Addressing Obesity in Europe

EUROHEALTH Quarterly of the European Observatory on Health Systems and Policies and Systems Health on Observatory European the of Quarterly Obesity › Addressing Addressing in Europe • • • requiring bold solutions address it Obesity in England: A big issue issue Abig England: in Obesity to policies and obesity Childhood organisations health public of role The Eu r opean on Healt h Sy st em s andP oli cies • • • • Public in health activities Poland of Republic the in obesity Addressing Tackling challenge in the obesity Italy in problem health public increasing An Germany Moldova RESEARCH • DEBATE • POLICY •NEWS •DEBATE •POLICY RESEARCH

Volume 25 | Number 1 | 2019 1030 –1030 1356 ISSN Still Steve Production: and Design permission. prior without form any in transmitted or system aretrieval in stored reproduced, copied, be may publication this of part No 2019. Policies and Systems Health on Observatory European of behalf on © WHO Medicine. &Tropical Hygiene of School London the and Science Political and Economics of School London Funds), Insurance Health of Union National (French UNCAM Bank, World the Commission, European the Italy, of Region Veneto the and Kingdom United the Switzerland, Sweden, Spain, Slovenia, Norway, Ireland, Finland, Belgium, Austria, of Governments the Europe, for Office Regional Organization Health World the between apartnership is Policies and Systems Health on Observatory European The for authors by submitted or editors the by commissioned independently are Articles sponsors. or partners its of any or Policies and Systems Health on Observatory European the of those necessarily not and alone authors in expressed views The beyond. and Europe in debate aconstructive to contribute so and issues policy health on views their express to policymakers and experts researchers, for Eurohealth at: Available SubmissionArticle Guidelines White: Caroline MANAGER SUBSCRIPTIONS Jonathan North: PRODUCTION MANAGER Still: Steve DESIGN EDITOR B. Richard Mossialos, Elias McKee, Martin Lessof, Suszy Palm, Willy Grand, Le Julian Figueras, Josep Busse, Reinhard Belcher, Paul ADVISORY BOARD EDITORIAL http://www.lse.ac.uk/lse-health 6803 7955 20 +44 F: 6840 7955 20 T: +44 Kingdom United 2AE, WC2A London Street, Houghton and Political Science Economics of School London Health, LSE Elias Mossialos: FOUNDING EDITOR Palm: Willy EDITORIAL ADVISOR Gemma Williams: 6381 7955 20 +44 McDaid: David 6194 7955 20 +44 Merkur: Sherry SENIOR EDITORIAL TEAM http://www.healthobservatory.eu Email: 0936 2525 +32 F: 9240 2524 T: +32 1060 /10 Brussels, Belgium 40 Hortaplein, /Victor Horta Victor Place 07C020) (Office Eurostation Policies and Systems Health on Observatory European ofQuarterly the EUROHEALTH consideration. [email protected] is a quarterly publication that provides a forum aforum provides that publication aquarterly is [email protected] [email protected] http://tinyurl.com/eurohealth [email protected] [email protected] [email protected]

[email protected] Eurohealth Saltman, Sarah Thomson Thomson Sarah Saltman, [email protected] are those of the the of those are [email protected]

Back issuesof To subscribeto receivehardcopiesof http://www.euro.who.int/en/home/projects/observatory/publications/e-bulletins in hard-copyformat.Ifyouwanttobealertedwhen anewpublicationgoesonline,pleasesignuptothe Eurohealth Walter Ricciardi & Hygiene of School London Policies, and Systems Bernd Rechel EUPHA Plümer D. Klaus and Pharmacy, Republic of Moldova Medicine of University State the at Management Health Galina Obreja John Middleton Poland Metelska Paulina UK Science, Political and Economics of School London Policies, and Systems Health on Cristina Hernández-Quevedo Charmaine Gauci Denmark Angela Ciobanu Poland Michał Brzezin´ski Center (IRCCS), Italy Elena Azzolini ofList Contributors Poland Sutkowska Bogumiła van CI May Italy Cuore, Sacro del Cattolica Università isavailableonlineat:

Tropical UK Medicine, Eurohealth

Pillar Advisor, Germany Schalkwyk

areavailableat: w w European Observatory

Department of Department

w Humanitas Clinical Humanitas w

w w

UK Faculty

WHO Regional WHO w

Independent consultant and w Department of Department w Ministry for Ministry Medical University Medical Medical University Medical http://www.euro.who.int/en/about-us/partners/observatory/publications/eurohealth

w Medical University Medical Imperial College London, UK London, College Imperial Eurohealth of Public Health, UK Health, Public of

w http://www.lse.ac.uk/lsehealthandsocialcare/publications/eurohealth/eurohealth.aspx Social Medicine and and Medicine Social European Observatory Health, Malta Office for Europe, Europe, for Office Public Health, Health, Public and Research Research and , pleasesendyourrequest andcontactdetailsto: on Health Health on of of of of Gdan´sk Gdan´sk, of of Gdan´sk , ,

[email protected] Observatory e-bulletin: Observatory and

CONTENTS EUROHEALTH Quarterly of the European Observatory on Health Systems and Policies and Systems Health on Observatory European the of Quarterly Obesity › Addressing Addressing

in Europe in

• • •

requiring bold solutions issue Abig England: in Obesity address it to policies and obesity Childhood The role of public health organisations health public of role The Eu r opean on Healt h Sy st em s andP oli cies • • • •

Public health activities in Poland in activities health Public of Republic the in obesity Addressing Tackling challenge in the obesity Italy in problem health public increasing An

Germany Moldova RESEARCH • DEBATE • POLICY •NEWS •DEBATE •POLICY RESEARCH

Volume 25 | Number 1 | 2019

OBESITY

HSPM COUNTRY NEWS COUNTRY HSPM NEW PUBLICATIONS Eurohealth Monitor Paulina INOBESITY POLAND and ADDRESSING and TACKLING Klaus May Schalkwyk van CI INOBESITY ENGLAND Eurohealth Systems and Policies Cristina Hernández-Quevedo, Gauci Charmaine CHILDHOOD IN EUROPE OBESITY Eurohealth International EUROPE IN HEALTH ORGANISATIONS PUBLIC OF ROLE THE Eurohealth Observer COMMENT EDITORS’ Angela Ciobanu Angela Walter Ricciardi

Metelska Metelska

Plümer

– AN INCREASING PUBLIC HEALTH PROBLEM HEALTH PUBLIC INCREASING –AN THE

– OBESITY IN THE REPUBLIC OF MOLDOVA OF REPUBLIC THE IN OBESITY Cristina OBESITY OBESITY and

Hernández-Quevedo Bogumiła Sutkowska Bogumiła

– PUBLIC HEALTH ACTIVITIES and : A BIG ISSUE REQUIRING BOLD SOLUTIONS BOLD REQUIRING ISSUE : ABIG CHALLENGE John Middleton John IN ITALY IN AND POLICIES TO ADDRESS IT TO ADDRESS POLICIES AND and

– Bernd Rechel Bernd Elena Azzolini Azzolini Elena and

– IN ADDRESSING OBESITY OBESITY ADDRESSING IN Michał Brzeziński, Brzeziński, Michał

Bernd Rechel Bernd IN GERMANY

– Galina Obreja Obreja Galina Eurohealth

–

— Vol.25

| No.1

| 2019 1 2 recognise and address it. to grow, some governments have started to take action to disorders can result from and prevalence obesity continues public health challenges. Since arange of serious health Currently, is one of obesity the most visible but neglected social components to consider. Everyone is affected complex condition with behavioural, psychological and a is it as challenging is obesity However, tackling a healthy life, including preventing obesity. to away as promote such in designed be could which addresses people’s living environment which approach an of taking benefits the emphasises an underestimated public health problem. He still is obesity that argues Plümer Germany, on action and bridging institutional silos. Focusing cross-departmental on more to focus need the for argue and obesity, to combatting barriers several face they as organisations health of public role the in evolution the present They decades. two over for priority anational as recognised been has obesity where of England, case the present who Middleton and by Schalkwyk article an with begins The to change. evoke approach a multisectoral require which industry, food the and media the by presented obstacles related the are discussed Also level. international and national the at burden growing this to address undertaken policies International The Europe. in concern growing of also is children in overweight and Obesity evaluation. and monitoring for efforts present implementation of obesity-related policies, then look at the level of planning, decision-making and also They debates. policy public in prominently health priority, while in others doesn’t obesity feature with some countries recognising as a obesity public contexts different the in very results The countries. of public health organisations in nine European role the review authors the Rechel, and Quevedo the In the ways they are recognising and addressing obesity. health organisations throughout Europe and examine to public we look issue, this In groups. social across and ages all across Europe, –across by obesity

EDITORS’ Policies and Systems Eurohealth COMMENT Eurohealth Observer article identifies the range of range the identifies article article by Hernández- article Eurohealth section The monitor section looks at health policy news and activities specific toundertaking combat obesity. started recently only have they where Poland and aproblem as of obesity of awareness level of alow challenge the faces that Moldova is presented Also prevailweaknesses including regional differences. several this, Despite systems. surveillance national to well-coordinated led have which efforts policy recent discuss authors The issue. health public important an represents obesity and high, is children Although Italy has lower adult obesity, in obesity Cite this as: as: this Cite Editor Williams, Gemma Editor McDaid, David Chief in Editor Merkur, Sherry enjoy! you We hope publications. new Eurohealth 2019; 25(1). 2019;

Eurohealth Observer 3

THE ROLE OF PUBLIC HEALTH ORGANISATIONS IN ADDRESSING OBESITY IN EUROPE

By: Cristina Hernández-Quevedo and Bernd Rechel

Summary: This article reviews the role of public health organisations in addressing obesity in nine European countries (England, France, Germany, Italy, the Netherlands, Poland, Republic of Moldova, Slovenia and Sweden). It finds that public health organisations contribute to issue recognition and the monitoring of obesity prevalence, but that recognition of obesity as a pressing public health challenge varies widely across countries. This is partly due to the influence of the food industry that works to undermine meaningful public health action, such as through public-private partnerships or more covert methods. Public health organisations should aim to address this interference.

