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CHRISTOPHER REYNOLDS[*]
This article considers how law might address the increasing problems associated with obesity. Using our experience with other areas of public health law it illustrates a number of strategies that could be devised. Our options in this area are far from simple: there is argument about what is effective; there is a tension between those who would favour an approach which deals with energy expenditure (exercise) and those who would focus on energy taken in (food consumption patterns). The food industry is powerful and influential, its interests not necessarily served by strategies to reduce obesity. Nevertheless, the potential impacts of obesity on individuals and communities make this a crucial issue that also illustrates important ideas about the role public health policy can play in sponsoring change and how it can also link in with initiatives to achieve a sustainable society.
Public health policies focus on populations and communities; they are directed at the things that threaten the health and wellbeing of the people who live within those communities. Public health laws aid these policies and many enactments can be called public health law, including requirements for good sanitation, controls on infectious disease and food and drug laws.
But not all of our regulatory or policy responses to public health problems are valued equally. Centrally, there are some high profile issues that engage the community and for which effective legislation is demanded. Over the past 25 years, HIV/AIDS and illicit drug use have occup1ed centre stage. More recently, the threats of new diseases (SARS and avian flu) have made us reth1nk the effectiveness of our laws to deal with a major outbreak. The possibility of bioterrorism further emphasises the importance of effective powers to deal with public health emergencies.
These new issues potentially might cause a public health catastrophe and demand preparedness, but they do not present sizeable threats at this stage. By comparison there are very significant public health problems that have not obviously engaged the public's interest and have remained less visible and less urgent than SARS and bioterrorism. These are the non-communicable diseases, the damaging consequences of everyday life, the burdens of illness, injury and death following on from normal behaviours such as the consumption of tobacco and alcohol. Our attention to them has always been tentative and distracted by a number of issues. Most importantly, lifestyle diseases are caused by 'normal' behaviour and, in addressing them, regulators have had to deal with powerful corporate interests and their lobbyists and supporters who often benefit from the continuing profitability of unhealthy products.
Over the past decades a new and very serious lifestyle disease has emerged. We are becoming heavier and the proportion of overweight and obese people is increasing steadily. With that comes a range of weight-related diseases including cardiovascular disease and diabetes, burdening to their victims while adding substantially to the health budget
Increasing levels of obesity are a feature of both developed and many developing countries. In Australia, it has been estimated that overweight and obesity are very prevalent and increasing, with almost 20% of the adult population obese, the figure nearly doubling since 1980.[1] Children's weight also increased dramatically with 14.3% of boys and 16.4% of girls overweight and 3.7% of boys and 5.6% of girls obese.[2] This is very concerning since it sets in place a life-long trend. Indigenous Australians are more obese than non-Indigenous Australians and it is also known that obesity correlates with poverty which is ironic given its association with abundance rather than deprivation.[3]
This dramatic increase in overweight and obese Australians is not surprising; there have been two major environmental changes over the past few decades. Food, especially high energy convenience food, has become far more available, is extensively promoted and is relatively cheap, packaged to eat whenever its consumers have the inclination or the opportunity. Today's abundance is in stark contrast with previous periods in the history of the world when recurring famine, hunger and uncertain sources of food, even in Europe, were commonplace. Humans evolved in an environment of nutritional uncertainty and for the many who now have access to super-abundant supplies of food this is a massive environmental change. It can then be coupled with the fact that we use less energy as work is mechanised, cars replace walking or cycling and people exercise less.
Both in Australia and overseas, governments are seeking strategies and policies to address the problems of obesity. Its dramatic increase and its potential impacts make obesity an extremely large and rapidly changing issue that warrants urgent action. But what should that action be? A problem as significant as this demands public policy to be applied at every level and directed at every cause. To date the approach of Australian gover!nments is curiously limited. Agencies, while increasingly aware of the problems of obesity and preparing numbers of reports on them,[4] have focused largely on activity and strategies to increase the rate of exercise. This is important but it only represents half of the equation (the 'energy expended' half). Equally important is 'energy consumed', which relates to our dietary habits and thus to the structure of the food industry and the marketing of food in Australia. In particular, there is a case to examine how marketing · and promotion of food, especially the promotion of high energy food to children, can be regulated, an issue not highlighted by the reports. Control at this level is a public health approach, which offers a real potential for improved nutrition. This is because a public health approach focuses on the population rather than on the individual (that is where it achieves its greatest gains overal;l). It has been said that '[a] mean weight loss of 1 kg in the Australian community would have a major impact on health'.[5] This invites policies that focus not on the extreme end of the problem just obesity)but on the things which influence weight across the whole community and on the trends towards obesity. It is a 'population' focused approach of the type used in tobacco control and often advocated for alcohol
control. As part of the population focus for overweight and obesity it is known that law can help change structures and environmental factors (such as the marketing of food and the transport and recreational option6) that influence individual behaviours.
