How Are Public Health Services Addressing Obesity

Introduction

Obesity and overweight are among the greatest public health challenges in the WHO European Region and are a major risk factor for several of the leading noncommunicable diseases. Indeed, prevalence rates of obesity have tripled in many European countries since the 1980s, posing important challenges to health systems across the region. This chapter examines the involvement of public health organizations in policies aiming to address the challenge of obesity in nine European countries (England, France, Germany, Italy, the Republic of Moldova, the Netherlands, Poland, Slovenia and Sweden). It is based on detailed country reports that describe the policy response and the involvement of public health organizations in the different stages of the policy cycle (see Online Appendix).

Scale of the problem

Obesity has been recognized as a core challenge for health systems worldwide, having been termed "the epidemic of the 21st century" (WHO, 2000). It has emerged on the political agenda of many countries and international organizations, as evidenced by an increasing number of national and international strategies and action plans to reduce its prevalence (WHO, 2004; WHO Europe, 2006; European Commission, 2014). Thus, obesity and overweight are no longer regarded as purely private issues (Vallgårda, 2015). Obesity has also been recognised as having an equity dimension: there is a socioeconomic gradient in both adults and children, with higher obesity rates in lower socioeconomic groups and in disadvantaged areas (Magnusson et al., 2014).

In all countries included in this study, the prevalence of obesity has increased between 2010 and 2016 (see Figs. 2.1 and 2.2). In the United Kingdom, projections made in 2007 suggested that over half of the adult population could be obese by 2050 (Foresight, 2007). One-third (33%) of women are forecast to be obese in 2030 in the United Kingdom, compared with over one-quarter (26%) in 2010, while 36% of UK men are forecast to be obese in 2030 compared with 26% in 2010 (WHO & UK Health Forum, 2015).

Fig. 2.1. Age-standardized prevalence of overweight (defined as BMI ≥ 25 kg/m2) in people aged 18 years and over, WHO estimates, 2010 and 2016 (%).

Fig. 2.1

Age-standardized prevalence of overweight (defined as BMI ≥ 25 kg/m²) in people aged 18 years and over, WHO estimates, 2010 and 2016 (%). Source: WHO Regional Office for Europe, 2018

In England and Germany, the prevalence of childhood obesity is twice as high in the most deprived areas when compared to the least deprived areas. In 2014 in the Netherlands, 63.1% of the population with only primary school education were overweight compared to 40.7% of those with university education. For obesity, these percentages were 23.1% and 8.4% respectively (CBS, 2016). In Sweden, growing social inequalities are increasingly perceived as a key contributor to rising overweight and obesity rates, given that unhealthy nutrition and low levels of physical activity are more prevalent among lower educated groups (Public Health Agency of Sweden, 2014; Li et al., 2014; Magnusson et al., 2014; Moraeus et al., 2012).

Fig. 2.2. Age-standardized prevalence of obesity (defined as BMI ≥ 30 kg/m2) in people aged 18 years and over, WHO estimates, 2010 and 2016 (%).

Fig. 2.2

Age-standardized prevalence of obesity (defined as BMI ≥ 30 kg/m²) in people aged 18 years and over, WHO estimates, 2010 and 2016 (%). Source: WHO Regional Office for Europe, 2018

Overweight and obesity among children are problems in each of the countries included in this volume, as illustrated by the Childhood Obesity Surveillance Initiative (COSI) data for 6–8-year-old children for the period 2012–2013¹: while in Moldova the prevalence of overweight children is below 20%, in Italy, which has the highest levels, it is over 35%. Sweden (2006–2007 data) and Moldova have the lowest prevalences of obesity in children among the countries included, at lower than 6%, while Italy has the highest prevalence of obesity, over 14% (WHO Regional Office for Europe, 2016).

The costs to the health system are substantial. Currently, treating obesity and its consequences is estimated to cost the English National Health Service (NHS) 6.1 billion pounds sterling (approximately 7 billion euros) per year, with the wider costs of obesity to society being estimated to be around three times this amount (Public Health England, 2017), while in Germany, the economic costs of obesity (including treatment, medications, surgery, rehabilitation and sick pay) are estimated to amount to up to 27 billion euros per year (Effertz, 2015). In the Netherlands, total direct costs of overweight to the health system were estimated at 2.2% of total health expenditure, not accounting for indirect costs (e.g. higher sick leave, lower labour productivity, lower performance at school).

