Policies to reduce and prevent excess body weight and obesity in children and adolescents: fact sheet No. 2.7, May 2007

The indicator measures the degree of implementation of 12 specific policies in 5 broad policy areas aimed at preventing excess body weight and obesity in children. The policies were selected in accordance with the WHO Global Strategy on Diet, Physical Activity and Health (1) and the WHO Food and Nutri- tion Action Plan for the European Region 2000–2005 (2). Countries reported a reasonably high level of implementation of policies to reduce obesity. Many policies are, however, only being partially implemented, and further efforts are needed to ensure more stringent implementation and enforcement. The wide variations between countries underlines that a multisectoral approach is required with policies spanning areas including diet, physical activity, mar- keting, education and the environment. RATIONALE Policies to reduce childhood obesity Policies to reduce and prevent excess body weight and obesity in children and adolescents FACT SHEET NO. 2.7 · MAY 2007 · CODE: RPG2_Hous_A2 KEY MESSAGE This summary presents a snapshot picture of the implementation of a set of policies aimed at reducing and preventing childhood excess body weight and obesity. Data were drawn from an Environment and Health Information System (ENHIS-2) project survey of national experts covering 16 countries in the WHO European Region in 2005–2006. They were analysed taking into account the environmental and policy context, and are followed by an assessment of the situation in the Region. Nine other countries also volunteered data (see below under Geographical coverage). 0 2 4 6 8 10 12 14 16 18 20 22 24 Armenia Albania The former Yugoslav Republic of Macedonia Romania Slovenia Czech Republic Bulgaria Slovakia Estonia Finland Greece Sweden Uzbekistan Belgium yItal Austria Croatia France United Kingdom (England) Lithuania Poland Hungary Netherlands Spain Malta Fig. 1. Degree of implementation of 12 policies aimed at reducing excess body weight and obesity in children, 25 selected countries, 2005–2006 Note. The total score for degree of implementation is the sum of the scores for each policy: 0 = no policy; 1 = partly implemented or enforced; 2 = substantially implemented or enforced. *TFYR Macedonia = The former Yugoslav Republic of Macedonia Source: ENHIS-2 project countries and countries volunteering data. Malt Spain Netherlands Hungary Poland Lithuania United Kingdom (Englan ) France Croatia Austria Italy Belgium Uzbekistan Swed n Greece Finla d Estonia Slovakia Bulgaria Czech R public Slovenia Romania TFY Macedoni * Albania Armenia 4 1 1 1 1 1 2 2 24 Total Score Fact sheet 2.7 22.05.2007 0:08 Uhr Seite 1 PRESENTATION OF DATA Figure 1 shows the degree to which countries are implementing policies to reduce childhood obesity through a score of 0, 1 or 2. The total score expresses the level of implementation of the 12 policy options listed in Table 1. Higher values indicate greater efforts to implement policies. Table 1 shows the proportion of countries implementing the policies to a high, medium or low degree. Only two policy elements were found to be widely enforced, although most were being at least partially implemented. HEALTH – ENVIRONMENT CONTEXT Obesity poses one of the greatest public health challenges for the 21st century; in the Region the prevalence of obesity has tripled in the last two decades – a particularly alarming trend. If no action is taken and it continues to increase at the same rate as in the 1990s, an estimated 150 million adults and 15 million children and ado- lescents in the Region will be obese by 2010 (3). Assuming the trends observed in 2006 continue on a linear basis, they would give a projection of approximately 41% of children in the east- ern Mediterranean region and 38% of children in the Region as a whole being overweight (4). Unhealthy diets and physical inactivity are the main contributors to excess body weight and obesity, which are among the leading risk fac- tors accounting for the burden of noncommuni- cable diseases. Excess body weight is responsi- ble for more than 1 million deaths and the loss of 12 million disability-adjusted life-years (DALYs) in the Region every year. This and obesity are responsible for about 80% of adult cases of type 2 diabetes, 35% of cases of ischaemic heart disease and 55% of cases of hypertensive disease among adults in the Region. Excess body weight (BMI exceeding 21 kg/m2) is also a risk factor for colon cancer, breast cancer, endometrial cancer and osteoarthritis. Obesity also has a negative effect on psychosocial health and personal quality of life (5). The health consequences of being overweight during childhood are less clear, but a systemat- ic review shows that childhood obesity is strongly associated with risk factors for cardio- vascular disease and diabetes, orthopaedic problems and mental disorders. Children are now more frequently subject to many obesity- related health conditions once confined to adults (6). Effective obesity management requires the exis- tence of an integrated multisectoral approach including comprehensive long-term policy meas- ures. Nutritional interventions in the school, workplace and community have proved moder- ately effective in the prevention of obesity. The combination of healthy eating and physical activity of at least a moderate intensity (such