Governments can create the supportive environment within which people can make healthy choices about their and their family's consumption and exercise patterns. This article considers these issues, commencing with the regulation and marketing of food. A precedent for this approach can be seen in the strategy set in place across Australia over the last 20 years in relation to tobacco. But the tobacco analogy will only take us so far: there are some obv1ous differences between the problems of tobacco consumption and the problems of over nutrition. Tobacco is an addictive carcinogen; food is necessary for survival. Tobacco-related diseases are specific to tobacco consumption; the diseases of over nutrition are multi causal and most obviously a balance of energy taken in (consumption) and energy expended (physical activity). There is also room for the food industry to restructure and exploit healthier options, as McDonalds is reportedly doing.[6]
Yet there are some similarities between nutrition and tobacco consumption. Most significantly there is a powerful food industry whose principal interests are to their shareholders and whose profitability inevitably depends on creating demand thereby selling as much of an attractive product to as many people as possible. · This was seen in the fuss about the World Health Organisation's (WHO) recommendations for added sugars. The threats (as they were reported)[7] made by the sugar industry against the WHO and the industry lobbying of the United States Government were not very different from the experience that many public health advocates have had with the tobacco industry.[8]
However normalised over-consumption is in Australia and however powerful and well placed the food industry might be, we are facing an epidemic which will make huge demands on health care and seriously reduce the quality of life and productivity of hundreds of thousands of Australians. This will be at a time when the 'baby boomer' population bulge will also be making substantial demands on health care. There are options for addressing these problems within the framework of a democratic society that respects the autonomy of individuals. Indeed, the exercise of choice is central to the autonomy of individuals and choice is more freely made in a neutral environment and with all of the necessary information available. This fits in with an idea advanced by the 1986 Ottawa Charter (a key document in public health policy) that 'healthy choices should be easy choices'.[9] But it is also a controversial idea because, implicitly, it is an argument to restrict or regulate the advertising of food.
Cunrent food laws in Australia provide little regulation of promotion or advertising. Rather they aim to protect the supply by creating offences for the sale of dangerous (unsafe) food and call up the food standards agreed to nationally by the Food Standards Australia New Zealand arrangements. Standards do relate to labelling and packaging, and nutritional and energy contents of foods are typ1cally required by law. However, there are still some foods that the standards do not apply to, notably unpackaged or 'take away' food and this is whene some of the sustained criticism about high energy food comes from.[10] Labelling could also be clearer, perhaps stating the proportion of daily nutritional needs the food contains or the energy expenditure necessary to burn off the food. Furthermore, where food is advertised as low in energy, the terms can be misleading. For example '90% fat free' means 10% fat, not that it contains 10% of the fat that a competitor's product might have.
Food policy could also require ingredient change by redrawing existing standards which could set maximum salt, fat or sugar content, thus preventing the manufacture of products that are implicitly unhealthy. There may be a case for this as high fat and high salt foods are commonplace, portions sometimes coming close to or exceeding daily allowances.[11]
Serving size is also an issue and they appear to have increased dramatically over the past decades. Some snack foods can contain as much as 20--25% of a person's daily nutritional needs, yet are packaged as one serving. Further, 'large' options are typically available and are better value than 'standard' options, so people tend to take in more calories in one sitting.[12]
The most controversial and problematic component of an obesity strategy would be restrictions on advertising and promotion of foods and, if imposed, the extent of those restrictions. For example, a ban on the advertising of 'undesirable' food would be difficult to define and enforce. Nevertheless, there is a case to develop some controls, since, as with tobacco, the advertising budget of the food industry vastly overshadows the budgets of health agencies trying to put a counter message.[13] There ace also examples of advertising aimed at children. This could suggest a partial regulation or ban that could focus on these kinds of representations. Another option would be to prevent food advertisements from promoting toys that come with the food or that can be collected during a visit to a restaurant since they are also aimed at children and distort nutritional choices. It might also be possible to prevent the promotion of certain types of food at certain times, for example during children's television periods.