Policies and programmes

Policy response at the global level

Action on obesity is required at global and local levels (Swinburn et al., 2015), with an emphasis on measures to tackle price, availability, and marketing of energy-dense food and drinks (Kleinert & Horton, 2015). In 2013, the WHO's World Health Assembly adopted the Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020, intended to tackle preventable chronic diseases, inter alia by stopping the increase in obesity and diabetes (Bergström et al., 2013). The Plan recognizes that an unhealthy diet and physical inactivity trigger major noncommunicable diseases and points to the need for a strong and effective cooperation between different actors and sectors of society, coordinated by national governments to tackle these risk factors. Among the policy actions to tackle physical inactivity and unhealthy diet, the Plan recommends the implementation of the WHO's Global Strategy on Diet, Physical Activity and Health (2004) and the WHO's Global Strategy for Infant and Young Child Feeding (2003), besides a list of additional policy actions (e.g. reduce salt intake, increase public awareness).

Policy response at the European level

In September 2015, the countries of the WHO European Region adopted the Physical Activity Strategy for the WHO European Region 2016–2025, with a specific focus on multisectoral collaboration (WHO Regional Office for Europe, 2015). Countries have also subscribed to the WHO's Global Action Plan for the Prevention and Control of Non-communicable Diseases.

2013–2020, including the recommendations on physical activity for health for children and adults.

The WHO's European Food and Nutrition Action Plan 2015–2020 and the Physical Activity Strategy for the European Region set priority areas for accelerating progress in meeting voluntary global targets on noncommunicable diseases (NCDs) of the WHO's Global Action Plan, particularly in relation to overweight and obesity. The WHO's European Food and Nutrition Action Plan 2015–2020 aims to reduce significantly the burden of overweight, obesity and all other forms of malnutrition prevalent in the WHO European Region, with a guiding principle of tackling inequalities in access to healthy food (achieving universal access across social gradients, by improving the availability, affordability and acceptability of healthy diets), emphasizing the recognition of existing inequalities in obesity and overweight.

The former WHO Director-General also established a high-level Commission on Ending Childhood Obesity to better inform a comprehensive response to childhood obesity, which met for the first time in 2014. In its latest report, the Commission introduced a comprehensive and integrated package of recommendations to address childhood obesity based on the following actions: promoting intake of healthy foods, promoting physical activity, preconception and pregnancy care, early childhood diet and physical activity, healthy nutrition and physical activity for school-age children and weight management (WHO, 2016).

At the European Union (EU) level, a Plan of Action was adopted in 2014 against childhood obesity for the period 2014–2020, which covered eight focal areas, including family, environment and research (European Commission, 2014). The Plan recognizes the increase in obesity and overweight in adults, children and young people in the EU and aims to demonstrate the shared commitment of EU member states to addressing childhood obesity; set out priority areas for action; develop a possible toolbox of measures for consideration; and propose ways of collectively keeping track of progress (European Commission, 2014). The Action Plan recognizes and respects Member States' roles and freedom of action.

National action plans and strategies

At the national level, many policies and programmes have been adopted in recent years in Europe, focusing on both the prevention of obesity and its treatment and management. Almost all of the nine countries considered in depth here have adopted national strategies or programmes in this area (Table 2.1). All plans define the physical and food environment as a crucial factor in the development of obesity.

Table 2.1

Obesity policies in the nine selected European countries.

Only Sweden has no national plan, although Stockholm County Council has a county Action Plan for overweight and obesity (Så kan vi vända trenden, Handlingsprogram övervikt och fetma 2016–2020), which includes action related to nutrition in schools; school-based health and nutrition programmes; regulation/guidelines on types of foods and beverages available; promotion of healthy diet and prevention of obesity and diet-related NCDs; and nutrition counselling on healthy diets. Quantitative objectives are also established in the Plan, for example: the proportion of 4-year-old children who are overweight should decrease to less than 7% and to less than 2% for obesity (by 2020) while the proportion of adults who are overweight should decrease to less than 25% and the percentage of adults with obesity, to less than 7% (by 2020) (WHO, 2016).

In Italy, several policies and programmes have been adopted over the years to tackle obesity. The existence of a National Prevention Plan was a major development in this area, as were Regional Prevention Plans, which increasingly concentrate on the prevention of noncommunicable diseases and the promotion of healthy lifestyles. However, this progress threatens to be undermined by recent budget cuts to prevention, which have left fewer resources that can be allocated to tackling obesity. There are also few efforts to make the required structural and systematic changes to urban environments to encourage people to increase their physical activity (De Feo & Sbraccia, 2014).

In France, the National Nutrition and Health Programme (PNNS) was initiated in 2001 and extended in 2006, as the initial objectives were not uniformly addressed and social inequalities in health increased. An obesity plan for France was adopted and a five-year government programme on nutrition and health was launched in 2010, both based on cross-government cooperation. Later in 2011, the programme was again extended until 2015, and proposals for a 2017–2010 PNNS were published in September 2017 (HCSP, 2017).

