early as we can, and making them aware of simple change, healthy lifestyle. The message is about prevention, and we don’t educate them and tell them exactly what to eat. People get very obsessed by the particular nature of the products that they’re eating, and in fact it’s all just very confusing. What we learned in school with the healthy pyramid or the plate with the division of food is still the most important message. High protein, low protein, it doesn’t really matter. The bottom line is it’s all about healthy food and healthy eating. There isn’t a simple way out. We spend quite a bit of time just making sure that message is there. Then the program is about supporting women to make healthy choices, and about what choices they want to make. They choose their own choice. It’s about behavioural change support and in the context of their family.

Helena Teede: We’ve run a program for a long time that’s very successful. Thousands of women have been involved. We know it works. The great thing about the Partnership Centre and the Prevention Centre that’s funding this is we’re funding implementation rollout, not just the research around this.

Gretchen Miller: This is Prevention Works, and we’re talking maternal and child obesity with Professors Louise Baur and Helena Teede.

What then does the Prevention Centre bring to that?

Helena Teede: The program is called Health in Preconception, Pregnancy, and Postpartum. It’s a lifestyle support program. What the Prevention Centre brings to that is we don’t need any more randomised controlled trials. There are 105 randomised controlled trials we estimate at a cost of around $50 million that have been done in pregnancy. They work, or at least the vast majority work.

Gretchen Miller: The trials have showed that it works.

Helena Teede: The trials have showed it worked. We need to stop doing the trials and look at how to do put that in practice. What the Prevention Centre is doing is allowing us to put all the evidence into practice, and actually deliver those programs on the ground to women. For example, how do you find out if women are thinking of planning a pregnancy in Australia? They don’t put their hand up. They’re not a population of women who are saying, “Oh, I’m thinking about getting pregnant.” We had to spend a lot of time working on how to reach them, and there’s a range of strategies we now do that with. We partner with the workplace, and employers want to provide that information to their women and actually usually co-subsidise it. We partner with infertility services. 15 per cent of our mothers now have a planned pregnancy ’cause they’re using assisted reproduction, so we can work with them. We plan with private health insurers. 51 per cent of Australian women now have private health insurance for a pregnancy. They have to have obstetric cover, so they’ve already put a flag up to say, “We’re potentially thinking of getting pregnant.”

The insurers are very happy for us to reach them through that avenue. We reach them through a range of strategies. In Indigenous settings, it’s through community health organisations. We’ve now got a platform to reach them. We then offer this program, which is very low cost and very simple to implement. Then we offer them to continue that through pregnancy and then out after they’ve had the baby. The program’s designed around what the families and mothers need, not around what the healthcare providers wish to support. Therefore, it’s really about what you need in your home. Any mum who’s had a baby knows you would never wake up a sleeping child when you’re sleep-deprived and the child’s five or six weeks old, to pick up the baby and go to some healthy lifestyle program that’s all about you. ‘Cause our self-care is very poor, but most of the programs were designed to bring mothers back to a large hospital, and in the middle of a sleep time, and provide healthy lifestyle advice. And they fail. They fail abysmally for obvious reasons.

This program by then is actually about as much information as we can during pregnancy, and then just remote support as they wish to have it early after the baby’s born. The program’s been designed around all sorts of deliveries. They can choose to use an app, a webinar, they can have their text messages, they can have the messages anywhere they like. They can tap in when they want. What we know is it works, but it’s really around what they need and supporting them.

Gretchen Miller: When it comes to children, the first intersection of a child with the health service is through a GP. What’s going on there with children who become obese, but are not being picked up by the healthcare system?

Louise Baur: Well, in fact, most kids who are well above a healthy weight aren’t really being picked up by the health system very much. We and others have done studies to show that while they present more frequently to either general practice or to secondary level care or tertiary level care in this country and others, they’re exceptionally unlikely to be actually picked up as having a weight problem. That’s in part because routine heights and weights aren’t always done, and then they’re not necessarily charted on a BMI-for-age chart. It’s also because GPs and other health professionals say, “It’s hard to raise the issue. I don’t really know how to do it. I haven’t been trained about it. I don’t know where to refer them. I don’t know the healthcare pathways. I’m not really reimbursed for this,” and so on. They know it’s important. So there are all sorts of barriers, one of them is the height and weight measurement. Certainly we’ve been working with NSW Health and others to actually look at strategies to make that easier, particularly within health systems.

But we also need to make it easier for people to raise the issue in a way that’s non-stigmatising and that engages families. If there are more and more people who are above a healthy weight, it gets harder for families to recognise if a child’s well above a healthy weight, because they don’t look that much different from their peers. Hence, good measurements, done routinely, which has always been part of paediatric practice for generations, can help pick that up. They can pick up kids who are dropping off their weight, but it also picks up kids who are well above a healthy weight. But we’ve also developed some online training modules that have been made available to help people think about, “How do I talk about the issue? What if I have a weight problem? How do I raise it with the family without putting myself at risk, as well?”