Keywords: Public Health Organisations, Obesity, Overweight

Introduction Scale of the problem Obesity and overweight are among the Obesity, “the epidemic of greatest public health challenges in the the 21st century”, 2 has been recognised WHO European Region; they are among as a core challenge for health systems the main risk factors associated with the worldwide. It is on the political agenda rise of noncommunicable diseases (NCDs). of many countries and international Prevalence rates of obesity have more than organisations, as evidenced by an doubled in Europe in the last decade. This increasing number of national and article reviews the involvement of public international strategies and action health organisations in policies aiming to plans, 3 4 5 Yet, despite these initiatives, address the challenge of obesity in nine the prevalence of obesity in adults selected European countries (England, has increased in all nine countries France, Germany, Italy, the Netherlands, between 2010 and 2016 (see Figure 1). Cristina Hernández-Quevedo Poland, Republic of Moldova, Slovenia Within most countries, obesity rates tend is Research Fellow, European Observatory on Health Systems and Sweden), based on detailed country to be higher in lower socioeconomic and Policies, London School of reports that describe the policy response groups and disadvantaged areas. 6 The Economics and Political Science, and the involvement of public health prevalence of overweight and obesity UK; Bernd Rechel is Research Fellow, European Observatory organisations in different stages of the among children is another major concern, on Health Systems and Policies, policy cycle. 1 as discussed in our second contribution London School of Hygiene & to this issue. Tropical Medicine, UK. Email: [email protected]

Eurohealth — Vol.25 | No.1 | 2019 4 Eurohealth Observer

Figure 1: Age-standardised prevalence of obesity (defined as BMI ≥ 30 kg/m2) Health care costs associated with obesity in people aged 18 years and over, WHO estimates, 2010 and 2016 (%) are substantial. Treating obesity and its (selected countries) consequences is estimated to cost the English National Health Service (NHS) E £6.1 billion (approximately €7 billion) nited ingdom per year, with the wider costs of obesity to society from lower productivity and Seden higher absenteeism estimated to be Slovenia around three times this amount. 8 In Moldova Germany, the economic costs of obesity Poland (including treatment, medications, surgery, Netherlands rehabilitation and sick pay) are estimated to amount to up to €27 billion per year. 9 Italy In the Netherlands, the total direct costs Germany to the health system of those who are rance overweight are estimated at 2.2% of total health expenditure. 10 0 5 10 15 20 25 30 Total 201 Total 2010 National action plans and strategies At the national level, many policies and programmes have been adopted in recent E years in Europe, focusing on both the nited ingdom prevention of obesity and its treatment Seden and management. Almost all of the nine Slovenia countries considered in our study have Moldova adopted national strategies or programmes in this area. 1 All plans define the physical Poland and food environment as a crucial factor in Netherlands the development of obesity. Italy Germany rance 0 5 10 15 20 25 30 Men 201 Men 2010 Prevalence rates of obesity have E more than nited ingdom Seden doubled in Slovenia Moldova Europe Poland Netherlands Problem identification and issue recognition ‘‘ Italy Germany While obesity is generally perceived as a public health problem, the level of rance recognition differs between and within 0 5 10 15 20 25 30 countries, with obesity hardly appearing omen 201 omen 2010 in public policy debates in some of the countries (e.g. Moldova and Poland), but recognised as a public health priority in others. Source: 7

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Observer 5

At the national level, the Ministry of Policy formulation setting priorities and implementing Health or its subordinated agencies activities according to the needs of their In all nine countries, the Ministry of (including public health agencies such as local population. Health is responsible for the formulation Public Health England, Santé publique in of national health policies as well as France or the National Centre for Disease for defining priority areas for national Prevention and Control in Italy) are in programmes. In all nine countries, public charge of identifying problems that require health organisations provide information the government attention. In some countries, to support policy formulation. The advisory bodies to the Ministry of Health European Union (EU) contributes to food industry is were specifically created to tackle obesity, national policy formulation to tackle such as the Council for Diet, Physical obesity. Its Action Plan on Childhood one of the most Activity and Health in Poland. Obesity 2014 – 2020 serves as a guidance document for many EU member states. influential lobby Other government departments have key roles to play in obesity policy in some of Policy formulation can be intersectoral. groups the countries. In England, for example, the For example, in Slovenia, an intersectoral Department for Education, the Department One of the key actors involved in decision- working group for developing the of Culture, Media and Sport (physical making on obesity policies is the food national programme was established activity and control of advertising/ industry. In Moldova, for example, the under the Ministry of Health, comprising marketing standards), the Department for food industry is powerful and intervenes representatives from the National Institute ‘‘ Communities and Local Government, and at different levels of policymaking, either of Public Health and other ministries the Department for Environment, Food directly or through public authorities (Ministry of Agriculture and Food and Rural Affairs are involved. This is such as the Ministry of Economy and Industry, Ministry of Education and Sport, not the case in other countries such as the Ministry of Agriculture and Food Ministry of Labour, Family and Social Moldova, where a lack of intersectoral Industry. For instance, the food industry Affairs, Ministry of Economy, Ministry of collaboration has been highlighted (see tried to prevent legislation banning the Transport, Ministry of Environment, and the article by Obreja and Ciobanu in sale of unhealthy foods within and around Ministry of Defence). this issue). schools; it also intervenes every time new initiatives emerge that may affect The regional or local level is responsible At regional or local level, local authorities their commercial interests. In Poland, for the formulation of regional or local tend to be responsible for assessing the the food industry is one of the most policies and for the implementation of health needs of the population, including influential lobby groups, with well- national policies on obesity. In Italy, for with regard to obesity, and for organising organised representation and significant example, the central government sets the and funding effective local interventions financial resources. main policy direction, while the regions (e.g. regional and local self-governments are responsible for the formulation of in Poland, municipalities in Sweden, and their respective regional policies and for Policy implementation regional health agencies in France). the organisation of regional public health Responsibility for the implementation of services and health care. While in some countries (such as obesity policies can lie at the national or England), non-governmental organisations regional level. Public health organisations (NGOs) play a strong role in lobbying, Decision-making are often given a leading role in either policy advocacy and services on food, overseeing implementation or directly Decision-making on obesity-related fitness and healthy environments, in implementing policies themselves. policies and programmes takes place others (such as Poland), they have little both at the national and regional level, impact on problem identification and issue In some countries, the Ministry of involving different levels of government. recognition. Other important actors are Health and the regions (e.g. France, As a rule, public health organisations international organisations and scientific Italy), county councils or municipalities are not involved in the decision-making or professional associations. International (e.g. Sweden) share responsibility for process. In England, for example, local commitments have been crucial for some policy implementation. In other countries, authorities are free to determine local countries to develop their strategies to responsibility for implementation of policies, based on local needs. In Slovenia, deal with obesity, such as for Moldova. national health policies rests with the the municipalities are the local authorities Furthermore, a number of institutions are local level, such as in the Netherlands and responsible for decision-making at the part of WHO’s European network for the Poland. However, responsibilities are not local level and can approve regional promotion of health-enhancing physical always clearly delineated or coordinated programmes on food and nutrition, activity (HEPA). 11 across different levels. addressing specifically obesity. In France, the regional health agencies have considerable autonomy in public health,

Eurohealth — Vol.25 | No.1 | 2019 6 Eurohealth Observer

A large range of other actors are involved Conclusion and outlook References

in the implementation of obesity policies, 1 Countries vary considerably with Rechel B, Maresso A, Sagan A, et al. (eds.) including other public authorities, NGOs, regard to whether and how public health The role of public health organizations in addressing the media, but also the food industry. In public health problems in Europe. The case of obesity, organisations are involved in addressing Italy, for example, formal mechanisms alcohol and antimicrobial resistance. Health Policy the burden of obesity. Not all nine for collaboration are established with Series 51. Brussels: European Observatory on Health countries have relevant national health Systems and Policies, 2018. Available at: http://www. the National Institute of Health (ISS), policies in place, with Sweden being a euro.who.int/__data/assets/pdf_file/0011/383546/ AGENAS, the National Medicines Agency notable exception. A challenge, pointed hp-series-51-eng.pdf?ua=1 (Agenzia Italiana del Farmaco), the out in Italy and Poland, is that the problem 2 WHO. 2000 World Health Report. Geneva: World Ministry of Education, University and of obesity is still poorly recognised by Health Organization, 2000. Research (e.g. Keep an Eye on Health, health professionals and policymakers. In 3 HBSC), the European Network for the WHO. Global strategy on diet, physical activity and some countries, obesity is mainly seen as health. Geneva: World Health Organization, 2004. Promotion of Health-enhancing Physical an individual lifestyle problem and not as 4 Activity – HEPA, the Department of Youth WHO Regional Office for Europe. Second Member a population health problem – a stance that Affairs, the Ministry of Agriculture (e.g. States consultation for the Ministerial Conference is strongly promoted by the food industry. on Counteracting Obesity 2006. Copenhagen: WHO for the development of dietary guidelines), In some cases, the industry and the private Regional Office for Europe, 2006. the food industry, trade and food chain sector prevent problem identification 5 associations, and the National Committee European Commission. EU Action plan and issue recognition. One of the main on childhood obesity 2014–2020. Brussels: for Dietetics and Nutrition. In some other challenges to implementation of obesity European Commission, 2014. Available at: countries, the food industry is also heavily policies is funding. In Moldova, for https://ec.europa.eu/health/sites/health/files/ involved in the implementation of obesity- nutrition_physical_activity/docs/childhoodobesity_ example, during the period of 2014 – 2015, related policies. In Poland, for example, actionplan_2014_2020_en.pdf no funds were allocated for implementing the food industry closely cooperates with 6 the National Food and Nutrition Magnusson M, Sørensen TI, Olafsdottir S, et al. the Ministry of Health, as well as with the Social inequalities in obesity persist in the Nordic Programme. National Food and Nutrition Institute and region despite its relative affluence and equity. the Chief Sanitary Inspectorate. Curr Obes 2014;3:1 – 15. 7 WHO Europe. Health for All Database [online database]. Copenhagen: WHO Regional Office for Monitoring and evaluation Europe, 2018. Available at: http://www.euro.who.int/ hfadb Monitoring and evaluation are most commonly done with regard to obesity obesity is mainly 8 Public Health England. Public Health Profiles. prevalence and most of the countries London: Public Health England, 2017. Available at: https://fingertips.phe.org.uk/ analysed (except Sweden and Poland) seen as an have mechanisms in place for monitoring 9 Effertz, T. Die volkswirtschaftlichen Kosten national obesity levels. Public health individual lifestyle gefährlichen Konsums. Eine theoretische und empirische Analyse für Deutschland am Beispiel agencies tend to play a leading role Alkohol, Tabak und Adipositas [The economic costs of in monitoring obesity prevalence, but problem dangerous consumption. A theoretical and empirical other actors are also important, such as analysis for Germany using the examples of alcohol, Worryingly, the food industry seems national statistical institutes or NGOs. tobacco and obesity]. Analyse des Rechts. Law and to have a major influence on obesity The monitoring and evaluation of national Economics, Band 15. Frankfurt am Main: Peter Lang, policies in several countries in Europe 2015. public health policies on obesity is less and this might counteract any influence 10 well developed, but in those countries ‘‘ Panhuis-Plasmans M in ‘t, Luijben G, public health organisations have. The where it exists, public health agencies Hoogenveen R. Zorgkosten van ongezond gedrag use of public-private partnerships in [Health care costs of unhealthy behaviour]. Bilthoven: also tend to have a leading role. In France, countries such as England, Germany and RIVM, 2012. for example, this role falls in part to the the Netherlands can pose a challenge 11 French Institute for Prevention and Health WHO. Report of the commission on ending to enacting and implementing effective childhood obesity. Geneva: World Health Education (Institut national de prevention obesity policies and public health Organization, 2016. Available at: http://apps.who.int/ et d’éducation pour la santé, INPES), now organisations need to be wary of overt and iris/bitstream/10665/204176/1/9789241510066_ part of Santé publique France. Since the eng.pdf covert interference from industry in public early 1990s, INPES, in cooperation with health policies. many institutions, has been conducting a series of surveys which examine health behaviours and attitudes.

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth International 7

CHILDHOOD OBESITY IN EUROPE AND POLICIES TO ADDRESS IT

By: Cristina Hernández-Quevedo, Charmaine Gauci and Bernd Rechel

Summary: Childhood overweight and obesity in Europe have taken on dramatic dimensions, with one in three 11-year-olds in the WHO European Region estimated to be overweight or obese in 2014. Boys are at higher risk than girls and there is a pronounced social gradient, with higher rates among the most disadvantaged groups. A range of policies at national and international level have been instigated to address this challenge. This article describes some promising examples, as well as some of the obstacles that will need to be overcome.