In Germany, one of the most important initiatives is the National Initiative to Promote Healthy Diets and Physical Activity, adopted in 2008. However, it focuses on physical activity and nutrition rather than weight. This focus on individual behaviours is favoured by the food industry, neglecting evidence on the importance of tackling the upstream social, commercial, and political determinants, most notably the role of the food and agriculture industries (IN FORM, 2014).

In England and the Netherlands, emphasis has been placed on collaboration with the private sector. In England, this has taken on the form of the Responsibility Deal, with a stated aim of bringing the food industry into discussions and to facilitate protection of the public from unhealthy foods and drinks. Although evaluations have revealed it to have been a failure, focusing on industry-friendly but ineffective measures (Box 2.1), the UK was an early mover on restricting marketing to children via legislation and introducing the front-of-pack traffic light label. Change4Life was also a well-funded behaviour change campaign.

Box 2.1

Obesity policies in England.

In the Netherlands, the government has taken the view that it cannot effectively address the problem of overweight on its own, but that it is highly dependent on other public and private actors. However, the effectiveness of public–private partnerships in preventing obesity is uncertain and they may offer the food industry, which is especially strong in the Netherlands, respectability and new channels for selling their products to young (and old) people.

In Moldova, the National Health Policy (2007–2021) was the first policy document that addressed obesity as one of the main health determinants and called for intersectoral, whole of government, and whole of society actions to prevent it. In 2014, the Moldovan Government endorsed the first National Food and Nutrition Programme for 2014–2020 and the Action Plan for 2014–2016. One specific objective of this programme is to halt the increase in obesity prevalence among children and adults.

In Poland, a Regulation of the Minister of Health (of 26 July 2016) addressed groups of foodstuffs intended for sale to children and adolescents in the education system (Table 2.2). In addition, a School Programme Strategy 2017/2018 to 2022/2023 has, as one of its goals, the promotion of a healthy, balanced diet among children and parents. In particular, it aims to change the eating habits of children by increasing the share of fruit and vegetables already provided (FV scheme) and milk (Milk scheme). Furthermore, the National Programme for the Prevention of Overweight, Obesity and Non-Communicable Diseases through Diet and Improved Physical Activity (2007–2016) includes goals to tackle: overweight, obesity and diet-related NCDs; overweight and obesity in school-age children and adolescents; overweight and obesity in adults; and diet-related NCDs (WHO Global Nutrition Policy Review 2009–2010). The Framework of the National Health Programme for 2016–2020 includes healthy public policies.

Table 2.2

Measures relating to schools (including standards or rules for foods, bans on vending machines, standards for marketing) and marketing food high in saturated fats, trans-fatty acids, free sugars or salt (HFFS foods) to children in 2017.

In contrast to the other countries reviewed in depth here, Sweden has no national strategy on obesity. In 2003, the government asked the Swedish National Food Administration and the then National Public Health Institute to prepare a draft national action plan for healthy eating and physical activity. A document with 79 action points was presented in 2006, but the plan was never formally adopted (Box 2.2).

Box 2.2

Lack of coordination and of a national strategy to tackle obesity in Sweden.

The role of public health organizations in addressing obesity in the selected countries

Problem identification and issue recognition

While obesity is generally perceived as a public health problem, the level of recognition differs between and within countries, with obesity hardly appearing in public policy debates in some of the countries included, such as Moldova or Poland. One of the challenges, pointed out in discussions on Italy, is that public health thinking in some countries is still largely based on infectious or environmental disease pathways and less oriented towards integrated multidisciplinary approaches and efforts to address the social and behavioural determinants of health and disease. Another challenge, pointed out in discussions on Italy and Poland, is that the problem of obesity is still poorly recognized by medical professionals and policy-makers. In contrast to many other European countries, many policy-makers in Italy believe that lifestyle interventions and weight-loss maintenance tools and policies are successful, despite evidence that suggests that weight loss is, in practice, extremely challenging to maintain (EASO, 2014). In Poland, too, obesity is mainly seen as an individual lifestyle problem and not as a population health problem – a stance that is strongly promoted by the food industry (with the industry in Poland also opposing salt reduction) (WHO Regional Office for Europe, 2013).

Where health policy focuses on the language of lifestyle choices, it is reasonable to assume that the food industry is playing a role, with increasing revelations about how some of the global corporations have used their considerable financial resources to shape the policy debate and, in particular, the available research, with their involvement often concealed. Economic factors also play a role: in 2014, the Italian Minister of Health did not agree with proposed new guidelines by WHO to halve consumption of sugar from 10% of total daily calories to 5%, as there was concern that the effects of such a policy were likely to affect many national brands (Health News Today, 2014).