Gretchen Miller: As a doctor?

Louise Baur:  Or as nurse or as an allied health professional. “How do I talk about this in a way that’s non-stigmatising to the family and the young person?” There’s a whole range of strategies for that, but people need to be trained. Because we’re dealing essentially with a 21st century health problem, many existing health professionals are really poorly trained in these issues and need skills to be able to deal with it.

Gretchen Miller: And yet, if you did something as simple as say, “Children’s height and weight should be measured regularly or each time they come to the GP,” you’ve then got science to say, “Look. This is their height. This is what their weight, and that’s where they should be.”

Louise Baur: Yes. Often, if you use a BMI-for-age chart, the language can be something, “I’ve just plotted your child’s height and weight. You can see that here. Here’s weight adjusted for height or BMI. You can see that it’s well above the healthy range. Is that something we could talk about today? Would you like to come and talk about it at another time? Is that something that surprises you?” There’s a range of ways of raising it in a way that does show this. Also, where you’re modelling also a way of engaging the parent often in our case in this issue, and you’re allowing time for people to reflect on it. We’ve also developed a range of core messages that health professionals can use. They’re very, very simple and relate exactly to the issues that Helena was talking about, healthy lifestyle. They talk about, “Eat breakfast. Drink water. Two fruit, five vegetables.” Those sorts of things. “Get enough sleep. Keep screen times down to less than two hours a day. Get enough physical activity.”

All the very straightforward, national physical activity and dietary guidelines, just in a very simple format that’s not at all complicated. Designed that any health professional could use with a family, and designed whether there’s a weight problem or not in the family. It’s around healthy eating, activity, and sleep, because all of those are really important for the health of the child or young person.

Gretchen Miller: I know that doctors must keep up to date, and I wonder whether this is where the state gets involved and says, “Part of being up to date is that you must complete this training.”

Helena Teede: One of the big barriers in pregnancy, for example, is the doctors and nurses were not weighing women during their pregnancy. Indeed, the national guidelines until the recent guidelines did not require women to be weighed. My grandma and my mother would tell you that they were very diligently weighed throughout their pregnancy, and if they were putting on a bit more than they should or not enough, they were quite clearly informed that that was happening. We stopped doing that for a long time. We’ve now started weighing, and health professionals tell us exactly what Louise has just said. “I don’t feel that’s something I should broach. What if there’s a concern about eating disorders?” All these barriers for what’s not appropriate, but if you look at the research in smoking, 20 years ago professionals said, “Oh, we don’t know how to have those conversations. We don’t have the skills. We don’t know what to do about it. It’s not my job to tell them they shouldn’t be smoking. That’s a social issue.” All the same barriers were there, and yet now it would be completely inappropriate not to counsel a pregnant mum about smoking.

We need that change, but our approach in this program that’s funded by the Prevention Agency has been around the fact that we will provide those resources and education to undergraduates when they have to learn what we need them to learn, and put it into the basic curriculum. Then offer it to postgraduates, but we actually need an imprimatur. We need the colleges to say, “This is mandatory.” We need the government to say, “All health professionals should receive this.” Because otherwise, it’s optional. The prevention of excess unhealthy weight is our biggest health burden, our biggest problem. Even regulation around what our health professionals have to be trained in is another form of regulation that’s really important.

Gretchen Miller: And we don’t have that yet. What’s it going to take to get that?

Helena Teede: Concerted effort and initiatives exactly like this, where we have all of the experts and the community and the healthcare providers saying the same thing. Saying that we need these systems to be implemented at a national level, so the national Partnership Centre is a really great platform for us to come together and say the same things nationally. For us to go and have the implementation imprimatur, which is what our work is now doing. We’re implementing the evidence, which is different to doing more studies, ’cause we know what to do. This is funding us to do it.

Gretchen Miller: As you’re just saying, your mission, your focus is to translate the research into face-to-face care. There are some grim facts, really, about treating established obesity. I think that’s obviously part of the message that you want to get across. What’s difficult about it?

Helena Teede:  Where do we start? We always frame the message about being the healthiest weight you can be, because the reality is once you have quite severe unhealthy weight, reversing that is incredibly difficult. One in 1,500 people over a five year period through lifestyle alone will reverse from a very unhealthy weight down to a healthy weight. So…

Gretchen Miller: One in 1,500?

Helena Teede:  One in 1,500 over a five year period.

Gretchen Miller: People who are dieting, take note. One in 1,500.