Keywords: Obesity, Overweight, Childhood, Intersectorality, Food Industry

Introduction (COSI) confirm the gender gap in obesity, but also show that southern European Increasing childhood obesity has been countries have the highest rates of recognised as an important public childhood obesity for six to nine year-olds health issue in Europe, as overweight in Europe. Cyprus, Greece, Italy, Malta, or obese children are likely to become and Spain have the highest obesity rates overweight or obese adults. They are for both boys (rates from 18% to 21%) and more likely to suffer serious health and girls (from 14% to 19%), while rates are social consequences, including a higher much lower in Denmark, France, Ireland, risk of premature death and disability in Latvia and Norway (from 5% to 9% for adulthood. Moreover, higher obesity rates both boys and girls). 3 are usually found in children from lower socioeconomic groups and disadvantaged Country-specific evidence included areas, illustrating the equity dimension of in Rechel et al. (2018) 1 suggests that obesity. 1 childhood obesity is unequally distributed within countries. For example, the Cristina Hernández-Quevedo is Research Fellow, European Scope of the challenge prevalence of childhood obesity is twice Observatory on Health Systems as high in the most deprived areas in Data from the 2013/2014 cross-national and Policies, London School of England and Germany, compared to the Economics and Political Science, survey on Health Behaviour in School- least deprived areas. In Sweden, growing UK; Charmaine Gauci is Director aged Children (HBSC) indicate General/ Superintendent of Public social inequalities are a key contributor to worryingly high obesity rates in 15-year- Health, Ministry for Health, Malta; rising overweight and obesity rates, given old boys and girls in a number of countries Bernd Rechel is Research Fellow, that unhealthy nutrition and low levels of European Observatory on Health (see Figure 1). They also show gender physical activity are more prevalent among Systems and Policies, London differences, with 15-year old boys more School of Hygiene & Tropical lower educated groups. Even countries likely to be overweight or obese. 2 The Medicine, UK. Email: C.Hernandez- with low levels of obesity, such as France, [email protected] latest data (2015–2017) from the WHO have high social inequalities, with an Childhood Obesity Surveillance Initiative

Eurohealth — Vol.25 | No.1 | 2019 8 Eurohealth International

Figure 1: Self-reported overweight (including obesity) among 15-year-olds, boys and girls, 2013 – 2014

20 Percentage 15

Italy Malta Spain EU27 Austr ia Croatia Es tonia Finland France Greece Iceland Ireland Latvia Poland Belgium Bulgaria Denmark Germany Hunga ry Lithua nia Norway Por tug alRomania Slovenia Sweden Luxembourg Netherlands Czech Republic Slovak Republic United Kingdom

Boys Girls Total

Source: 2 Note: No data available for Cyprus.

obesity prevalence of 1.3% in children obesity from the 2016 report include: Italy, Poland, the Republic of Moldova, from the upper class and 5.8% in children promoting intake of healthy foods; Slovenia, Sweden, the Netherlands) 1 from working class families. 1 promoting physical activity; preconception found that almost all of them had adopted and pregnancy care; improving early national strategies or programmes in this childhood diet; and promoting physical area. This also applies to Malta, which had International responses activity and healthy nutrition for school- placed childhood obesity as a priority area A range of international and national aged children. 5 during its European Presidency in the first responses have been developed to tackle half of 2017. 7 childhood obesity. In 2013, the WHO At the European Union (EU) level, a Plan World Health Assembly adopted the of Action against childhood obesity was In the Republic of Moldova, for example, Global Action Plan for the Prevention adopted in 2014 for the period 2014–2020, the National Health Policy (2007–2021) and Control of Non-communicable which covered eight focal areas, including was the first policy document that Diseases 2013–2020, to tackle preventable family, environment and research. The addressed obesity as one of the main chronic diseases, by stopping the increase Plan recognised the increase in obesity health determinants and called for in obesity (including among children) and overweight in adults, children and intersectoral, whole-of-government and diabetes. In September 2015, the young people in the EU and aims to: and whole-of-society actions to prevent countries of the WHO European Region demonstrate the shared commitment of it. In 2014, the Moldovan Government adopted the Physical Activity Strategy EU member states to addressing childhood endorsed the first National Food and for the WHO European Region 2016– obesity; set out priority areas for action; Nutrition Programme for 2014–2020 2025, oriented towards both children develop a possible toolbox of measures and the Action Plan for 2014–2016. One and adults, with a specific focus on for consideration; and propose ways of specific objective of this programme is multisectoral collaboration. 1 The WHO’s collectively keeping track of progress. to halt the increase in obesity prevalence European Food and Nutrition Action The Action Plan recognises and respects among children and adults. Plan 2015–2020 aims to reduce the burden member states’ roles and freedom of of overweight, obesity and malnutrition action. 6 In England, an action plan on childhood and to halt the increase in overweight obesity was published in 2016, but largely among children under five years of age. 4 shied away from regulatory measures. National responses Other international responses include However, in recognition of the fact that the high-level Commission on Ending At the national level, many policies teenagers in England are the biggest Childhood Obesity established by the and programmes have been adopted in consumers of sugar-sweetened drinks in former WHO Director-General to better recent years in Europe, aiming to prevent Europe, an introduction of a tax on sugary inform a comprehensive response, meeting obesity and improve its treatment and drinks was announced in March 2016 for the first time in 2014. Its latest policy management. A review of nine European and came into force in April 2018. The recommendations to address childhood countries (England, France, Germany, levy is applied to manufacturers, with

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth International 9

Strategy 2017/18 – 2022/23 has, as one of its goals, the promotion of a healthy, Box 1: Tackling children obesity in Malta balanced diet among children and parents. In particular, it aims to change the eating The increasing prevalence of overweight and obesity especially in children is a habits of children by increasing the share major public health issue in Malta. It has been estimated that 40% of school-aged of fruit and vegetables and the intake children in Malta are overweight or obese. Various actions have been put in place of milk. to tackle this problem.

A. Use of legislative instruments for noncommunicable diseases

Considering the fact that children spend a lot of time in school, the school setting was a particular focus. In 2016, the government of Malta enacted the “The growing Healthy Lifestyle Promotion and Care of Non-Communicable Diseases Act” which aimed to establish and ensure an inter-ministerial lifecourse approach favouring social inequalities physical activity and healthy balanced diets to achieve healthy lifestyles and reduce noncommunicable diseases in all age groups. 8 An intersectoral Advisory are a key Council was set up that recommended various measures. One of the initiatives the Advisory Council developed was outlining a legislative tool for schools. A situation contributor to analysis was carried out on school environments, showing that there was a need for strengthening the school environment to help the whole school community to rising overweight adopt healthier patterns of living by encouraging consumption of healthy foods and limiting the availability of products high in salt, sugar and fats. and obesity rates

In August 2018, the Maltese government issued subsidiary legislation to regulate A multisectoral approach to tackle the food being sold and provided by schools, implement programmes for healthy childhood‘‘ obesity eating, ban advertising or sponsorship of unhealthy foods, and ensure provision of drinking water in schools. The Advisory Council developed criteria for healthy foods In some countries, reducing childhood which were based on the WHO nutrient profiling model. Random inspections are obesity is a task shared by the Ministry carried out by specifically trained environmental health practitioners. of Health with the Ministry of Finance (responsible for taxes for food high in B. Public Procurement of Food for Health – technical report on the saturated fat and sugary soft drinks), school setting the Ministry of Education (for school The Maltese Presidency of the Council of the EU selected childhood obesity as curricula, healthy nutrition education one of its priority areas. One of the gaps identified across EU member states was and physical activity), the Ministry of in outlining food procurement tenders for schools that promoted healthy eating. Agriculture and Food Industry (for free The major obstacle was in the translation of school food standards into adequate school fruit and vegetable schemes and procurement contract language. To ensure the smooth implementation of public sustainable healthy food supplies), and the procurement of healthy food, it is important to set clear specifications of the foods sports sector, among others. For example, and food services to be procured. in England, government departments other than health have key roles to A technical report on public procurement guidelines for healthy food within school play in obesity policy, including the settings was developed with support from the Joint Research Centre and experts Department for Education, the Department from EU member states. It is intended as a practical tool for those who purchase of Culture, Media and Sport (physical food and food-related services for schools at national, regional or local level, as activity and control of advertising / well as for health and nutrition awareness and capacity building. The report details marketing standards), the Department for a range of options and considerations that EU member states may wish to use Communities and Local Government, and and adapt for their specific context. Adaptation to the national and local context the Department for Environment, Food through consultations with all relevant stakeholders ensures that the legal, cultural and Rural Affairs. This is not the case in and economic context are taken into consideration. 9 other countries, such as the Republic of Moldova, where a lack of intersectoral collaboration has been identified. drinks with more than 8g per 100ml via legislation and to introduce a front-of- facing a tax rate equivalent to 24p (€0.28) pack traffic light label, although this has The media per litre while those containing 5 – 8g of remained a voluntary scheme. sugar per 100ml, a slightly lower rate of In some countries, television, radio, tax, of 18p (€0.21) per litre. Furthermore, In Poland, a 2016 Regulation by the telecommunications and wireless the United Kingdom was one of the first Minister of Health addressed groups of communication services are regulated, countries to restrict marketing to children food intended for sale to children and setting standards for advertising to protect adolescents in the education system. children from the overconsumption of In addition, the School Programme foods high in fat, salt and sugar. For

Eurohealth — Vol.25 | No.1 | 2019 10 Eurohealth International

example, in the United Kingdom, the in response to WHO’s call for the food and which can be extended to other national Office of Communications industry to take an active voluntary role in sectors. Progressive and targeted public (Ofcom) is the independent regulator of tackling obesity. The programme has since procurement of healthy food can reward television, radio, telecommunications and been expanded to the Czech Republic companies that provide nutritionally wireless communications services and and Poland. 10 balanced meals and food products, sets standards for television advertising. prompting innovation, food reformulation Its regulatory objectives include the In the United Kingdom, as mentioned and social responsibility to achieve better protection of children under the age of 16 above, Childhood obesity: a plan for diets and positively impact public health. from the overconsumption of foods high action, was adopted in August 2016, in fat, salt and sugar. Since 2006, Ofcom covering the period 2016–2026. Its key References does not allow TV advertisements for anticipated actions include the introduction such foods to be shown in or around of a levy on the soft drinks industry 1 Rechel B, Maresso A, Sagan A, et al. (eds.) programmes specifically made for children and the encouragement of the foods and The role of public health organizations in addressing public health problems in Europe. The case of obesity, (which includes preschool children) or drinks industry to voluntarily reduce alcohol and antimicrobial resistance. Health Policy in or around programmes of particular the sugar content of their products. The Series 51. Brussels: European Observatory on Health appeal to children under 16. The United overall emphasis on voluntary action and Systems and Policies, 2018. Available at: http://www. Kingdom’s statutory ban on television the failure to include further restrictions euro.who.int/__data/assets/pdf_file/0011/383546/ advertising of foods high in fat, sugar to advertising aimed at children in the hp-series-51-eng.pdf?ua=1 and salt during children’s programming action plan, however, were criticised by 2 Inchley J, Currie D, Young T, et al. Growing up was a world first. It broke new ground for public health experts and attributed to unequal. HBSC 2016 Study (2013/2014 survey). imposing more stringent conditions on the sustained lobbying by industry against Health Policy for Children and Adolescents, No. 7. Copenhagen: WHO Regional Office for Europe, food and drink industries. regulatory measures. 2016. Available at: http://www.euro.who.int/en/ publications/abstracts/growing-up-unequal.-hbsc- 2016-study-20132014-survey Future challenges 3 WHO Europe. Childhood Obesity Surveillance Tackling childhood obesity is a very Initiative. Highlights 2015 – 2017. Copenhagen: complex issue. The most progress has WHO Regional Office for Europe, 2018. Available imposing more been made on topics such as issuing at: http://www.euro.who.int/__data/assets/ nutritional guidance, encouraging pdf_file/0006/372426/WH14_COSI_factsheets_ v2.pdf?ua=1 stringent breastfeeding, banning vending machines and encouraging physical activity in 4 WHO Europe. European Food and Nutrition schools. EU member states are waiting Working Plan 2015 – 2020. Copenhagen: WHO conditions on Regional Office for Europe, 2014. Available at: for the revision of the audio-visual media http://www.euro.who.int/__data/assets/pdf_ the food and services directive (AMSD), which also file/0008/253727/64wd14e_FoodNutAP_140426.pdf regulates advertising. Advertising, not 5 WHO. Report of the Commission on Ending only on TV, but also through tablets and drink industries Childhood Obesity. Geneva: World Health mobile phones, has a significant impact Organization, 2016. on children. The role of the food industry 6 European Commission. Study on the ‘‘ implementation of the EU Action Plan on Childhood In some of the countries of the WHO What is worrying is that, despite increases Obesity 2014 – 2020. Brussels, 2017. European Region, the food industry has in prevalence, there are still countries in 7 Calleja A, Gauci C. Childhood obesity: a priority considerable influence, both formal and Europe in which childhood obesity has not area of the Maltese presidency of the Council of informal, into policies aimed to tackle entered public health debates. Among the the European Union. Journal of the Malta College of childhood obesity. In the Republic of many areas of potential action, in some Pharmacy Practice 2017;23:31 – 4.