National level

The role of public health organizations in problem identification and issue recognition varies, but at the national level, the Ministry of Health or its subordinated agencies are usually in charge of identifying problems that require government attention (e.g. Public Health England, Santé Publique in France or the National Centre for Disease Prevention and Control in Italy).

In some countries, advisory bodies to the Ministry of Health have been created, such as the Council for Diet, Physical Activity and Health in Poland, although its role has remained marginal. In some countries, such as Germany, public health organizations have only had a small role in shaping policy responses.

The German alliance "Platform on Diet and Physical Activity" (PEB) is dominated by representatives from the food industry, while public health organizations are not involved at all. It seems likely that this is a major explanation of the individually focused approach dominant in Germany, recalling earlier concerns about the powerful role of the tobacco industry in the German research and policy communities (Grüning et al., 2006).

The degree of intersectoral collaboration also matters for problem identification and issue recognition. In England, for example, government departments other than Health have key roles to play in obesity policy, including the Department for Education, the Department of Culture, Media and Sport (physical activity and control of advertising /marketing standards), the Department for Communities and Local Government, and the Department for Environment, Food and Rural Affairs. This is not the case in other countries, such as the Republic of Moldova, where a lack of intersectoral collaboration has been pointed out.

Regional/local level

At regional or local level, local authorities tend to be responsible for assessing the health needs of the population, including those related to obesity, and for organizing and funding effective local interventions (e.g. regional and local self-governments in Poland, municipalities in Sweden, and regional health agencies in France).

Other actors

While in some countries (such as England), NGOs play a strong role in advocating for policy (although now more limited following the passage of legislation on lobbying promoted by some industry-funded thinktanks concerned about the role of civil society), as well as provision of activities related to food, in particular the rapidly growing number of foodbanks (supporting those facing food insecurity as a consequence of austerity measures), fitness and healthy environments, in others (such as Poland), they have little impact on problem identification and issue recognition. Other important actors are international organizations and scientific or professional associations (Box 2.3).

Box 2.3

Interaction of public health agencies with other agencies in Italy.

International commitments have been crucial in encouraging some countries to develop their strategies to deal with obesity, such as Moldova (Box 2.4). Furthermore, a number of institutions are part of the WHO's European Network for the Promotion of Health-Enhancing Physical Activity (HEPA) (WHO, 2016).

Box 2.4

Problem identification and issue recognition in Moldova.

These policy documents, together with the situation described above, led to the development and the approval by the Moldovan Government of the National Food and Nutrition Programme for 2014–2020, where obesity was addressed as one of the key public health problems.

The food industry and the private sector are also involved in different initiatives and, as mentioned above, influence (or rather prevent) problem identification and issue recognition. For example, in England, Change4Life (Change4Life, 2018), the national website providing advice on healthy lifestyles, was established in 2008 with contributions from private industries, although it is now managed by Public Health England. Furthermore, commercial weight management services, such as Weight Watchers and Rosemary Conley, are increasingly being commissioned by local authority public health services, instead of or alongside NHS-provided services. In Poland, the food industry plays an important role in public health discussion, promoting the idea that the solution to the obesity problem lies in health promotion, education and personal responsibility for making decisions on nutrition and physical activity, all measures known to be ineffective.

Policy formulation

National level

In all nine countries, the Ministry of Health is responsible for the formulation of overall national health policies, as well as for defining priority areas for national programmes. Often, the Ministry of Health plays a coordinating role, drawing on the advice of arms-lengths bodies and scientific associations, while building capacity of other bodies to promote and support obesity control measures. In Germany, the National Initiative to Promote Healthy Diets and Physical Activity, established in 2008, was drawn up by a joint working group of the national government, the federal states, and local organizations, which has also been involved in the implementation of the corresponding Action Plan (IN FORM, 2008). Similarly, in Italy, a technical committee has been set up for this purpose, the National Platform on Diet, Physical Activity and Tobacco. It is composed of representatives from national administrations, regions and autonomous provinces, institutes and research centres, GPs and paediatricians, as well as manufacturers' and consumers' associations and most trade unions. The Platform is tasked with formulating policies and implementing actions.

Not all ministries of health have been successful in assuming a role in obesity policies. In Sweden, efforts to strengthen national influence in the area of obesity during the latter part of the 1990s and throughout the 2000s, for example by developing national "action plans", were unsuccessful. Challenges faced by other countries include a lack of capacity in the Ministry of Health. This has been described in Moldova, where there is no designated person at the Ministry of Health or the National Centre of Public Health working on obesity. The lack of locally produced evidence on the clinical and cost–effectiveness of interventions in the area of obesity was noted in Poland, as well as its limited use of international evidence.