Sponsorship can be read as a benevolent action, an industry giving back something to a community or activity that supports it. But it also allows for loosely disguised advertising and promotion. Sponsorship in schools is of particular concern, though arrangements vary. Sponsorship of a school soccer team by the local supermarket is different to a national sponsorship run by a fast food company. To take one example of the latter, the British 'Cadbury Get Active' marketing scheme required 5400 chocolate wrappers in return for a volley ball net and posts. This works out at around $5000 and 1.25 million calories worth of chocolate.[14] Another problem of sponsorship in the education environment is that it can 'capture' schools offering a much needed source of revenue for many schools, masking legitimate concerns about the longer term adverse impact on students. This is particularly serious since schools ought to be a source of good nutritional advice.[15]
Taxation has long been used as a way of influencing behaviours. What role should it play in nutritional policy beyond its current role of excluding fresh food from the GST? Since the price of food, particularly fresh food, fluctuates, tax benefits may be lost in price changes overall. Certainly tax could be used to discourage unhealthy eating (a 'fat tax'). However, all taxes in this area (tobacco included) are likely to be regressive, their impact being greatest on those least able to pay them. The effectiveness of such a tax in public health terms will be gauged by its ability to influence 'healthy nutrition' choices and, this depends on the extent to which price does affect demand.[16] Healthy choices are not necessarily cheaper than the energy dense unhealthy choices, particularly in remoter areas where transport is expensive and storage of fresh food difficult.[17]
How formal should our approach be? Self-regulation is commonly offered' as an alternative to regulation. Forms of self-regulation such as 'codes of conduct' are often not sustained by any real penalties and are expressed in broad general terms which allow for technical interpretation and nitpicking exclusions when the need arises. Often they are 'policed' by bodies that have a close association with the industry. Self-regulation is often proposed by an industry facing the real prospect of actual regulation, and may well be an attempt to forestall government action, offered and policed by an industry which has the understandable goal of selling as much of its product as possible to as many people as possible. More effective than self-regulation are the changes that an industry may consider in order to minimise its exposure to public criticism or legal liability, a point now discussed.
Public health law is generally the product of statutes and the possibilities canvassed above would be introduced by legislation. But there is another dimension to public health enforcement, offered by the courts. More particularly, if governments refuse to regulate in this area, they may implicitly be opting for civil actions that will fill the regulatory vacuum. To date civil actions have been prominent responses to outbreaks of food poisoning. The damages and costs that come with them also provide substantial incentives for companies to improve their performance, more so than prosecution. A well publicised case of peanut paste contamination occurred in 1997. If the manufacturer had been prosecuted it might - if found guilty - have risked a fine of less than $10,000 under the food laws existing at the time. The costs associated with settling the various civil claims brought against it were reportedly many millions of dollars. In terms of financial risk management, civil litigation was of far greater concern.[18]
Civil actions and the threat of them can also change marketing practices. In July 2003, Kraft Foods announced that it was proposing to reduce its serving sizes and discontinue its marketing in schools. It also announced that it was considering expanding its nutritional information to include the value of the food in a packet as a proportion of a person's daily calorific needs and how much physical activity is required to bum off those calories.[19] This new policy happened in the wake of a short lived case against the Company in respect of its failure to list the 'trans fat' content of its Oreo biscuits.[20] Litigation has also been brought against fast food companies in respect of their products contributing to obesity among child customers. While these cases are very difficult to prove (since obesity is multi-causal) and they attract criticism from many quarters, they do make the point that companies are liable for their products and that there is often scope for a healthier version and more nutritional information.[21]
Thus civil proceedings can fill a void that the public health regulations may have chosen not to occupy. However, recent changes to tort law, have limited the rights of plaintiffs and implicitly weakened these alternative public health sanctions. But more focused and direct ways of protecting the food industry from litigants has been considered in the United States.