Moldova, for example, the food industry countries there is a lack of resources for 8 Act No. III of 2016 – Healthy Lifestyle exerts influence through the Ministry of the implementation of publicly financed Promotion and Care of Non-Communicable Economy and the Ministry of Agriculture education programmes for children Diseases Act, 15 January 2016. Valletta, Malta: and Food Industry. It attempted to block and young people dedicated to obesity. Department of Information. Available at: http:// legislation banning the sale of unhealthy Constructively engaging with the food www.justiceservices.gov.mt/DownloadDocument. aspx?app=lp&itemid=27263&l=1 foods within and around schools and industry, including through regulation, intervenes every time new initiatives taxation and market mechanisms, is 9 Subsidiary legislation 550.01 procurement of food emerge that may affect its commercial another challenge. for schools regulations, 10th August, 2018. Valletta, Malta: Department of Information. Available at: http:// interests. In Poland, the food industry is www.justiceservices.gov.mt/DownloadDocument. one of the most influential lobby groups, The case of Malta highlights some of the aspx?app=lom&itemid=12892&l=1 with well-organised representation and areas where progress can be made through 10 Choices programme web site, 2019. Available at: significant financial resources. Poland multiple approaches. The development http://www.choicesprogramme.org/ is also one of the participating countries of healthy food procurement guidelines in the Choices Programme, an initiative for schools can be used to initiate change introduced in the Netherlands in 2006 across EU member states in schools

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 11

OBESITY IN ENGLAND: A BIG ISSUE REQUIRING BOLD SOLUTIONS

By: May CI van Schalkwyk and John Middleton

Summary: Since 1998, when England recognised obesity as a national priority, a range of policies and strategies have been developed with concomitant evolution in the role of public health organisations. However, progress in addressing obesity – which continues to be a leading cause of ill-health and inequalities – has been minimal, hindered by siloed working, focused on individual responsibility, and lacking in much-needed systems thinking and regulation. Until recently, there has been political reluctance to address commercial vested interests in the food and related sectors, who profit from the obesity epidemic. A step change is needed to achieve meaningful impact.

Keywords: Obesity, Overweight, Inequalities, Public Health

Scale of the problem In 2007, the then Government’s Foresight report, predicted that greater than half of Tackling the obesity epidemic is one of the UK adult population could be obese the greatest public health challenges of by 2050, with a concomitant doubling the 21st century, affecting populations of the cost to the health service. Wider globally, irrespective of level of income societal and productivity costs were or development. Nations around the estimated to reach almost £50 billion per world continue to struggle to address year (at 2007 prices, about €55 billion). 2 high obesity rates, and the consequent Furthermore, obesity remains an important detrimental health impacts, in children and driver, and result, of social and health adults of all ages. The picture in England inequities. is no exception. The Health Survey for England (2016) estimated that 26% of Obesity has been recognised as a national adults were obese, almost double the level priority since the late 1990’s. Public recorded in 1993 (15%). 1 According to interest, as evidenced by media coverage, May CI van Schalkwyk is a Public the National Childhood Measurement has accelerated since then, and it remains Health Registrar and Academic Programme 2016 – 2017, approximately Clinical Fellow at Imperial a topical agenda. Recent media coverage 10% of children in their reception year College London, London, UK; predominantly frames obesity in terms John Middleton is President of the (aged 5 – 6 years) and 20% in year 6 of “self-control” with an emphasis on UK Faculty of Public Health and (aged 10 – 11 years), are obese. 1 Between President Elect of the Association personal responsibility and medical 2015 and 2017, hospital admissions of Schools of Public Health in the interventions. 3 The Foresight report recorded as directly attributable to European Region at the United identified parental obesity as the most Kingdom Faculty of Public Health, obesity increased by 8%, totalling 10,705 London, UK. Email: m.van- significant predictor of childhood obesity (with 72% being female). 1 [email protected] and promoted the “calories in – calories out” model as a means of conceptualising

Eurohealth — Vol.25 | No.1 | 2019 12 Eurohealth Systems and Policies

the problem. 2 This framing has been obesogenic environments and sedentary doors. Subsequent evaluations have found favourable to industries who produce high- lifestyles, which in turn prompted the 2008 the Public Health Responsibility Deal as sugar products, allowing them to assert Department of Health initiative on Healthy being ineffective and flawed. 7 – 9 that there are “no bad foods, only bad Towns. This focused on healthy town diets”. There has been a renewed interest planning that promoted active travel and Childhood obesity: a plan for action, in the theory that sugar plays a key role in accessible physical activity. Additionally, an action plan for tackling childhood the causation of obesity. Sugars, which are broadcasting restrictions were introduced obesity, was adopted in August 2016, not as high calorie as fats, contribute to in 2007, limiting exposure of children spanning 2016 – 2026. Its overarching obesity substantially through their impact to television advertising of foods high in emphasis on voluntary action and omission on insulin sensitivity. 4 A report by Public fat, saturated fat, salt and sugar. In 2008, of further restrictions to advertising aimed Health England (PHE) on the evidence for an ambitious cross-government strategy, at children were met with widespread action further encouraged the view that which set out to ensure that everyone was criticism by the public health community sugar consumption was a key component able to achieve and maintain a healthy and was attributed to continued industry of obesity and recommended control weight, was adopted. The UK’s proposed lobbying against regulation. Although measures and further research of sugar’s statutory ban on television advertising of PHE had endorsed a sugar tax and role in obesity and diabetes. 5 foods high in fats, sugar and salt during reductions in the sugar content of children’s programming represents a world foods (included in the plan), it had also first, setting a precedent for imposing advocated for more effective measures Policies and programmes more stringent conditions on the food and such as banning price-cutting promotions The Health of the Nation, England’s drink industries. 6 of junk food in supermarkets, banning the first health improvement strategy, was promotion of unhealthy foods to children launched in 1992. This report made very The formation of the coalition government in restaurants, cafes and takeaways, little mention of obesity, but by 1998, (between 2010 and 2015) saw the and further restricting advertising of when the Public Health Green Paper, dissipation of any central government unhealthy food to children on TV, social Saving Lives: Our Healthier Nation pressure to control irresponsible fast media and the Internet. As part of this was released, obesity represented a new food advertising. Radical organisational strategy, a Soft Drinks Industry Levy priority. Importantly this paper outlined changes, including the transfer of public (SDIL), or “sugar tax”, came into effect the need to adopt a life course approach health departments to local authorities in the UK in April 2018, aiming to to address such factors as smoking, from 2013, exacerbated uncertainties curb sugar consumption by influencing poor nutrition, obesity and physical around investment in obesity programmes manufacturers to reformulate brands high inactivity, and fundamentally recognised and it became difficult to plan and develop in sugar and avoid paying the levy. This inequalities in the distribution of adverse new services, or advocate for national resulted in 50% of soft drink products behaviours and that action directed at policy changes. Furthermore, while certain having their sugar content reduced even the underlying social, economic and public health services were mandated to prior to the levy’s implementation. environmental conditions was required. be provided or commissioned by the local While this link among obesity, health authority under the Health and Social Care In her 2018 annual report, England’s variables and socioeconomic inequality Act 2012, obesity prevention and weight Chief Medical Officer (CMO), called was echoed in the Wanless Report (2002), management were omitted. upon the UK Government to extend the the publication of the government White levy to other food products that are high Paper Choosing health: making healthy Alongside the reforms moving towards in trans fats, salt and sugar to address choices easier (2004) would see a focus the Act, the Public Health Responsibility noncommunicable diseases. The National on individual behaviour change and the Deal was introduced in 2011. The Health Service (NHS) forward view, role of primary care trusts in reducing Responsibility Deal was intended to be like the NHS five year forward view inequalities. The White Paper also set a public-private partnership between before it, similarly focuses on prevention. out a Public Service Agreement (PSA) on government, industry and public health However, this latest strategy frames child obesity incorporating measures that organisations to co-develop interventions prevention within the context of informing aimed to curb the year-on-year increase in by industry to demonstrate their corporate and supporting individual choice and obesity rates among 11-year-olds by 2010. social responsibility and promote health. responsibility to adopt healthy lifestyles It also introduced “health trainers” aimed Multiple public health lobby groups aided by technological solutions. This at supporting individuals, particularly refused to take part, and many withdrew would seem at odds with the current stance those living in poorer communities with subsequently, as it became apparent that taken by the CMO who stated in late 2018: “lifestyle problems”, an approach drawn government commitments to legislate • “We have a system at the moment where from the “personal trainer” model within on plain packaging for cigarettes, and people are benefiting from selling the private sector. a minimum unit price for alcohol, unhealthy foods and then not paying for were shelved. Adoption of meaningful the harm that that’s doing … to us as a As mentioned, the Foresight report raised interventions by government, such society and the NHS.” obesity even further up the national as effective legislation, taxation and agenda and detailed the complexities regulation was successfully prevented by of factors driving obesity, including industry lobbying conducted behind closed