The EU contributes to national policy formulation to tackle obesity. As mentioned above, an EU Action Plan on Childhood Obesity 2014–2020 has been formulated (European Commission, 2014), which has been endorsed by several countries, including Sweden. Successive reforms of the Common Agriculture Policy have also responded to criticism that it encouraged consumption of energy-dense foods.

Intersectorality

Tackling obesity is one of the areas in which intersectoral cooperation seems to be better developed than in many other health policy areas. In several countries, other ministries are involved in policy formulation (e.g. France; see Box 2.5).

Box 2.5

Intersectorality in policy formulation in France.

In Slovenia, an intersectoral working group was established under the Ministry of Health to develop a national programme, comprising representatives from the National Institute of Public Health and other ministries (Ministry of Agriculture and Food Industry; Ministry of Education and Sport; Ministry of Labour, Family and Social Affairs; Ministry of Economy; Ministry of Transport; Ministry of Environment; and Ministry of Defence).

Regional/local level

Regional or local administrations are responsible for the formulation of policies at those levels, as well as implementation of some national policies on obesity. Even in more centralized countries such as France, the regions (more specifically, the regional health agencies (ARSs)) are tasked with ensuring that health care provision meets the needs of the local population. This is also the case in England, where local authorities, through their Health and Wellbeing Boards and public health departments, are charged with the assessment of local needs and policy formulation. The Fingertips information system managed by Public Health England (PHE; Public Health England, 2018) is a major intelligence resource for local authority public health.

In more decentralized countries, such as Italy, the central government sets the main policy directions, while the regions are responsible for the formulation of their respective regional policies and for the organization of regional public health services and health care. In Italy, regional departments of health and public health observatories are key actors involved in formulating regional policies on obesity. The situation is similar in Sweden, where county councils are tasked with regional policy formulation. Some county councils (e.g. Stockholm and the region of Västra Götaland) have been active in the prevention of obesity, elaborating action plans for health services, but also in collaboration with other actors. In Poland, this role falls to regional self-governments.

Information to support policy formulation

In all countries covered, public health organizations provide information to support policy formulation. In France, for example, the EHESP School of Public Health, INPES (now merged into Santé publique France) and the Ministry of Health have launched a national initiative to help ARSs and NGOs by providing easy access to literature, data, and the scope for transferability of measures developed in one region to others.

In Italy, the national lifestyle and disease monitoring systems that collect data on adults and children ("Keep an Eye on Health", HBSC Study, PASSI and PASSI d'Argento systems) provide data to guide policy formulation and decision-making and to provide useful information for all stakeholders (policy-makers, administrators, health workers and citizens). These information systems provide data on the prevalence of overweight and obesity, monitor trends over time, assess the need for interventions and gauge the effectiveness of implemented actions in different areas of the country.

Decision-making

Decisions are taken at different levels within government, depending on both the nature of the decision being made and the distribution of administrative and regulatory powers in a country and the discretion given to lower administrative tiers. The ability to coordinate decisions across organizations at a particular level and at different levels also varies. Thus, in Sweden, while municipalities can seek advice from county councils, there are no formal mechanisms for coordinating among adjacent municipalities. In contrast, Italy has established mechanisms for coordinating national and regional decision-making (Box 2.6).

Box 2.6

Coordinating national and regional decision-making in Italy.

Other actors

In several of the countries included, the food industry has considerable influence, both formal and informal, into policy. In Moldova, for example, it exerts influence through the Ministry of Economy and the Ministry of Agriculture and Food Industry. It attempted to block legislation banning sale of unhealthy foods within and around schools and intervenes every time new initiatives emerge that may affect its commercial interests. In Poland, it is one of the most influential lobby groups, with well-organized representation and significant financial resources.

Policy implementation

Responsibility for the implementation of policies again varies according to the policies in question, reflecting the powers at each level. In some countries, the Ministry of Health and the regions (e.g. France, Italy), county councils (e.g. Sweden) or municipalities (e.g. Sweden) share responsibility for policy implementation, although in practice this may be poorly coordinated, as has been noted in Sweden. However, responsibilities are not always clearly delineated, and this was identified as a challenge to the successful implementation of measures against obesity in Moldova.

In most countries, the Ministry of Health has overall responsibility for the implementation of (national) obesity policies. In this task, it can often rely on dedicated health agencies under its supervision, as well as on other public bodies. For example, in France, INPES (now merged into Santé Publique France) is in charge of implementing policies in matters of prevention and health education included in the government's public health policy framework. In Sweden, the public health agencies at national level that have a clear mandate for policy on obesity include the Public Health Agency of Sweden, the National Food Agency and the National Board of Health and Welfare.