The potential for civil actions is clearly alarming and the counter to them is the notion of 'personal responsibility', which provides the formal grounds for legislation seeking to protect the industry from liability. A proposal introduced into United States House of Representatives, the Personal Responsibility in Food Consumption Act 2003, excludes food companies from civil liability 'unless the plaintiff proves that, at the time of sale, the product was not in compliance with applicable statutory and regulatory requirements'.[22] This is an extraordinary shield for any company, especially in a climate that favoured less regulation of the industry. Reinforcing this 'personal responsibility' theme, a 2004 Colorado proposal, aimed at obesity related litigation, was even more sweeping. The Bill stated:
(a) Obesity and many other conditions that are detrimental to the health and well-being of individuals are frequently long-term manifestations of poor choices that are habitually being made by those individuals;
(b) Despite commercial influences, individuals remain ultimately responsible for the choices they make regarding their body; and
(c) Excessive litigation restricts the wider range of choices otherwise available to individuals who consume products responsibly.
It then provides that '[a] manufacturer, distributor, seller or retailer of food or beverages shall not be subject to civil liability for injury or death in cases in which liability is based on the individual's weight gain, obesity, or a health condition related to weight gain or obesity, and the weight gain, obesity or health related condition related to weight gain or obesity results from the individual's long-term consumption of a food or beverage'.[23]
Notions of personal responsibility shift liability from industry. Yet in emphasising the responsibility of the consumer they are, ironically, denying any responsibility on the part of those whose advertising and marketing and general inducements to consume more, and consume more often, distorts and colours the environment in which parents and their children are expected to make responsible nutritional choices.
So far our discussion has been on the 'input' side of the equation. We should focus equally on the 'output' or energy expended side. How do our built and social environments shape our expenditures of energy?
Can we change them to influence opportunities to exercise? Here law is relevant. We might consider how environmental and planning controls could be structured to encourage more physical activity or whether they impede physical activity at present.
Environmental changes such as safer streets, better lighting and local shops are important and reinforce the key idea in the Ottawa Charter that if we want people to take more exercise we must provide a supportive environment that encourages it. The design and safety of the built environment and the amount of land we set aside for horticulture and growing fresh food locally are all influenced by our patterns of land use and the regulations that apply to them. A report for the National Public Health Partnership asserts that '[t]here is emerging evidence but a clear suggestion that much of the physical activity encouragement and facilitation occurs at the environmental change level'.[24] It adds that a range of things influence physical activity: 'sport and recreation, and education [and] ... less obvious areas, such as transport, urban safety, urban planning and design, worksite legislation, entertainment and environmental policies'.[25] These less obvious ideas are very important. Organised sport, however much encouraged, is often left behind at adolescence as adults become passive followers of the games they used to play. But active commuting and transportation (walking and cycling) is an exercise pattern that can be continued for most of a person's life. Government policy can influence and encourage exercise patterns. It can influence journeys to work, emphasising cycling or dual mode journeys such as a combination of walking or cycling and public transport. This involves road engineering and a restructuring of public transport options.
Indeed, it is within the power of governments to either encourage or discourage active transport and too often decisions are made which are likely to reduce rather than to increase the level of activity in the community. One of the most destructive policies of the Federal Government is to allow tax advantages for motor vehicle use through salary sacrifice, an attractive option for many wage earners. This encourages more vehicles and changes journey to work patterns. The blatant unsustainability of this scheme is compounded by the fact that the more the vehicle is used the more tax effective it becomes. It penalises people who have no car, or who reduce their vehicle use and the scheme is highly detrimental in at least three social policy areas. First, it reduces opportunities to exercise even if this is only a walk to the bus stop and back Second, additional vehicles on the road leads to the production of more greenhouse gases as does encouraging these drivers to drive as many kilometres a year as possible. Finally, it reduces the extent to which commuters use public transport.
Our private vehicle dependence (with its 'door to door' convenience and lack of opportunities for exercise) has increased dramatically over the recent years. For example, in South Australia travel by private vehicles comprises 80% of the journeys to work (walking and cycling is 14% and public transport is 5%).[26] The public health consequences of such a pattern should not be underestimated:
Adverse effects on both health and environment have increased in recent years, in parallel with the steady rise in road traffic and the use of the private car.[27]
What can be done to remove these distortions to good public health and environmental policy? Tax schemes that encourage commuting by car and reward their excessive use need to be eliminated. Further disincentives to private vehicle use could include taxing car parking and taxing fuel at a higher rate. These policies would encourage commuting by foot or bicycle or public transport.