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 13

• “We have an unbalanced societal and year 6 (aged 10 – 11 years) health priority in the 1990’s, none have environment. It’s not easy to make documenting overweight and obesity been translated into the real-world healthy choices. We’ve got to make it levels in primary school aged children. changes that are ultimately needed. easier.” 10 The data are used to calculate a body Industry continues to benefit from mass index (BMI) centile. These data close relationships with government, Role of public health organisations can be used to support local public health allowing it to influence policy content and initiatives and inform the local planning implementation which, in combination Setting of public health policy in England, and delivery of services for children. Data with ineffective voluntary targets, like including that pertaining to obesity, is the from the NCMP 2006/2007 to 2014/2015 those set out in the Responsibility Deal, responsibility of the Secretary of State are now available online as a child hinders meaningful progress. This has for Health and the Department of Health obesity data tool for local authorities. been accompanied by the adoption of a and Social Care. PHE is the national This tool also includes inequalities data policy stance, by successive governments, public health body charged with policy and information on the density of fast predominantly centred on personal formulation and implementation, acting food outlets. These data were previously responsibility and the blaming of as an advisory body to the Department collected and analysed by the National individuals for their poor choices. of Health and Social Care on policy Obesity Observatory. The Observatory direction, as well as providing advice is now part of PHE’s knowledge and The precariousness of the current political on policy and strategy implementation intelligence function, which assimilates environment in the UK and the single to local authorities, the NHS and others. evidence into practical analytical and focus on Brexit, continue to leave little PHE develops, translates and assembles evidential tools for the local system, space for debate and focus on other issues, evidence, and oversees surveillance data including the dataset for local authorities particularly ones as complex and heated for England on all aspects of obesity. known as Fingertips. Additionally, Public as obesity. However, it is exactly for these Informed by consultation with Directors Health Outcomes Framework profiles are reasons that we cannot be complacent. of Public Health on what the priorities available for the nine regions of England. Maintaining momentum, and public and should be for PHE to tackle obesity in These collate local authority indicators political interest are paramount to ensure local communities, PHE have previously for physical activity, fruit consumption, any gains are not lost and that real change developed an obesity workplan and breast-feeding rates, life expectancy and is delivered to the English population. published advice on early approaches to diet-related cancers. tackling obesity. References The English public health community On the ground, local authorities are 1 plays an important role in researching and NHS Digital. Statistics on Obesity, Physical afforded the freedom to implement voicing the co-benefits of adopting an Activity and Diet – England. 2018. Available at: local policies. Local government can https://bit.ly/2K96oAn upstream and broader systems approach strive to address obesity and associated 2 to obesity. Cross-departmental action Butland B, Jebb S, Kopelman P, Mcpherson K. issues through its management of public is arguably pivotal to tackling leading Tackling Obesities: Future Choices – Project Report health services, environmental licensing, 2nd Edition. Available at: www.foresight.gov.uk drivers of ill-health and health inequities, consumer protection and social care, as 3 such as obesogenic environments and Atanasova D, Koteyko N. Obesity frames and well as through forming partnerships with systems that concomitantly contribute counter-frames in British and German online health and community organisations. The newspapers. Health 2017;21(6):650 – 69. to other pressing issues, such as climate transfer of public health responsibility 4 change and air pollution. Public health Lustig RH. Fat Chance: The Hidden Truth about to local authorities since 2013 has meant professionals and institutions play a key Sugar, Obesity and Disease. New York: Harper Collins, that they provide or commission services 2014. role in advocating for interventions that such as weight management and local 5 maximise the health co-benefits and in Public Health England. Sugar Reduction The preventive campaigns and services. While helping to bridge institutional silos. Evidence for Action. 2015. Available at: https://bit. public health agencies are vital to their ly/2O3GkIz local communities, their ability to act 6 HM Government. Childhood Obesity: A Plan for and be accepted in local partnerships is Conclusion Action Chapter 2. 2018. Available at: https://www. variable and precarious, depending on how gov.uk/government/publications/childhood-obesity- Obesity remains a major public health their host councils view their relevance a-plan-for-action-chapter-2 issue in England and indeed the world. and importance, and on other competing 7 While it has received much public and Bryden A, Petticrew M, Mays N, et al. Voluntary local priorities. agreements between government and business – political attention, arguably little has A scoping review of the literature with specific been achieved in having a meaningful PHE monitors obesity prevalence and reference to the Public Health Responsibility Deal. impact on an issue that continues to drive Health Policy 2013;110(2 – 3):186 – 97. other relevant lifestyle factors, including ill-health and inequalities, simultaneously 8 dietary habits, through the National Diet Bekker MPM, Mays N, Kees Helderman J, et al. placing a substantial burden on the NHS and Nutrition Survey. The National Child Comparative institutional analysis for public health: and compromising economic productivity. governing voluntary collaborative agreements for Measurement Programme (NCMP) 1 Despite the plethora of policies and public health in England and the Netherlands. measures the height and weight of children strategies that have been produced since Eur J Public Health 2018;28(suppl_3):19 – 25. in school reception year (aged 4 – 5 years) obesity gained recognition as a national

Eurohealth — Vol.25 | No.1 | 2019 14 Eurohealth Systems and Policies

9 Petticrew M, Eastmure E, Mays N, et al. OBESITY – AN The Public Health Responsibility Deal: how should such a complex public health policy be evaluated? J Public Health 2013;35(4):495 – 501.

10 INCREASING PUBLIC Lacobucci G. Tax foods high in sugar and salt to improve nation’s health, CMO urges. BMJ 2018;363:k5411. HEALTH PROBLEM IN GERMANY

By: Klaus D. Plümer

Summary: Obesity is a growing public health problem in Germany. The share of adults with obesity almost doubled between 1990 and 2015, and lies above the OECD average. A social gradient in obesity prevalence exists, with overweight and obesity occurring more often in people with a low socioeconomic status. In 2008, the nationwide Initiative to Promote Healthy Diets and Physical Activity (IN FORM) was set up but did not reverse the trend. The 2015 Act to Strengthen Health Promotion and Prevention addresses explicitly living- environment intervention measures in relevant settings as a promising approach.

Keywords: Obesity, Overweight, INFORM, Public Health Service, Setting Approach, Germany

Scale of the problem in 2015 well above the OECD average of 19.5%, ranking in the top ten of obese Obesity is an ongoing issue on the health countries. 1 agenda in Germany, with cyclical debates about healthy and unhealthy diets in the The third health report of the Robert Koch media. Diets are a domain of dieticians, Institute ‘Health in Germany’ (2015) nutritionists and sports scientists in summarised the most important results on conjunction with general practitioners and overweight (defined as BMI ≥ 25 kg/m2) health scientists yet the recommendations and obesity (defined as BMI ≥ 30 kg/m2): given can be of dubious value and have very little effect. Several intervention • Almost 25% of adults and about 6% of measures over recent years have not been children and adolescents are severely Klaus D. Plümer is an independent able to reverse the steadily increasing overweight (obese). public health and health promotion trend of overweight and obesity. consultant. He has formerly worked • Especially among young men, the at the Academy of Public Health proportion of obese adults has risen in Düsseldorf, Germany and is According to OECD data, the share of significantly in the last 15 years. currently EUPHA Pillar Advisor for adults with obesity in Germany almost Training, Education and Life-long Learning. Email: klauspluemer@ doubled between 1990 and 2015, from 12% gmail.com to 23.6%, and was – for the first time –

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 15

• In adolescents, obesity prevalence A range of other federal policies have Role of public health organisations has increased since 2006, while the an impact on overweight and obesity, Public health services (Öffentlicher prevalence of overweight has remained sometimes in line with a Health in All Gesundheitsdienst, ÖGD) in Germany the same. Policies (HiAP) approach. Some of the have played no major role in putting most important are the National Cycling • The lower the socioeconomic status, obesity on the political agenda. They Plan 2020, 5 which promotes cycling, the more often overweight and mainly deal with obesity from three walking and the use of public transport, obesity occur. specific perspectives: in child and and two programmes of the Federal Centre adolescent health services; as case-based In Germany, 53% of women and 67% of for Health Education (FCHE): Gut Drauf nutrition counselling; and when hiring men are overweight, while 24% of women (Feeling Well), which aims to improve staff in the public service, particularly and 23% of men are considered obese. the health of children and adolescents regarding permanent employment. The prevalence of obesity in the adult aged 12 to 18 years, and Tutmirgut population has remained stable at a high (Good For Me), aimed at children aged 5 A National Action Plan against Obesity level over the last decade, but over the to 11 years. was presented to the Federal Ministry of same period the incidence of obesity has Health (BMG) and the Federal Ministry increased, especially among young men. 2 of Food, Agriculture and Consumer Protection (BMELV) in March 2007, It has been estimated that the economic most of following an initiative by the German costs of obesity in Germany (including Obesity Society. 9 The corresponding treatment, medications, surgery, the programmes National Action Plan for the Prevention rehabilitation and sick pay) amount to up of Poor Dietary Habits, Lack of Physical to €27 billion per year. 3 Most of these lacked proper Activity, Overweight and Related costs are borne by the Statutory Health Diseases in 2013 makes explicit reference Insurance funds. evaluation to overweight in its title and also discusses obesity. Many programmes that tackle obesity have Policies and programmes been set up at the local level, and mostly IN FORM shies away from regulatory Recognising the importance of obesity focus on children and adolescents. In 2007, measures, and instead relies on informing as a health issue, in 2008 the German there were 708 programmes for overweight consumers and freedom of choice. The government, led by the Federal Ministry or obese children and adolescents in underlying expectation is that various of Food, Agriculture and Consumer Germany, reaching approximately 44 ‘‘ stakeholders, including individuals and Protection and the Federal Ministry of 000 persons. However, their quality and industry, will opt for healthier nutrition Health, set up the intersectoral National the financial resources devoted to them and more active lifestyles, if they are well Initiative to Promote Healthy Diets and differed greatly. 6 Calculations suggest informed about these. 10 A traffic-light Physical Activity, called IN FORM. 4 This that the programmes reached 33–55% of food coding system has been discussed, initiative aims to achieve sustainable overweight or obese children at the time, but not adopted. There has also been no improvements in healthy diets and physical indicating major gaps in coverage. An ban on the sale of unhealthy foods in activity by 2020. It frames obesity as a assessment concluded that most of the vending machines in schools. public health problem and contains five programmes lacked proper evaluation, had main areas for action: only short-term effects and that the actual As is typical for Germany the ‘setting impact on BMI was low. 7 1. for the Federal government, the states approach’ has been undertaken, which and communes to ‘set an example’ (such means using an interplay of behavioural Within the context of IN FORM, a toolbox as through Health Impact Assessments, and living environment prevention consisting of seven workbooks has been in the allocation of public funds, as measures. Beyond only promoting healthy developed by the Federal Centre for Health employers, and as funding bodies of behaviours among participants, the living Education and the State Association Health community facilities); environment should be designed in such Berlin-Brandenburg for practitioners in a way as to promote a healthy life. Hence, 2. the provision of information on diet, the field, entitled Take Action for Health. the core strategy and measures of IN physical activity and health; Work tools for prevention and health FORM start where people live, work, promotion in the neighbourhood. The 3. the promotion of physical activity learn or play. seven workbooks provide background in daily life; information, practical examples and Since 2008, the two leading ministries 4. improving the quality of catering checklists for daily activities. As an aid for have funded over 200 projects with a away-from-home; and projects on a smaller budget, IN FORM total of €77 million. 8 The collaborative has also developed three online guidelines 5. providing a fresh impetus for research. for ‘Quality Assurance’, ‘Communication’ and ‘Evaluation’. 8

Eurohealth — Vol.25 | No.1 | 2019 16 Eurohealth Systems and Policies

stakeholder strategy was already The report makes for interesting reading, 5 Ed BMVBS. National Cycling Plan (2020) – established with the National Cooperation especially since the Platform on Diet Joining forces to evolve cycling. Federal Ministry Network ‘Equity in Health’ in 2003. and Physical Activity (PEB) was heavily of Transport, Building and Urban Development. Berlin, 2012. Available at: http://edoc.difu.de/edoc. criticised in 2014 by some of its public php?id=1U032RD6 health members on Frontal21, a feature of Conclusion 6 the German TV channel ZDF. 11 In view Kliche T, Mann R. Prevention and care for obese children and adolescents in Germany: quality Obesity is still an underestimated public of the dominant approach of IN FORM and efficiency of programs and interventions. health problem in Germany; the policy of focusing on individual behaviours Bundesgesundheitsblatt 2008;51(6):646–56. response has so far been insufficient in addressing obesity and neglecting 7 Kliche T, Koch U. Die Versorgung übergewichtiger and obesity levels continue to increase social and political determinants, most und adipöser Kinder und Jugendlicher in Deutschland. dramatically. However, along with Canada notably the roles of the food industry and (The number of overweight and obese children and and the United States, Germany is one of agriculture, outcome measures on obesity adolescents in Germany). Cologne: Federal Centre for the countries that has an explicit state- levels are unlikely to be encouraging. Health Education, 2007. level obesity policy, aiming to encourage 8 IN FORM. Interims Report 2017. Available at: healthy diets and physical activity. During the ‘Green Week’ in Berlin, https://www.in-form.de/in-form/in-form- farmers and citizens protested against zwischenbericht/ industrial agriculture. Tens of thousands 9 Müller MJ, Maier H, Mann R. Nationaler of participants, interested in a more Aktionsplan gegen das Übergewicht – eine Initiative conscious agricultural policy, gathered der Deutschen Adipositas-Gesellschaft. (National around the Brandenburg Gate under the Action Plan against Obesity – an initiative of the German Obesity Society). Martinsried, 2007. motto ‘We are fed up!’ campaigning for Germany has an Available at: http://tinyurl.com/y52g2f2n climate-friendly agriculture and healthy 10 food. The organisers reported the number Vallgårda S. Governing obesity policies from explicit state-level England, France, Germany and Scotland. Soc Sci of demonstrators at 35,000. Med. 2015;147:317–23.