Intersectoral collaboration

Several ministries have a role to play in relation to obesity. In Germany, a national steering group oversees implementation of the Action Plan to Promote Healthy Diets and Physical Activity. The steering group consists of one representative of each of the lead ministries of the Federal Government, one representative of each of the Conferences of the Ministers of Health, Consumer Protection and Agriculture and one representative of the municipal umbrella associations. It also includes representatives of employer and employee associations, a representative of the Federal Association for Disease Prevention and Health Promotion, of the Platform Diet and Physical Activity, a representative of civil society and one representative of the main specialist associations and societies.

In France, the Minister of Agriculture, the Minister of Health and the Minister for Consumer Protection collaborate on the implementation of obesity policies through the National Food Council (Conseil National de l'Alimentation (CNA)), established in 1985 (CNA, 2016). In Italy, public health agencies and services engage with a large number of health professionals (e.g. GPs, paediatricians, nutritionists) and other involved stakeholders (e.g. trade and food chain associations, private sector).

In Moldova, as well, a number of other authorities are involved in the implementation of the NFNP Action Plan. Thus, the Ministry of Finance is responsible for excise taxes for food high in saturated fat and sugary soft drinks; the Ministry of Education for school curricula and healthy nutrition education; the Ministry of Agriculture and Food Industry for free school fruit and vegetable schemes; and local authorities for ensuring a healthy nutritional environment in the schools. However, so far, little has actually happened.

Regional level

In several countries, certain obesity policies are implemented by public health organizations at the regional level. One example is France, where ARSs (regional health agencies) play a key role in policy implementation (Box 2.7).

Box 2.7

The role of ARSs in policy implementation in France.

In England, local authorities have certain responsibilities for local policies on obesity (see Box 2.8).

Box 2.8

The role of local authorities in policy implementation in England.

In Italy, regional health departments implement national guidelines and laws and may directly fund some regional projects, which are all detailed under Regional Prevention Plans. They work with their networks of Local Health Authorities and hospital trusts (Aziende Ospedaliere, AOs) to which executive functions are largely delegated.

In the Netherlands, responsibility for implementation of the national public health plan and the corresponding municipal public health plans rests largely with the municipalities. However, an evaluation by the Healthcare Inspectorate of the content and quality of local health plans in 2009 found that these were often insufficient, did not always include all strategic priorities ("spearheads") and were poorly implemented (Health Care Inspectorate, 2009).

In Sweden, county and municipal levels have considerable autonomy in implementing activities for public health, including setting priorities, funding and implementing activities (Allin et al., 2004). Some county councils (e.g. Stockholm and the region of Västra Götaland) have been very active in the area of obesity and have elaborated action plans on obesity for health care services.

Other actors

A large range of other actors are involved in the implementation of obesity policies in the various countries, including other public authorities, NGOs, the media, but also the food industry.

In Italy, formal mechanisms for collaboration have been established with the National Institute of Health (ISS), AGENAS, the National Medicines Agency (Agenzia Italiana del Farmaco), the Ministry of Education, University and Research (e.g. Keep an Eye on Health; HBSC), the European Network for the Promotion of Health-Enhancing Physical Activity – HEPA, the Department of Youth Affairs, the Ministry of Agriculture (e.g. for the development of dietary guidelines), the food industry, trade and food chain associations, and the National Committee for Dietetics and Nutrition.

In Germany, the Platform for Diet and Physical Activity (PEB) was established in September 2004 (Platform for Diet and Physical Activity, 2018). It aims to promote healthy diets and active lifestyles and to give consumers a voice in the discussion with policy-makers and representatives from industry. The platform promotes a number of programmes and is supported by a scientific committee. It brings together approximately 100 stakeholders, including stakeholders from the food industry, food producers, researchers, health insurers, sports unions and government representatives (EASO-Study, 2014). However, the platform has been heavily influenced by the food industry, which dominates its membership. Out of more than 100 members, only 6 represent consumers and educators, 8 come from the sports sector, 10 represent the public sector, 11 are from science, 16 from the field of health, 20 represent companies, associations or foundations, and 31 represent the food industry, including Coca Cola and Danone (ZDF Frontal 21, 2014). Public health organizations have not been involved in the platform.

In some other countries, the food industry is also heavily involved in the implementation of obesity-related policies. In Poland, the food industry closely cooperates with the Ministry of Health, as well as with the National Food and Nutrition Institute (NFNI) and the Chief Sanitary Inspectorate. For example, it contributes to public health education campaigns aiming to raise awareness on obesity, such as the "Trzymaj Formę" ("Keep in shape") campaign run by the Chief Sanitary Inspectorate (Trzymaj Formę, 2018). This has similarities with the discredited Global Energy Balance Network established by Coca Cola to focus attention on physical inactivity rather than consumption of its sugar-sweetened products (Barlow et al., 2018). A consistent feature of food industry messaging is individual responsibility for health and health choices, rather than legislative or regulatory action, promoted through well-funded mass media campaigns and, in some countries, educational activities and sponsorship in schools. Most large private or public food corporations in Poland support actions aimed at raising awareness in the area of nutrition and physical activity, such as through sponsoring sport events organized at the local or national level, e.g. football championships for school pupils. In contrast, the involvement of NGOs in policy implementation is limited in Poland.