However, no one should talk lightly about increasing fuel prices or the costs of motoring. There are obvious impacts and the right to drive the vehicle of your choice as far as and as much as you want is seemingly inviolable. Further, such tax policies are intended to change behaviours, not to make people poorer as they continue the same pattern of car use. There must be real commuting choice via an efficient, safe and reliable public transport system. The geography of urban centres and substantial 'cross town' commuting, create challenges for public transport services, and the particularly Australian problem of remoteness and the great distances that country people have to drive raise special problems. But this issue is crucial to both our public health and environmental wellbeing: the historic decline in the use of public transport needs to be turned around and the levels of active transport increased. Governments will need to pursue this with a mix of 'carrots' and 'sticks', preferably with the carrots in place and sufficiently attractive before the sticks are applied.
Beyond the immediate public health issues of addressing obesity, there is another issue that impacts more generally on our environmental wellbeing. The decisions we make must be sustainable, in line with our obligations to the planet and to future generations. The environmental and public health consequences of global warming are dramatic and it presents as our greatest long-term issue. A world where people use active transport or public transport is a more sustainable world than one where people commute by private car.
Strategies to promote good public health outcomes and polic1es to achieve a more sustainable environment come together and while increasing our levels of active transportation is an obvious example, there are others. For example, diets comprising large portions and high in animal fats are common in Australian with obesity the public health consequence. The natural resources necessary to produce the food that allows these diets, takes a toll on the environment. A healthier diet involves eating less and eating down the food chain. It is also a more 'environmentally sustainable diet', providing another link between population health and the environment Similarly food produced and then consumed locally, generally involves less energy inputs than processed foods transported long distances from factories interstate or overseas. Where the locally produced food is fruit and vegetables (as it often is) it is a healthier alternative to packaged or highly refined food. A strategy that encourages local production and consumption of fresh food is desirable environmentally and also for public health. Strategies to encourage local production of fresh food and to identify barriers (such as land use policies) further both interests.
This article aims to contribute to the increasing debate on obesity in Australia by offering some insights into issues and legislative possibilities. It demonstrates how our response might allow the opportunity for lively policy making, linking areas not so often seen as complementary (food regulation and land use and transport policy), illustrating another point from the Ottawa Charter-that health promotion occurs in many contexts. It also shows how public policies (such as nutrition and sustainability) can support each other.
REFERENCES
[*] CHRISTOPHER REYNOLDS teaches law at Flinders University.
© 2004 Christopher Reynolds
email: chris.reynolds@flinders.edu.au
[1] Australian Institute of Health and Welfare, Bulletin A Growing Problem Trends and Patterns in Overweight and Obes1ty Among Adults in Australia, 1980 to 2001 (2003) 1 <www.aihw.gov.au> at 28 July 2004, see also A Cameron et al
'Overweight and Obesity in Australia the 1999-2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab)' (2003) 178 MJA 427
[2] Australian Institute of Health and Welfare, Australia's Health 2002(2002) 178 <www.aihw.gov.au> at 28 July 2004
[3] Australian Institute of Health and Welfare, The Health and Welfare of Australia's Aboriginal and Torres Strait Islander Peoples 2003 (2003) 171 <www.aihw.gov.au/publicationsilhw/hwaatsip03ilndex.html> at 28 July 2004 The Report Australia’s Health 2002, Ibid indicates that among Indigenous Australians, '[a]pproximately 25% of adult Indigenous males and 29% of adult Indigenous females were classified as obese compared to about 19% of both either Australian adult males and adult females' 206
[4] Eat Well Australia A Strategrc Framework far Public Health Nutrition, Developed by Strategic Inter-Governmental Nutrition Alliance of the National Public Health Partnership <www nphp.gov.au/publications/index.htm#srgnal> (2001) (at September 2003), Natrona/ Health and Medical Research Council, Acting on Australia’s Weight A Strategic Plan for the Prevention of Overweight and Obesity and Acting on Australia’s Weight Summary Report (1997)
[5] Editorial, 'What should we Do about Overweight and Obesity?' (1999) 171 MJA 599 (author's italics)
[6] 'McDonald's Fat Plan. just Watch your Step', The Weekend Australian (Sydney) 16-17 April 2004, 13
[7] S Boosley, 'WHO 'Infiltrated' by Food Industry', The Guardian (London) 9 January 2003
[8] See M Nestle, Food Politics How the industry influences Nutrition and Health (2002) Part Two- 'Working the System', 93, 17t See also J Graham, 'U S Sets off Furor in Anti-Obesity Fight’, Chicago Tribune Online Edition <http://storynews.yahoo com/news> a report of the Bush Administration's objection to a WHO anti obesity plan It was said that 'US criticism of the [WHO's] plan is being driven by the sugar industry, grocers and other US multinational food companies that want to forestall emerging international efforts to regulate food marketing, pricing, production and trade' See also R Stern, 'US to fight WHO anti-obesity plan'. The Guardian Weekly (London) 25 January 2004 (originally in The Washington Post)
[9] Ottawa Charter for Health Promot1on (1986)<www who.rnt/hpr/NPH/docs/ ottawa_charter_hp pdf> at 30 July 2004
[10] Current requirements for labelling are provided by Standard 1 2 8 Food Standards Code (Nutritional Information requirements) <www.foodstandards.gov.au/foodstandardscode/> at 28 July 2004
[11] Sir John Krebs (Speech delivered at the Westminster Diet and Health Forum Seminar), 3 April 2003 <wwwfood.gov uk/ aboutus/ourboard/boardmem/Johnkrebs/ westminster> at 30 July 2004
[12] G Critser, Fat Land How Americans Became the Fattest People In the World (2003) claims, for example, that a serving of McDonalds chips has increased from 200 calories (1960) to 610 calories (2002) 28.