obesity policy 11 With the Act to Strengthen Health ZDF Frontal 21. Zum Wohle des Kindes? – Kritik an Ernährungsplattform (For the benefit of the child? – The Robert Koch Institute has launched Promotion and Prevention the practiced Criticism of the nutritional platform). Manuscript by the German Health Interview and core strategy of IN FORM, which starts Jörg Göbel and Julian Prahl, ZDF Mainz. Broadcast Examination Survey for Children and where people live, work, learn or play, from 21 January 2014. Adolescents (KiGGS-Study) as part has become the guiding concept that of its health monitoring programme, explicitly addresses living-environment with a baseline study‘‘ in 2003–06 and intervention measures in relevant settings a follow-up study in 2014–17 (KiGGS as a promising approach. This is based Wave 2). The results of the second study on a target-oriented cooperation of were published in March 2018. They stakeholders in the field of action at a local pointed to a strong social gradient, with and regional level. the prevalence of overweight (including obesity) reaching 27.0% and 24.2% in girls References and boys respectively aged 3 to 17 years with low socioeconomic status compared 1 OECD. Obesity Update 2017. Available at: http:// to 6.5% in girls and 8.9% in boys with www.oecd.org/health/obesity-update.htm high socioeconomic status. 2 2 Schienkiewitz A, Brettschneider A-K, Damerow S, Schaffrath RA. Overweight and obesity among IN FORM, as the main obesity-related children and adolescents in Germany. Results of the cross-sectional KiGGS Wave 2 study and trends. policy and programme, has had some J Health Monitor 2018;3(1). Available at: http:// encouraging impacts in terms of tinyurl.com/yyyz5ntk attempts to enhance the quality of local 3 Effertz T. Die volkswirtschaftlichen Kosten interventions and health promotion gefährlichen Konsums. Eine theoretische und activities. Toolboxes and instruments empirische Analyse für Deutschland am Beispiel for practitioners in the field have been Alkohol, Tabak und Adipositas. (The economic developed, and databases of activities costs of dangerous consumption. A theoretical and and models of good practice have been empirical analysis for Germany on the example of alcohol, tobacco and obesity.) Reihe: Schriftenreihe set up, providing an overview of what is ökonomische Analyse des Rechts (Series of economic going on in the country. However, a first analysis of law). Band 15. Frankfurt am Main, 2015. interim report, originally planned to be 4 IN FORM. German National Initiative to Promote published in 2011 was only released in Healthy Diets and Physical Activity. Federal Ministry December 2017. of Food, Agriculture and Consumer Protection and Federal Ministry of Health. Berlin, 2008. Available at: http://tinyurl.com/y4ygnxc9

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 17

TACKLING THE OBESITY CHALLENGE IN ITALY

By: Elena Azzolini and Walter Ricciardi

Summary: Overweight and obesity represent a priority public health issue in Italy. Although the adult obesity rate is one of the lowest in OECD countries, rates of child obesity are among the highest in Europe. Several policies and programmes involving multiple strategies have been implemented in the last decade to tackle obesity. The responsibility for identifying health needs, formulating health care policy and for policy implementation is shared between the central government and the regions. To reverse the obesity epidemic among the Italian population several weaknesses need to be addressed, including the persistence of strong regional disparities in health status.

Keywords: Obesity, Overweight, Public Health Policy, Public Health Organisations, Italy

Scale of the problem is that, despite the high rate of obesity, the proportion of obese and overweight Notwithstanding pasta, lasagne, pizza or children in Italy has decreased by 13% in calorie-laden gelato, Italy has long been less than ten years, according to the OKkio recognised as having one of the healthiest Health Surveillance System, promoted by populations in the world. But can all the Ministry of Health and coordinated by Italians expect to live a long and healthy the Italian National Institute of Health. 2 life? Obesity is having a serious impact on the physical health and wellbeing of As for adults, in Italy more than a third of the Italian population and it would not the adult population (35.5%) is overweight, be a surprise if in a few years Italian life while just over one in ten people are expectancy began to decline. It seems obese (10.4%); overall, 45.9% of people almost a paradox considering the benefits aged 18 years and over carry excess of the Mediterranean diet, but countries weight. 3 bordering the Mediterranean Sea have the highest rates of childhood obesity in The differences by territory are Europe. Data from the Childhood Obesity considerable and, in the interregional Surveillance Initiative (2015 – 17) of the comparison, the North-South gradient Elena Azzolini is Public Health World Health Organization show that is pronounced: the southern regions Medical Officer, Humanitas Clinical Italy is ranked first in Europe for child and Research Center (IRCCS), show the highest prevalence of obesity, with 21% of children obese or Milan, Italy; Walter Ricciardi is obesity and overweight for people Full Professor, Department of overweight, above the prevalence recorded aged 18 years and over (Abruzzo 14.2%, Public Health, Università Cattolica in Greece and Spain. 1 Some 42% of boys del Sacro Cuore, Rome, Italy. Puglia 13.1% and Molise 12.4%), are obese or overweight, while among girls Email: [email protected] (Basilicata 40.6%, Calabria 40.4% and the figure drops to 38%. The good news

Eurohealth — Vol.25 | No.1 | 2019 18 Eurohealth Systems and Policies

Molise 39.8%), compared to Northern Table 1: Excess weight by age and gender regions, which show the lowest prevalence for obesity (Bolzano 8.1%, Population group Overweight Obese Trento 8.3% and Lazio 8.6%) and 18 – 24 years 14.8% 2.6% overweight (Bolzano 30.7%, Trento 31.6% 65 – 74 years 45.6% 15.5% and Valle d’Aosta 31.7%). The percentage of the population with excess weight All Men 44.5% 11.1% grows with increasing age and also differs All Women 27.2% 9.8% by gender (see Table 1). The highest Men 65 – 74 years 52.9% 16.0% percentage of people with excess weight Women 65 – 74 years 39.1% 15.1% is for those aged 65 – 74 years. 3

However, despite being considered an Source: 3 important issue, with numerous obesity- related organisations and initiatives, the true extent of the problem is often Box 1: not properly considered and accurate Italian monitoring systems for public health knowledge of the national obesity rate is • “Keep an Eye on Health” (OKkio alla Salute), coordinated by the National still very low among policymakers. 4 Institute of Health, in collaboration with the Ministry of Education, University and Research; Efforts to tackle child obesity are seen as more successful than efforts to combat • the HBSC (Health Behaviour in School-aged Children) study promoted by WHO; adult-obesity, but a high percentage of • the Health Progress in Italian Local Authorities system (Sorveglianza PASSI – policymakers are not sure about the impact Progessi delle Aziende Sanitarie per la Salute in Italia), which provides information of policies. This uncertainty is particularly about risk factors (including obesity), people’s perceptions of health, and the alarming in a country where, although delivery of health services to people aged 18 to 69; adult obesity is one of the lowest in OECD countries, 5 the rates of child obesity are • the “PASSI Silver” system (PASSI d’Argento): a surveillance system on the health among the highest in Europe. and quality of life of people over 64;

• the “Heart” project (Progetto CUORE): a large prospective cohort follow-up study of cardiovascular risk factors and high-risk conditions, such as obesity, in the Italian population through periodic standardised, rigorous and accurate rates of physical examinations. child obesity are among the An important milestone in the recent climate, chronic diseases, promotion of history of Italian public health has been healthy lifestyles, support for vulnerable highest in achieved with the national programme people, and information flows. “Gaining Health” (Guadagnare Salute), Europe with the main objective to prevent and National monitoring systems for adults change unhealthy behaviours that promote and children have also been established increases in degenerative and chronic to collect evidence on the spread of Policies and programmes diseases. unhealthy lifestyles and diseases In the last decade, several policies and (see Box 1). However, this progress programmes‘‘ involving multiple strategies At the European level, “Gaining Health” is threatens to be undermined by recent have been implemented to tackle obesity fully part of the strategy for the prevention budget cuts to prevention, which have left in Italy. One of the greatest achievements and control of chronic diseases promoted fewer resources that can be allocated to is the presence of a National Prevention by the WHO in 2006. 7 The programme tackling obesity. Plan, as well as Regional Prevention Plans, is promoted by the National Centre for which increasingly concentrate on the Disease Prevention and Control (CCM), Role of public health organisations prevention of noncommunicable diseases whose main target is active prevention (NCDs) and the promotion of healthy through the promotion of healthy lifestyles In Italy, the Ministry of Health is in lifestyles. All Italian regions have adopted and screening. Since 2004, concrete charge of identifying health problems at least one intervention specifically aimed projects have been undertaken towards and priorities that require government at controlling obesity, albeit with great health prevention in many areas relevant attention. diversity between regions. 6 to obesity including: environment and