as brisk walking and other activities that make you breathe harder and feel warmer) in daily life for approximately 30 minutes per day is effective in reducing obesity. The promotion of physical activity through health education is, therefore, essential for weight reduction strategies to succeed. Increas- ingly, the evidence suggests that policies and practices intended to enable people to be physi- cally active are more likely to be successful if they modify both the physical and social envi- ronments (7). Policy changes at the local level may be particularly effective at encouraging increased physical activity over the long term by making it an easier choice. For example, a reduction in the speed of vehicular traffic and provision of safe cycling and walking routes can lead to increased physical activity. People are also more likely to walk when land use is mixed (locating shops, schools, workplaces and other destinations close to dwellings). Table 1. Proportion of the 25 surveyed countries implementing and enforcing key policies for preventing and reducing obesity and excess body weight in children, 2005-2006 Policy topic Key policies to reduce and prevent obesity Proportion of countries implementing the policy* (%) 1. Marketing/labelling Legislation requiring labelling of foods with nutritional information such as ingredients and High the corresponding energy intake Legislation to practise responsible advertising and marketing of food, particularly with regard Low to promotion and marketing aimed at children of foods high in saturated fats, trans-fatty acids, free sugars and salt 2. Healthy diet and National strategy to promote and increase the consumption of fruit, vegetables and legumes Medium nutrition and to reduce the consumption of saturated fats, sugars and the elimination of trans-fatty acids Written policy document, adopted by a political body, explicitly concerned with nutrition Medium Set of recommended nutrient reference values High 3. Physical activity Legislation requiring a minimum of 30 minutes of physical activity per day in schools Low 4. Education/awareness/ Health and nutrition education and awareness programmes in schools Medium research National health survey or participation in an international health survey that allows Medium the monitoring of the prevalence of obesity, eating habits, physical activity and health in children 5. Implementation Special administrative structure with responsibility for implementation of the policy Medium structures/collaboration Nutrition council or other advisory structure responsible for providing scientific advice Medium to national policy-makers Any form of regular government-initiated collaboration between the various parties Medium responsible for food production, manufacture and sale, control and legislation and nutrition education Any form of regular consultation between the ministries of health and of agriculture Low on matters related to nutrition * The percentage of countries was calculated for those scoring 2 for a given policy. The percentages are grouped as: low = <50% of countries, medium = 50–69% of countries, high >_70 % of countries. Source: ENHIS-2 project countries and countries volunteering data. Fact sheet 2.7 22.05.2007 0:08 Uhr Seite 2 POLICY RELEVANCE AND CONTEXT In 2004, the World Health Assembly in resolu- tion WHA57.17 adopted the global strategy on diet, physical activity and health (8). The strat- egy contains recommendations for WHO and its Member States, international partners, non- governmental organizations and the private sec- tor to develop, implement and evaluate activi- ties to combat the rise in noncommunicable dis- eases through a healthier diet and increased physical activity. The results of the implementa- tion of the global strategy were presented at the World Health Assembly in 2006. In 2004, the Fourth Ministerial Conference on Environment and Health adopted the Chil- dren’s Health and Environment Action Plan for Europe (CEHAPE), which includes four regional priority goals to reduce the burden of environmental-related diseases in children (9). One of the goals (RPGII) aims to reduce the prevalence of excess body weight and obesity by implementing health promotion activities in accordance with the global strategy on diet, physical activity and health. The European Charter on Counteracting Obe- sity was adopted in November 2006 at the WHO European Ministerial Conference on Counteracting Obesity (10). The Charter sets the goal of reversing the trend in childhood obesity by 2015 at the latest, which will require specific targeted action across many sectors. The Charter identifies as key areas of action: reducing marketing pressure, particu- larly towards children; promoting breastfeed- ing; reducing free (particularly added) sugars, fat and salt in manufactured products; ade- quate labelling of the nutritional content of food; and promoting walking, cycling and active living through better urban design and transport policies. The document Promoting physical activity for health – a framework for action in the WHO European Region, also presented at the Conference, provides guid- ance to Member States, experts and policy- makers on designing and implementing poli- cies and activities which, through multisec- toral cooperation, promote physical activity as part of the national public health agenda (7). The Regional Office will also present the