In Sweden, measures have been promulgated in some other areas to address obesity. Maternal and child health services, which reach virtually all pregnant women, partners and their children, are responsible for monitoring the development of weight and height among children and mothers, and provide some health information to families. Another important policy is the provision of Sweden's free and nutritious school meals for all pupils in primary and secondary schools, which dates back to the 19th century, and more recently, EU-subsidized low-fat school milk (Patterson & Schäfer Elinder, 2014).

Funding

One of the main challenges to implementation of obesity policies is funding. In Moldova, for example, during the period of 2014–2015, no funds were allocated for policy implementation (Box 2.9).

Box 2.9

Lack of funding for policy implementation in Moldova.

Monitoring and evaluation

Most of the nine countries (except Sweden and Poland) have some mechanisms in place for monitoring national obesity levels. Public health agencies tend to play a role but other actors may be important, such as national statistical institutes or NGOs. The monitoring and evaluation of national public health policies on obesity is less well developed, but in those countries where it exists, public health agencies tend to have a leading role.

Monitoring of obesity levels

In France, this role falls in part to the French Institute for Prevention and Health Education (Institut national de prevention et d'éducation pour la santé (INPES)), now part of Santé Publique France. Since the early 1990s, INPES, in cooperation with many institutions, has been conducting a series of surveys which examine health behaviours and attitudes. The National Institute for Public Health Surveillance (InVS), another public health agency in France now merged into Santé Publique France, is responsible for surveillance in all domains of public health. It is responsible for collecting, analysing and updating information on health risks, causes and trends, and to identify the most vulnerable or most-at-risk population groups.

In England, Public Health England has a role in the overall monitoring of obesity prevalence and other important lifestyle factors, including dietary habits, through the National Diet and Nutrition Survey. The Health Survey for England is also an important source of data. The National Obesity Observatory is now part of Public Health England's knowledge and intelligence function, which helps to assimilate evidence into analytical and evidential tools for the local system, including the dataset for local authorities known as Fingertips (Public Health England, 2018). NHS Choices is a major online public and patient health information resource. Its information on obesity is extensive, and written in accessible English (NHS Choices, 2014). There is also a specific weight loss support guide (NHS Choices, 2014b).

In Germany, support from the Federal Government for the monitoring of obesity levels has been systematically extended in recent years, e.g. through the German Health Survey, the German Health Survey for Children and Adolescents, the National Food Consumption Survey and nutrition monitoring, which is hoped to result in a strong health monitoring system based on regular surveys (IN FORM, 2008).

In Italy, an example of routine monitoring is the Ministry of Health's annual monitoring of the delivery of the health benefits package, known as the Essential Levels of Assistance (Livelli Essenziali di Assistenza (LEA)) across the country. Obesity is included as part of the descriptive lifestyle indicators and as a risk factor for chronic noncommunicable diseases. In addition, the National Observatory on Alcohol and the National Institute of Statistics (ISTAT) and the National Institute of Health (ISS) coordinate the main national surveillance systems for children and adults which provide useful information for planning preventive and protective measures for population health.

In the Netherlands, development of the national public health plan is based on the periodical publication of the National Public Health Status and Foresight Report by the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu (RIVM)). One of RIVM's main responsibilities is data collection on population health, including obesity.

In Moldova, the obesity surveillance system has been strengthened with technical support by WHO and financial support by development partners such as the EU and the Swiss Development Agency. In 2013, the Republic of Moldova became part of the COSI and STEPS surveys. The first COSI survey was implemented in 2013 and the same year also saw the first STEPS survey of NCD risk factors among Moldova's adult population (18–69 years).

In Sweden, nationally representative data on overweight and obesity are lacking (Box 2.10). In Poland, too, there is little systematic data collection on the prevalence of obesity and overweight and data gathered are often not representative of the whole population nor comparable across surveys. The 2015 Public Health Act states that at least 10% of resources allocated to the implementation of the National Health Programmes (NHP) will be dedicated to monitoring, evaluation, and scientific research in the field of public health, including obesity. If this target is met, significant improvements could be made to data collection and evaluation in this area.

Box 2.10

Monitoring obesity prevalence in Sweden.

In a number of countries, national institutes of statistics contribute to the monitoring of obesity prevalence. For example, in Italy, the National Institute of Statistics (ISTAT) produces the multipurpose Aspects of Daily Life Survey, and collaborates with the National Observatory on Health Status in the Italian Regions (Osservatorio Nazionale sulla Salute nelle Regioni Italiane), which collects comparable regional data from different sources and monitors population health in Italy's regions.