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 19

The National Centre for Disease Other key actors involved in decision and geographical inequalities observed Prevention and Control (CCM) is making are health professionals who in the country, and the definition of the public health agency with a clear provide primary care services and more homogeneous, measurable and robust mandate to detect (and prevent) major generally, each region’s network of Local indicators linked to monitoring of LEA. health problems and potential threats Health Authorities (Aziende Sanitarie to public health, including obesity. Locali, ASLs) and hospital trusts (Aziende Overweight and obesity prevalence are It operates as a coordinating body Ospedaliere, AOs) to which executive also monitored by the Italian National between central and regional health functions are largely delegated. Institute of Health and the National institutions for surveillance, prevention Institute of Statistics (ISTAT) which and effective emergency response ASLs are also required to promote contact produces the multipurpose Aspects of activities. Negotiations between the state between social and health services Daily Life Survey, and collaborates with and regional governments result in the and schools, businesses, the youth the National Observatory on Health Status ratification of National Prevention Plans, entertainment sector, sports associations, in the Italian Regions (Osservatorio the most recent of which covers the the voluntary sector and patients’ Nazionale sulla Salute nelle Regioni period 2014 – 18. associations. Italiane). This body collects comparable regional data from different sources and Responsibility for formulating health care monitors population health in Italy’s policy and for policy implementation is regions. These national surveillance shared between the central government systems provide useful information and the regions. Within Italy’s quasi- for planning preventive and protective federal arrangements, the Ministry of persistence of measures for population health. Health fulfils the function of setting the main policy directions, while the regions strong regional Conclusion are responsible for the formulation of their respective regional policies and for disparities in Obesity represents an important public the organisation of regional public health health issue in Italy. Although the adult services and effective local interventions. health status obesity rate is one of the lowest in Europe, rates of childhood obesity are among the Other local and national bodies responsible With regard to funding, there is no highest. for obesity are the Food and Nutrition specific budget allocation to address Health Services (SIAN); the National obesity. The Ministry of Health and the In the last decade, Italy has adopted Institute for Food and Nutrition Research CCM decide on ‘‘an annual programme of and implemented several policies and (INRAN), which is responsible for national prevention-related activities to be funded. programmes to tackle obesity. These guidelines on healthy diets; the National Several million Euros per year have been developments have been underpinned Platform on Diet, Physical Activity and assigned to reinforce organisational and by policymakers’ strong advocacy for Tobacco, established and chaired by the professional resources involved in the more public health-oriented policies and Ministry of Health, which is a technical implementation of activities coordinated or practices at the national and regional level committee tasked with formulating financed by the CCM, including planning, and have given rise to well-coordinated policies and implementing actions, in line monitoring and evaluating Regional national surveillance systems. with the "Gaining Health" programme, Prevention Plans. providing the arena for defining cross- However, several weaknesses need to be sectorial strategies and for developing Monitoring and evaluation of policies addressed, including the persistence of synergies among all stakeholders addressing obesity are directly undertaken strong regional disparities in health status according to the principle of Health in All by Regional Health Departments. and in the quality of public health services, Policies. Routine monitoring is also provided coupled with budget cuts to prevention by the Ministry of Health’s annual funding over the last few years, which Formal mechanisms for collaborations monitoring of the delivery of the health have left fewer resources that can be are established with the National Institute benefits package, known as the Essential allocated to tackling obesity. Furthermore, of Health (ISS), the Italian National Levels of Assistance (Livelli Essenziali health information and monitoring systems Agency for Regional Healthcare Services di Assistenza, LEA) across the country. are not always fully capable of translating (AGENAS), the National Medicines Obesity is included as part of the findings to aid decision makers and Agency (AIFA), the Ministry of Education, descriptive lifestyle indicators and as a government mechanisms to support high University and Research, European risk factor for NCDs. The State-Regions quality research are lacking. Network for the Promotion of Health- Conference has approved the issuing of an enhancing Physical Activity (HEPA), the improved instrument for the evaluation of An urgent stepping-up needs to be taken Department of Youth Affairs, the Ministry Regional Prevention Plans for 2020–25, to raise awareness among policymakers of Agriculture, the food industry, trade whose priority lines will be a proactive and the population of the extent of the and food chain associations, and National action aimed at tackling health needs, challenge posed by the consequences of Committee for Dietetics and Nutrition. including the reduction of the main social obesity, as well as the benefits associated

Eurohealth — Vol.25 | No.1 | 2019 20 Eurohealth Systems and Policies

with healthy diets and active lifestyles. ADDRESSING OBESITY Future developments are likely to focus on increasing the number and improving the governance of inter-sectoral plans/actions IN THE REPUBLIC OF on obesity, putting in place a broad range of communication policies, as suggested by Goryakin et al, 8 and strengthening MOLDOVA intensive collaboration with the food supply chain. Therefore, a long-term evidence-based commitment is required to tackle one of the greatest health challenges of this century. By: Galina Obreja and Angela Ciobanu

References

1 WHO Europe. Childhood Obesity Surveillance Initiative: Highlights 2015 – 17. Copenhagen: WHO, Summary: Overweight and obesity are among the main risk factors 2018. Available at: http://www.euro.who.int/__data/ assets/pdf_file/0006/372426/WH14_COSI_ associated with the rising prevalence of noncommunicable diseases factsheets_v2.pdf?ua=1 (NCDs) in the Republic of Moldova. Moldova’s government has 2 Italian National Institute of Health. OKkio alla Salute: i dati nazionali 2016. (National data 2016). recognised obesity as an important public health issue and has Rome: ISS, 2017. Available at: http://www.epicentro. iss.it/okkioallasalute/dati2016 committed to its prevention and control by developing and endorsing 3 Observatory on Health Status in the Italian the Food Law and the multisectoral National Food and Nutrition Regions. Rapporto Osservasalute 2017: Fumo, alcol, alimentazione, eccesso ponderale e prevenzione. Programme (NFNP) and its Action Plan. The low level of awareness of (Smoking, alcohol, nutrition, weight excess and prevention) 2018:46 – 58. the obesity problem, a lack of resources and unclear responsibilities

4 EASO. Obesity Perception and policy. Multi- undermine the achievement of targets in counteracting obesity. country review and survey of policymakers 2014. European Association for the Study of Obesity, 2014. Keywords: Obesity, Overweight, Public Health Policy, Noncommunicable Disease, 5 OECD. Obesity Update. Paris: OECD, 2017. Available at: www.oecd.org/els/health-systems/ Public Health Organisation, Republic of Moldova Obesity-Update-2017.pdf

6 Nicolucci A, Sbraccia P, Guerra R, et al. Il burden of disease dell’obesità in Italia. (Health policy in non- Scale of the problem (7% boys vs. 4% girls). 6 Overweight and communicable diseases). Speciale 2015;1:5 – 22. obesity lead to an increase in cholesterol, A survey on NCD risk factors found 7 WHO Europe. Gaining health: The European insulin resistance and blood pressure. that more than half of adults (56%) Strategy for the Prevention and Control of In 2013, one in five (20.6%) adults had were overweight or obese in 2013 in Noncommunicable Diseases. Copenhagen: WHO, impaired fasting or raised blood glucose, 2006. Available at: http://www.euro.who.int/__data/ the Republic of Moldova. Overweight, and three out of ten (29.4%) had raised assets/pdf_file/0008/76526/E89306.pdf including obesity is similar in men total cholesterol. 1 8 Goryakin Y, Sechi Gatta M, Lerouge A, Pellegrini T, (56.0%) and women (55.8%) with more Cecchini M. The Role of Communication in Public women being obese (28.5%) and more The increasing rates of obesity are Health Policies. The Case of Obesity Prevention in men being overweight (38.2%). 1 These contributing to a rise in the prevalence of Italy. OECD Health Working Paper. Paris: OECD figures are higher than in 2005, when half Publishing, 2017. chronic diseases, which pose a significant of adults were overweight or obese. 2 The burden for the health system, families increasing trend has accelerated in recent and society as a whole. The incidence years and in 2016, almost seven out of ten of cardiovascular disease has recently individuals were overweight or obese. 3 stabilised, but remains one of the highest Overweight and obesity among children Galina Obreja is Associate in the region. The incidence of diabetes is also of concern. About 5% of children Professor, Department of Social and cancer are continuously increasing. Medicine and Health Management under five were overweight in 2012 4 In 2017, these diseases accounted at the State University of Medicine compared to 0% in 2005. 5 The survey on and Pharmacy, Chisinau, Republic for 75.1% of deaths and 44.4% of disability seven year-old children conducted in 2013 of Moldova; Angela Ciobanu is in the Republic of Moldova. 7 Overweight Technical Officer in Tobacco Control as part of the WHO European Childhood is mainly seen as the responsibility of the at WHO Regional Office for Europe, Obesity Surveillance Initiative found that individual and not as a population health- Copenhagen, Denmark. Email: one in five boys (19%) and one in eight [email protected] related issue. girls (13%) were overweight or obese, with the prevalence of obesity higher in boys

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 21

Policies and programmes the involvement of children in food is to conduct surveys as part of the advertising, elimination of trans-fats, surveillance system for NCDs and their The government started to address reformulation of food to reduce the content risk factors. The above-mentioned surveys obesity during the last decade. The of sugar, fat and salt, health education collected data on BMI and physical National Health Policy (2008 – 2021) and establishing a national obesity activity. The Agency is also responsible addressed obesity as one of the main surveillance system. for routinely collecting, analysing and health determinants for the first time and annually publishing data on morbidity and called for multisectoral actions to prevent In 2017, the Parliament adopted the Law mortality. These publications are used as it. In 2009, the Law on Public Health on the provision of food information reference tools by decision makers. established methods to control obesity to consumers (which came into force including: from 2019), which introduced mandatory • reducing the consumption of high nutritional labelling. energy density, but nutrient-poor food; However, the implementation of these • reducing marketing of unhealthy foods, interventions in counteracting obesity has especially for children; concrete actions been minimal and subject to delay. The • food reformulation to reduce the content banning of unhealthy food was enforced to tackle obesity of salt, sugar and saturated fat; within schools, but was unsuccessful in the areas surrounding schools. The • ensuring adequate nutrition and physical were only advertising and promotion of unhealthy activity within preschools and for school food has neither been properly regulated children; undertaken nor enforced. • ensuring access to healthy foods, in 2012 especially fruit and vegetables; Nutritional surveillance data are essential to effectively design, implement and Policy formulation. The Ministry of • providing accurate and adequate evaluate national policies on prevention Health, Labour and Social Protection is information to consumers regarding the ‘‘ and control of obesity. Thus, the Republic the central level authority responsible nutritional value of food via labelling of Moldova became part of the WHO for the development of overall national and advertising. Europe Childhood Obesity Surveillance health and public health policy. In 2013, Initiative (COSI) from 2013 and in order to tackle the increasing burden participated in the third and fourth rounds of NCDs and obesity as a key risk factor, of this initiative. The baseline ‘STEPS’ the Ministry initiated the development of survey was conducted in 2013 and the a policy document to address this issue. ‘Salt consumption survey’ was carried out An intersectoral working group, which Overweight and in 2016; 1 3 both being part of the national included representatives of relevant surveillance system on NCDs. central level authorities (agriculture obesity among and food industry, education, economy, finance) as well as civil society, was Role of public health organisations children is also of established under the Ministry with the Problem identification and issue aim to develop a draft National Food and concern recognition. The Ministry of Health, Nutrition Programme and the Action Plan. Labour and Social Protection recognises The Ministry’s Department of Public Nevertheless, concrete actions to tackle obesity as an essential public health Health led the process together with the obesity were only undertaken in 2012. The issue and has addressed it in the National NAPH. In 2014, after many debates, Food Law was amended and preparation, Health Policy (2007), Law on Public the policy documents were endorsed by selling and distribution of unhealthy food ‘‘ Health (2009), Food Law amended in 2012 the government. There are also other on school premises and within 100 meters and 2016, and Law on the provision of authorities with specific roles in policy of schools was banned. food information to consumers (2017). formulation (see Table 1). Further in 2014, the government endorsed Scaling up obesity at the international and There is no clear delineation of the first National Food and Nutrition regional levels and with WHO efforts, responsibilities between central and Programme for 2014 – 2020 (NFNP) and as the main international partner, have local authorities, including for public its Action Plan with a specific objective: contributed to the prioritisation of obesity health issues such as obesity. National zero increase in obesity prevalence. The on the government policy agenda. health programmes are not mandatory NFNP and its Action Plan provide for for local authorities, even though they are multisectoral actions regarding health The National Agency for Public Health responsible for protecting and promoting promotion and obesity prevention via (NAPH) with its territorial departments health and preventing disease. Local taxes, mandatory nutritional labelling, is responsible for surveillance in all areas restrictions on advertising and banning of public health. One of its missions