Sec- ond Action Plan on Food and Nutrition Policy to the WHO Regional Committee in Septem- ber 2007 (11). This will address obesity and nutrition-related chronic diseases, micronutri- ent deficiencies, food insecurity and malnutri- tion and foodborne diseases. In 2005, the European Union (EU) launched the Green Paper Promoting healthy diets and physical activity: a European dimension for the prevention of overweight, obesity and chronic diseases (12). The purpose of the paper was to consult stakeholders with the aim of identifying a possible contribution at EU level of promoting healthy diets and phys- ical activity. The paper also gave an overview of food labelling legislation. In the same year, the EU also launched the EU platform on diet, physical activity and health (13). Under the leadership of the European Commission, the platform brings together stakeholders from commercial, professional, consumer and other civil organizations to take voluntary action to halt and, hopefully, reverse the rise in obesity, particularly among children. The spirit of the platform is to work under the leadership of the European Commission and to provide an example, which others will choose to follow across Europe, of coordinated but auto- nomous action by different parts of society to deal with the many aspects of the problem. In the European’s Commission White Paper on Food Safety (2000) and the Programme of Community action in the field of public health (2001–2006), there are elements of food, nutrition and physical activity policy. ASSESSMENT Overall, there is a reasonably high degree of implementation of policies to reduce child- hood obesity, with a considerable number of countries scoring above 12, the mid-point of the scoring scale. The wide range of scores suggests differences in policy efforts and com- mitment between countries. The most widely enforced policies are those requiring: (i) a set of recommended nutrient reference values; (ii) labelling of foods with nutritional information; and (iii) national, or participation in an international, health survey to monitor the prevalence of obesity, eating habits, physical activity, lifestyle and health in children. Close collaboration between the par- ties involved and those responsible for nutri- tion also indicates successful nutrition-related policy activities. In general terms, responses to this question were positive. Sixteen of the twenty-five participating countries reported that their governments had initiated some form of collaboration between the various parties responsible for the production, manu- facture, sales, control and legislation of food and nutrition education. The health promotion component of the obe- sity and excess body weight section of CEHAPE RPGII is relatively well addressed in participating countries, although only through nutritional awareness and education. Thirteen of the participating countries have clearly stat- ed policies on health and nutrition education and awareness programmes in schools and strategies to promote and increase the con- sumption of fruit and vegetables. A further five and nine countries, respectively, imple- mented these two policies to some degree. Only a small proportion of countries have clearly stated policies requiring a minimum of 30 minutes of physical activity per day at schools, and 60% of the participating countries have no legislation in this connection. Accord- ing to the international inventory of documents on physical activity promotion (14), most of the policies to encourage physical activity focus on cycling as well as walking. Policies addressing the responsible advertising and marketing of food products for children are poorly implemented. This is a particularly important area, as evidence clearly shows the link between the promotion of unhealthy food and drink to children and poor diets (increasing the risk of obesity and excess body weight). DATA UNDERLYING THE INDICATOR Data source The 25 participating countries with the con- sultation of experts, public health profession- als and policy-makers. Description of data Data were collected using a questionnaire. A score of 0, 1 or 2 was given to each of the 12 policies based on the three options: 0 = no policy; 1 = partly implemented or enforced; 2 = substantially implemented or enforced. Coun- tries also supplied the titles of the legal meas- ures and the year of their implementation. Method of calculating the indicator The indicator is presented as a composite index (sum of scores for each item of the policy ques- tionnaire). Geographical coverage ENHIS-2 project countries: Austria, Bulgaria, the Czech Republic, Estonia, Finland, France, Greece, Hungary, Italy, Lithuania, the Nether- lands, Poland, Romania, Slovakia, Slovenia, Spain. Volunteering countries: Albania, Arme- nia, Belgium, Croatia, Malta, Sweden, The former Yugoslav Republic of Macedonia, the United Kingdom (England), Uzbekistan. Period of coverage 2005–2006. Data quality The indicator does not yet cover the full range of available policy options. The strength of the data obtained lies in the fact that countries reported a high level of understanding and applicability of the 12 policy options and con- firmed the existence and availability of the information needed to respond to the ques- tionnaire. Generally, the countries that partic- ipated in the earlier ENHIS project considered the indicator to be highly relevant in terms of policy-making (15). Fact sheet 2.7 22.05.2007 0:08 Uhr Seite 3 © 2007 World Health Organization All rights reserved. The views expressed do not necessarily represent the decisions, opinions or stated policy of the European Commission or the World Health Organization. For further information, see the web site of the WHO European Centre for Environment and Health, Bonn www.euro.who.int/ecehbonn. World Health Organization · Regional Office for Europe Scherfigsvej 8 · DK-2100 Copenhagen Ø · Denmark · Tel.: +45 39 17 17 17 · Fax: +45 39 17 18 18 · postmaster@euro.who.int · www.euro.who.int References 1. WHO Global Strategy on diet, physical activity and health [web site]. Geneva, World Health Organization, 2004 (http://www.who.int/dietphysicalactivity/en/, accessed 10 April 2007). 