[13] Ibid Critser claims that in the United States, the advertising budget of the soft drink industry is US$600 million annually. By comparison, the National Cancer Institute has a budget of US$1 million to promote healthy eat1ng of fruit and vegetables, 173 in Britain it is said that 'less than £2m was being spent to encourage children to eat and drink healthy products, compared with £600m on commercial food'. P Wintour, 'Ad agency apologises over "pester mum" commercial', The Guardian Weekly (London) 20-26 November 2003
[14] F Lawrence, 'Eat Chocolate and Get a Free Volleyball?', The Guardian Weekly (London) 1-7 May 2003 See also The Guardian (London) 29 April 2003 The Food Standards Agency (the UK regulatory agency) responded to the arrangement by saying 'We were not consulted about this scheme and do not endorse it Nor do we consider it desirable in terms of diet ' D Batty, 'Food Watchdog Angry at Schools Chocolate Deal', Guardian (London) 1 May 2003 <http//society.guard an co.uk/publichealth/story/0,11098,947434,00 html>.
[15] See M Nestle, Food Politics How the Industry Influences Nutrition and Health (2002) ch 9, Critser, above n 13, 170; and E Schlosser, Fast Food Nation ( 2002) 51-7.
[16] The effect of a tax is open to debate See T Marshall, 'Exploring a Fiscal Food Policy the Case of Diet and Ischaemic Heart Disease', (2000) 320 BMJ 301, E Kennedy and S Offutt, 'Commentary Alternative Nutrition Outcomes Using a Fiscal Food Pol1cy' (2000) 320 BMJ 304, J Stanley, 'Will Sales Tax Influence Consumption?' (letter) (2000) 320 BMJ 1469; and R Walter, 'Food Taxation and Price Elasticity' 28 January 2000 <http·// bmj.bmjjournals. com/cg,/eletters/320/7230/301 #6468> at 28 July 2004
[17] A Drewnowski and S Specter, 'Poverty and Obesity The Role of Energy Density and Energy Costs' (2004) 79 Am J Clin Nutr 6.
[18] ABC 'Class Actions', The Law Report, Tuesday, 3 June 1997 <www abc net.au/m/talks/8.30/lawrpt/lstones/lr970603. htm> at 30 July 2004
[19] <www.kraft com/obesity/responses html> at 28 July 2004
[20] These are hydrogenated oils, which raise 'bad' cholesterols. See R Savioan, 'Science Kraft's Cookie Caper' <http II hiphopcongress.com/columns/science/ archive_kraft html> at September 2003.
[21] BBC News, 2 July 2003, 'Kraft plans to cut snack sizes' www.bbc.co.uk/food/ features/news shtml>
[22] HR339 IH
[23] Colorado Senate Bill 04-020.
[24] Adrian Bauman, Getting Australia Active Towards Better Practice for the Promotion of Physical Activity, NPHP 2002 executive summary <www.nphp.gov.au/publications/ sigpah/gaa.pdf> at 30 July 2004.
[25] Ibid 88.
[26] Ibid
[27] C Dora and F Raooppi, 'The Charter on Transport, Environment and Health: Raising Awareness to Promote Evidence-based Action across Europe' <http://www.who. dk/eprise/main/who/progs/hcp/UrbanHealth Topics/20020107_2> at 30 July 2004
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