Helena Teede: The reason that’s important to put out there is we can’t set people up to fail, which is what happens so often. It’s why we need to do exactly what Louise was talking about before. We need to make it easier to stop people from getting there, and no matter what their weight, we need to focus on prevention. The Australian women at the moment are putting on around one kilo a year. Doesn’t sound much, but that’s actually, it gets up there very quickly by the time you get to mid-life. How do we stop and prevent that? Really easily compared to what we have to do to treat it. When we get to treatment of obesity, specialty services become really important. For example, we now have integrated into routine pregnancy care our healthy pregnancy clinics. In those clinics, the mums have come in at what would conventionally be called obesity or at an unhealthy weight, and are at risk of more weight gain. We actually provide much more support and intensive care and monitoring for those women during pregnancy, and there’s much more focus on maintaining the healthy weight range.

We do need better services. We also know that often medical therapy in adults is important, especially for weight loss maintenance, and, potentially, the truth is, we actually need to have a surgical option. Unfortunately, once we get to established obesity, really, or unhealthy weight, really people need more intensive support than just saying, “Go and walk more, and eat less.” That will help you prevent. Don’t think that’s not really critically important no matter what your weight. An extra one or two or three kilos is still really important. But also, don’t set yourself unrealistic goals. 5 per cent drop in your body weight actually has a profound effect on your health. Just remember that. Make a goal that’s realistic. Aim for that. You don’t have to be in the healthy weight range. Any reversal is great. Any prevention is great. Aim for what you can do, and if you can do anything, own that success and don’t feel guilty.

Gretchen Miller: Louise, for children, what are we talking about here?

Louise Baur: Certainly with children who are well above a healthy weight, it’s really important that they’re offered some form of medical treatment. This always involves the family, particularly the younger you are, but even as adolescents, you really need the people who are buying and cooking the food, who are setting the family rules around TV and screens, and who allow or don’t allow physical activity absolutely need to be involved. That can be mum, dad, grandparents, whoever.

Gretchen Miller: Is it as hard for children to do this?

Louise Baur: The results in children who are above a healthy weight are better than the results for adults in terms of long-term weight interventions. In part because you have other support, families, in part because you’re at a much earlier stage of lifestyle, life. You have less entrenched lifestyle behaviours. You may also may not have the metabolic dysregulation and central resetting of appetite and so on that’s so well established in adults. There’s a number of ways in which things can be turned around. Basically, childhood and adolescence is a time of enormous physiological and anatomical change. Opportunities to turn around unhealthy weight gain to something that’s more in the healthy range is more possible. That’s not to say it’s always completely easy by any means, but it is a more positive environment than it is with adults. But we would still have, the focus will be on family lifestyle change long-term, and we would certainly talk about things like sleep and screens, as well as physical activity, and healthy food intake.

But we’d also think about some medications in those with more severe obesity or insulin resistance. In some, the older adolescents, bariatric surgery may well be an option if they have severe obesity. We’d have some of the same approaches as with adults, but we certainly take a much more whole of family approach. We’re very much, obviously, very developmentally aware. We would treat a four-year-old different from a 14-year-old.

Gretchen Miller: So, Louise, you’ve done some work on looking at children from nought to two. That is probably a really critical point at which to try and catch this.

Louise Baur: Indeed. In New South Wales, we actually conducted the Healthy Beginnings trial where we looked at first time mothers. We recruited them antenatally, and then in a trial, so this is in a trial, we actually did home visiting to new mums. Made visits over two years, and showed improvements in breast feeding and a range of forms of infant feeding, and a decreased prevalence of overweight and obesity at age two years compared with those that got usual care. We …

Gretchen Miller: So you went in there. It was eight times in two years. So four times a year, someone would come and visit the mothers and tell them how best to feed their children.

Louise Baur: Yes. Most of the visits were actually in the first year of life, where there’s so much change happening. It was around supporting breast feeding, appropriate introduction of solids, and later on about use of screens and physical activity and being a healthy family. What we found at two years, great outcomes. We thought, “Fantastic.” Then we decided to follow up to age five without anything else happening, and of course in the end there was no difference between those who took part in the study and those who didn’t, because we had provided all this excellent support, particularly in the first year of life. Found a difference at age two, but then we did nothing thereafter, and guess what? They went out into the broad world, all the other things that happen when you’re a young child, then starting school. We found that we weren’t supporting the families in that way.

Gretchen Miller: Why were the parents falling back? Because you’d think that a year or two would be quite a lot of intensive information training, things to learn that would have become, to some degree, a family habit, surely, within a year.