2. The First Action Plan for Food and Nutrition Policy. WHO European Region 2000–2005. Copenhagen, WHO European Region, 2001 (http://www.euro.who.int/Document/E72199.pdf, accessed 10 April 2007). 3. WHO Global InfoBase online [online database]. Geneva, World Health Organization, 2007 (noncommunicable diseases, comparable esti- mates; http://www.who.int/ncd_surveillance/infobase/web/InfoBaseCommon, accessed 8 April 2007). 4. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. International Journal of Pediatric Obesity, 2006, 1:11–25. 5. James WPT et al. Overweight and obesity (high body mass index). In: Ezzati M et al., eds. Comparative quantification of health risks: global and regional burden of disease attribution to selected major risk factors. Vol. 1. Geneva, World Health Organization, 2004:497–596 (http://www.who.int/publications/cra/en, accessed 7 December 2006). 6. Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics, 1998, 101:518–525. 7. Promoting physical activity for health – a framework for action in the WHO European Region. Steps towards a more physically active Europe. WHO European Ministerial Conference on Counteracting Obesity, Istanbul, Turkey, 15–17 November 2006 (http://www.euro.who.int/Document/NUT/Instanbul_conf_edoc10.pdf, accessed 10 April 2007). 8. World Health Assembly resolution WHA57.17 on a global strategy on diet, physical activity and health. Geneva, World Health Organiza- tion, 2004 (http://www.who.int/gb/ebwha/pdf_files/WHA57/A57_R17-en.pdf and http://www.epha.org/a/1253, accessed 8 April 2007) 9. Children’s Environment and Health Action Plan for Europe. Declaration. Fourth Ministerial Conference on Environment and Health, Budapest, 23–25 June 2004 (http://www.euro.who.int/document/e83335.pdf, accessed 2 March 2007)). 10. European charter on counteracting obesity. WHO European Ministerial Conference on Counteracting Obesity, Istanbul, Turkey, 15–17 November 2006 (EUR/06/50627008; http://www.euro.who.int/Document/E89567.pdf, accessed 9 April 2007). 11. Proposed outline for the second action plan for food and nutrition policy. Copenhagen, WHO Regional Office for Europe, 2006 (http://www.euro.who.int/Document/NUT/Instanbul_conf_edoc09.pdf, accessed 10 April 2007). 12. Green Paper. Promoting healthy diets and physical activity: a European dimension for the prevention of overweight, obesity and chronic dis- eases. Brussels, Commission of the European Communities, 2005 (COM(2005) 637 final; http://ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/nutrition_gp_en.pdf, accessed 9 April 2007). 13. platform on diet, physical activity and health. Brussels, European Commission, Directorate-General for Health and Consumer Protection, 2005 (http://ec.europa.eu/health/ph_determinants/life_style/nutrition/documents/eu_platform_en.pdf, accessed 9 April 2007). 14. European Network for the Promotion of Health-Enhancing Physical Activity. International inventory of documents on physical activity pro- motion [web site]. Copenhagen, WHO Regional Office for Europe, 2007 (http://data.euro.who.int/PhysicalActivity/, accessed 10 April 2007). 15. WHO European Centre for Environment and Health. Implementing environment and health information system in Europe. Copenhagen, WHO Regional Office for Europe, 2005 (http://ec.europa.eu/health/ph_projects/2003/action1/docs/2003_1_28_frep_en.pdf, accessed 7 March 2007). Further information The world health report 2002 – reducing risks, promoting healthy life. Geneva, World Health Organization, 2002 (http://www.who.int/whr/2002/en/, accessed 26 March 2007). Comparative analysis of food and nutrition policies in WHO European Member States. Copenhagen, WHO Regional Office for Europe, 2003 (http://www.euro.who.int/Document/E81506.pdf, accessed 15 April 2007). Programme National Nutrition-Santé PNNS 2001–2005. Paris, Ministère de L’Emploi et de la Solidarité, Secrétariat d’Etat à la Santé et aux Handicapés, 2001 (http://www.sante.gouv.fr/htm/actu/34_010131.htm, accessed 10 April 2007). Marketing of Food and Non-Alcoholic Beverages to Children. Report of a WHO Forum and Technical Meeting, Oslo, Norway, 2–5 May 2006. Geneva, World Health Organization, 2006 (http://www.who.int/dietphysicalactivity/publications/Oslo%20meeting%20layout%2027%20NOVEMBER.pdf, accessed 10 April 2007). WHO European Centre for Environment and Health. Prevalence of excess body weight and obesity in children and adolescents. Copenhagen, WHO Regional Office for Europe, 2007 (ENHIS-2 fact sheet No. 2.3). Authors: Alejandro Ramirez, María José Carroquino, Instituto de Salud Carlos III, Madrid, Spain. Fact sheet 2.7 22.05.2007 0:08 Uhr Seite 4