Monitoring and evaluation of obesity policies

Several countries have also established mechanisms for the monitoring and evaluation of obesity policies.

In the Netherlands, evaluation of the national public health plan is the responsibility of the Health Care Inspectorate. An evaluation by the Healthcare Inspectorate of the content and quality of local health plans in 2009 found that 50% of municipalities did not monitor or evaluate their activities in public health (Health Care Inspectorate, 2009).

In the Republic of Moldova, the Ministry of Health is responsible for monitoring and reporting annually to the government on progress with implementation of the first National Food and Nutrition Programme for 2014–2020 (NFNP).

In Poland, systematic evaluation of programmes is still lacking. However, the 2015 Public Health Act states that at least 10% of resources allocated to the implementation of the National Health Programmes (NHP) will be dedicated to monitoring, evaluation and scientific research in the field of public health.

In Sweden, the responsibility for conducting evaluations of national public health policies lies with the Public Health Agency. Other national-level institutions evaluate the implementation of their own protocols. For example, in 2015 the National Board of Health and Welfare evaluated the implementation of national guidelines on disease prevention that it had issued in 2011, concluding that action needed to be intensified (National Board of Health and Welfare, 2015).

In Italy, monitoring and evaluation of policies addressing obesity are directly undertaken by regional health departments. In some regions, health agencies have been given dedicated funds to provide technical and scientific advice to the regional health departments and local health authorities. Furthermore, some public health observatories have been set up in different regions, provinces and local health authorities to deliver a range of quality indicators for planning and monitoring purposes. In a further initiative, in November 2014, the State-Regions Conference approved the issuing of a decree that will provide an improved instrument for the evaluation of Regional Prevention Plans for 2014–2018, extending to some of the most significant areas of prevention.

Conclusion and outlook

Obesity is one of the greatest challenges to health systems worldwide. Effective responses require an intersectoral approach, but public health organizations should play a key role. This chapter has presented an in-depth assessment of the role played by public health organizations in addressing obesity in nine European countries, exploring their involvement in the various stages of the policy cycle, from agenda-setting to policy formulation, decision-making, policy implementation, monitoring and evaluation.

As expected, policy development, implementation, monitoring, and evaluation take place at different levels within each country, largely reflecting the distribution of responsibilities within the administrative structure. What is important is not the level that these activities take place but whether they are at the level that corresponds with the ability to obtain resources and to take action. Thus, in Moldova, there is a national plan and many different organizations are expected to implement it but they have been given no resources to do so. In England, local authorities have responsibility to address the health needs of their populations but many of the most effective measures in tackling obesity are denied to them because of constraints in their powers in areas such as planning (for example, limiting numbers of outlets selling junk foods in certain areas).

Monitoring and evaluation is generally limited. There are few high-quality surveys undertaken regularly, with measurement, as opposed to the less accurate self-report, of height and weight. The Health Survey for England is a rare exception.

Worryingly, the food industry has a major influence on obesity policies in several countries, despite what is now considerable evidence of how they divert attention away from measures that work towards those that are ineffective.

One striking finding from the countries studied is the lack of action on the upstream determinants of health. These should address, for example, food insecurity – now a major problem in many countries, with large numbers of people unable to afford a healthy diet. This is compounded, in some countries, by difficulties in accessing fresh food at affordable prices, as retailers inevitably concentrate their outlets where they can maximize profits. Countries should also make full use of fiscal measures. The sugar tax in the United Kingdom is a good example of what can be done, as manufacturers have suddenly discovered that it is possible to reformulate products to have less sugar, after many years of arguing that it was impossible. However, much more could be done elsewhere and, as with tobacco taxation, it is important to maintain continued upward pressure. Other opportunities are almost completely lacking. Thus, the alcohol industry has been very successful in blocking nutritional labelling on its products, even though they are a major source of calories for many people. Urban planning and other measures to encourage physical activity are other areas where responses have been patchy, although there are some excellent examples of what can be done in some countries, such as the networks of cycle lanes in the Netherlands, Denmark and Germany.

However, the biggest barrier to effective responses is the continued perception of obesity as a result of freely taken lifestyle choices, with the corollary that measures to legislate or regulate are in some way an assault on freedom. This conveniently ignores how many policies that are adopted are even greater restrictions on freedom, such as welfare policies that deny the poorest in society the ability to eat a healthy diet, or lobbying activities, sometimes verging on corruption, that block healthy public policies ever getting onto the agenda.

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1: No COSI data are available for the United Kingdom, Poland, the Netherlands, Germany and France.