Louise Baur:  But remember, that period of time from two to five, dramatic other changes are happening. The child and family are interacting far more with the broader outside world. Children are really being exposed to food marketing. They’re going to daycare, early childhood centres and then starting school. It’s a very, very different world. Mothers are often going back into the workforce full-time. It was busy in that first year in one way, but it’s busy in another way later on. I think these families essentially need support at every stage through a life course. People in mid-life need support, but particularly in that important period of time through pregnancy and childhood and beyond. I think we need different types of strategies at different parts of our life. I think we’ve got ideas and, in fact, good evidence about strategies that need to happen. What we need to do is implement probably a whole range of these that look somewhat different at each part of the life stage that support the vulnerable aspects then.

Gretchen Miller: How do you do that? Because that sounds very intensive and expensive.

Louise Baur: This particular Healthy Beginnings trial is now being modified into a phone coaching and SMS support strategy, and for particularly vulnerable families, it’s been incorporated into the routine health system in NSW Health as part of a maternal home visiting system, but particularly for vulnerable families. But for those who aren’t as vulnerable, so the vast majority of new mums, it’s just part of an SMS or a phone coaching support service. All of these designed to support at a distance at a time that fits in with the mother, who’s a very busy person. It’s not about that intense support, which I think only some people need.

Helena Teede: The evidence in women’s health, as I mentioned, there’s been multiple randomised control trials. What we’ve done recently, actually funded by the Prevention Centre, has been to extract the structure of all of the programs that have occurred, and the most important success factors. There was a huge study in the US for $30 million looking at the different ways to provide these services. It didn’t matter whether it was intensive and face-to-face or indeed a program of support and app and SMS. It just needed to be a program to provide support. So in fact, we now know, as Louise said, that low cost, remote delivery largely with some personal element, our research and others show they want some personal element. So phone coaching or a single face-to-face or a chatroom on a webinar. Something that allows people to link in, but it can be incredibly low cost. The other thing we found is that whether we did this four times face-to-face or once didn’t matter. It was equally effective. It was about offering a whole range of very low cost strategies people could buy into, and that’s what the evidence now shows.

It need not be prohibitive, and the beautiful model Louise has described of putting that into routine care, that maternity child health nurses who are already there provide. Or putting in our case it into routine maternity care that midwives can provide. It’s no more cost, it’s already in the system. What we did is look at all the evidence that’s out there, and we did this analysis called taxonomy, which means you pull out is it phone or is it text message or is it face-to-face? How many visits and who provides it, and how much it costs. We analysed all of that to say, “These are the five different strategies.” Then we’re doing a health economic analysis to say, “This is how much we’ll save by implementing it, so this is how much we can afford to spend and what fits in that model.” Out of this we will have the optimal intervention at the lowest cost that can be run in the system. I think that principle can be applied in paediatrics, in any form of public health intervention. Low cost, most effective, integrated into the system we already have.

We’re using a risk prediction model coming into pregnancy, and we can, quite simply, actually, ascertain who’s at risk of developing gestational diabetes, who’s at risk of having adverse outcomes in pregnancy related to weight, and who’s going to get type 2 diabetes afterwards. Then target the dose of intervention, and therefore the cost to those who are most vulnerable and need it at which time, based on which risk. Because we can’t offer everything to everyone, the system would just not do that. But the exact consequence and principles about who’s most at need, which includes social determinants and other health-related issues, and who needs how much support has to be a principle that underpins this.

Louise Baur:  If I think back to what I was thinking 10 years ago as opposed to now, one, we’ve got a whole lot more things. It’s interesting, the problem of obesity isn’t any better. In fact it’s worse. But I think we and many of our colleagues around Australia and internationally have a much better idea of the strategies that are needed. We recognise the need for these upstream changes that need to occur to support individuals, but also how you might try to intervene and support people more locally, and who needs that help most of all. When I look at where we’ve got to go though, I can sometimes feel like, “Oh my goodness. Will we get there?” But I’m glass half-full person.

Helena Teede: Actually, that might be just one point to highlight here, is that we are spending an absolutely fortune and suffering greatly in terms of a health burden as a country, because of unhealthy weight. Yet we invest almost nothing or a very negligible amount in prevention. If we ask the Australian community what they would prefer to do, “Would you rather have a small investment in prevention or wait until you’re very unwell with the complications of this. Where would we choose as a community to invest?” That’s a discussion we have not had, and I would very much be passionate about going back to the Australian people. It is their taxpayers’ dollars that we are spending in our healthcare and in our research, and saying, “What is most important to you? What do you value most?” Because when you ask them, almost unequivocally, they will say, “Help us in prevention.”

Gretchen Miller: This has been Prevention Works, the podcast of The Australian Prevention Partnership Centre. If you’ve enjoyed listening to Professors Helena Teede and Louis Baur, why not check out the rest of our series or browse the transcripts you’ll find online? I’m Gretchen Miller, and I’ll catch you next time.