Eurohealth — Vol.25 | No.1 | 2019 22 Eurohealth Systems and Policies

Table 1: Authorities tasked with working to address obesity Conclusion The main strength in obesity prevention Authority Task and control is the recognition of obesity as Ministry of Agriculture, Regional Development Increasing the availability of fruits and a public health problem by the government and Environment vegetables via agricultural policies and its commitment to prevent and control Ministry of Finance Establishing excise taxes for unhealthy food it, as demonstrated by the development Ministry of Economy and Infrastructure Observing food prices and endorsement of the multisectoral Development and integration of nutrition and NFNP and enacting legislation. Among Ministry of Education, Culture and Research health and physical activity in school curricula the weak points are the low level of Development and implementation of local awareness of obesity issues and lack of policies directed at creating an environment that willingness to act by some authorities Local authorities encourages physical activity and a healthy food (specifically agriculture and finance), a environment in schools lack of dedicated human resources in the Ministry of Health, Labour and Social Protection and NAPH, and the absence authorities are, however, invited by the resources, both human and financial, or of financing. Obesity continues to be a central government to contribute to using support provided by development public health problem in Moldova and to implementation. partners. counteract it, intersectoral cooperation could be strengthened. Decision making is divided between the The NAPH is the main institution Parliament, government and the Ministry responsible for the implementation of References of Health, Labour and Social Protection at the NFNP and its Action Plan, both at central level and municipal/rayon Council national and local level. Other authorities 1 WHO Europe. Prevalence of noncommunicable at local level. Parliament adopted the are also responsible for implementation disease risk factors in the Republic of Moldova laws mentioned above. The government as mentioned above. To date only a STEPS 2013. Copenhagen: WHO Regional Office for Europe, 2014. Available at: http://www.euro.who.int/ approved the National Health Policy as few activities have been initiated and en/countries/republic-of-moldova/publications2/ well as the NFNP and its Action Plan. implemented by these authorities. prevalence-of-noncommunicable-disease-risk- Local authorities can decide on additional factors-in-the-republic-of-moldova.-steps-2013-2014 initiatives to promote health and to prevent 2 National Bureau of Statistics of the Republic obesity. It should also be mentioned of Moldova. Results of survey on health status of that the food industry is powerful in the specific population in the Republic of Moldova. Chisinau: Republic of Moldova and can interfere at National Bureau of Statistics of the Republic of different levels of policymaking. objective – zero Moldova, 2006. 3 WHO Europe. Dietary Salt Survey in the Republic Policy implementation. For every activity increase in of Moldova, 2016. Copenhagen: WHO Regional Office specified in the NFNP and Action Plan, for Europe, 2018. Available at: http://www.euro.who. int/__data/assets/pdf_file/0009/386694/mda-salt- including for those on obesity prevention, obesity intake-eng.pdf?ua=1 there is a designated responsible authority. 4 The Ministry of Health, Labour and UNICEF. Republic of Moldova: Multiple Indicator prevalence Cluster Survey, Summary Report. New York: UNICEF, Social Protection is the leading institution 2012. Available at: http://www.unicef.org/moldova/ responsible for intersectoral coordination Monitoring and evaluation. The Ministry Unicef_booklet_ENG.pdf and the organisation of the implementation of Health, Labour and Social Protection is 5 NSACPM (Moldova), ORC Macro. Republic of of the NFNP and its Action Plan. Public responsible for monitoring and reporting Moldova Demographic and Health Survey 2005. health interventions, including on obesity annually‘‘ on the progress of NFNP Calverton MA: National Scientific and Applied Centre are financed by the state budget that is implementation to the government. This for Preventive Medicine (Moldova) and ORC Macro. allocated by the Ministry of Finance based responsibility was delegated to the NAPH. Available at: https://dhsprogram.com/pubs/pdf/ on the midterm budgetary framework. Other responsible central authorities fr178/fr178.pdf Even though interventions to control have to report annually to the Ministry of 6 WHO Europe. WHO European Childhood Obesity obesity are part of the Action Plan of the Health, Labour and Social Protection on Surveillance Initiative: overweight and obesity NFNP approved by the government, there the progress of NFNP implementation. among 6–9-year-old children. Report of the third round of data collection 2012–2013. Copenhagen: are no specific activities reflected in the WHO Regional Office for Europe, 2018. Available midterm budgetary framework. Therefore, at: http://www.euro.who.int/__data/assets/pdf_ financial resources have been not allocated file/0010/378865/COSI-3.pdf?ua=1

by the government to implement the 7 National Public Health Agency. Annual public NFNP and Action Plan. So, activities health statistical book of the Republic of Moldova. are implemented using scarce internal Chisinau: National Public Health Agency, 2017.

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 23

OBESITY IN POLAND – PUBLIC HEALTH ACTIVITIES

By: Michał Brzeziński, Paulina Metelska and Bogumiła Sutkowska

Summary: Poland is a high-income country in Central Europe that has undergone a significant transition over the past thirty years from a communist regime to a democracy. Nowadays, about one quarter of adults, 12% of boys and 6% of girls are obese. For many years, obesity was not recognised as a disease, but rather as a risk-factor for cardiovascular diseases. It was only in 2016 that the government undertook specific activities, such as the National Health Programme, and secured financial resources to tackle the burden of obesity. Nevertheless, there remains a large gap between the strategy and actual implementation.

Keywords: Obesity, Overweight, Public Health Policy, Public Health Organisation, Health Programme, Poland

Scale of the problem average of 15.5% (2006 –2013 data), it has increased over the last 20 years (11.4% Until 1989, Poland was ruled by an of adults self-reported as being obese authoritarian communist regime. in 1996). 2 Recent data from representative Following a transition to democracy, studies (WOBASZ) show an increase the country joined NATO (in 1999) and in the prevalence of both obesity and the European Union (in 2004) and has overweight in all adult age groups and in undergone significant social and economic both sexes. In the years 2013–2014, the transformation, with per capita GDP rising age-standardised prevalence of obesity from €5,000 in 1995 to €11,200 in 2016. 1 (body mass index [BMI] ≥ 30 kg/m2) This socioeconomic transformation, along was 24.4% in men and 25.0% in women, with improvements in health system an increase from 20.0% and 22.3% performance, has contributed to increasing respectively in 2003 – 2005. 3 life expectancy, but has also been associated with deteriorating diets and The fastest increase has been observed in decreased physical activity. Consequently, children and adolescents. Evidence shows since the mid-1990s, Poland has seen an Michał Brzezin´ski is Assistant that 22% of primary school children were increase in the prevalence of overweight Professor, Department of Public overweight or obese (2013), 4 compared Health and Social Medicine, Paulina and obesity across all age groups. to 15% in 1990. 5 This is among the Metelska is Co-ordinator “6 – 10 – 14 most rapid increase in Europe. 6 Recent for health” University Clinical As such, overweight and obesity are Center, and Bogumiła Sutkowska data from the European Childhood public health challenges of growing is Ph.D. student, Department Obesity Surveillance Initiative (COSI) of General Nursing, Medical importance in Poland. While the self- study 7 performed in Poland in 2016 show University of Gdan´sk, Poland. reported obesity rate in Poland, at 15.8% Email: [email protected] that 32.4% of 8-year-old boys and 29.1% in adults (2009 data), is close to the OECD of 8-year-old girls were overweight (based

Eurohealth — Vol.25 | No.1 | 2019 24 Eurohealth Systems and Policies

Figure 1: Prevalence of overweight and obesity in Polish adults, of program implementation. Rather, 1975 – 2016 the programs described above were implemented mainly at the national level 5000 by the Ministry of Health (MoH) and its 500 agencies including the National Institute 000 for Public Health – National Institute of 500 Hygiene (NIPH-NIH) and the National

000 Food and Nutrition Institute (NFNI), with

2500 little impact on and support from regional and local governments. The MoH was 2000 not able to engage the local level in the 1500 implementation process due to restricted 1000 human and financial capacity. 500

000 19 5 19 19 19 19 9 19 0 19 1 19 2 19 19 19 5 19 19 19 19 9 199 0 199 1 199 2 199 199 199 5 199 199 199 199 9 200 0 200 1 200 2 200 200 200 5 200 200 200 200 9 201 0 201 1 201 2 201 201 201 5 201 Overweight men Overweight women Obese men Obese women obesity Source: 8 appears to be on WHO 2007 cut-off points). Other data The first National Program for the underestimated from the Health Behaviour in School-aged Prevention of Overweight and Obesity Children (HBSC) study from 2014 show and Chronic Non-Communicable by medical that overweight and obesity was present Diseases through Improved Nutrition in 20.5% of 11-year-old boys and 15.1% and Physical Activity 2007 – 2011 was professionals of 11-year-old girls, 18.8% of 13-year-old introduced in 2006, largely as a response boys and 10.1% of 13-year-old girls. to the WHO Global Strategy on Diet, and policymakers Physical Activity and Health (the latter Figures 1 and 2 show the increase in was published in May 2004). In 2012, Health education is the primary approach obesity and overweight prevalence over the programme was further extended to ‘‘tackling obesity promoted in national the period of 1975 – 2016 for Polish adults as the National Programme for the health policy documents, such as the and children, respectively. Prevention of Non-Communicable National Health Programmes (NHPs) Diseases 2012 – 2014. Both versions of for 2007 – 2015 and 2016 – 2020. However, the programme outlined an active role there are no publicly financed education Policies and programmes for the central and local governments in programmes for children and young In spite of these negative trends, the health polices and promoting prevention people dedicated to obesity, nor are there problem of obesity appears to be on noncommunicable diseases (NCDs), national education campaigns for the underestimated by medical professionals including NCD-related risk factors such general population. The only medical and policymakers. Obesity is mainly seen as obesity. Finally the problem of obesity obesity treatment that is available under as an individual lifestyle problem or as is recognised in Poland’s strategic public the public system is bariatric surgery. an aesthetic issue and not as a population health document, the National Health Little attention is also paid to policy tools health issue. Programme 2016 – 2020, as one of the such as legislative change, marketing bans main strategic goals. 9 Yet, the obesity- or fiscal instruments such as taxes. The Since 1995, Poland has adopted three related goals included in these documents focus of health policy debates on lifestyle editions of the National Health Programme are poorly translated into actions and choices is partly due to the active role of (1995 – 2005, 2007 – 2015, 2016 – 2020). few measures are undertaken to address food industry representatives in policy These Programmes have provided the problem as can be inferred from the debates. They have successfully argued strategic direction for the Polish health first three years of implementation of that the responsibility for health choices system, identifying key health challenges the strategy. lies with individuals and not with the state. and ways of addressing them. The first The control of advertisements and TV two editions of the programme focused Responsibility for implementing the broadcasters was dominated by advertisers rather narrowly on cardiovascular disease program was delegated to the local level, who created their own self-regulation, and cancer treatment and prevention including responsibility for the financing/ which effectively stopped all attempts to strategies. Despite the growing burden co-financing of program implementation. comply with external control regulations of overweight and obesity, Poland had no This was despite local authorities being in this area for many years. specific national programme to tackle poorly prepared in terms of technical these concerns until 2007. expertise and personnel. As a result, few On the whole, the problem of obesity activities have been carried out at the attracts little attention in public policy local level, which decreased the speed debates in Poland. More controversial

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Systems and Policies 25

Figure 2: Prevalence of overweight and obesity in Polish children, are financed from national sources 1975 – 2016 (MoH, National Science Centre) or with support from EU strategic funds, or the 2000 Swiss Contribution (a fund organised by 100 Switzerland for the 10 countries that joined 100 the EU in May 2004). However, there is

100 little systematic data collection on the

1200 prevalence of obesity and overweight in Poland and data that are gathered are often 1000 not representative of the whole population 00 or comparable across surveys. Except for 00 the international HBSC survey, there are 00 no systematic national surveys in the area 200 of obesity in Poland. None of the major

000 national population surveys (NatPol, 5 9 0 1 2 5 9 0 1 2 5 9 0 1 2 5 9 0 1 2 5 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 NatPol 2011, WOBASZ, MONICA) 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Obese boys Obese girls Overweight boys Overweight girls focus on obesity (they mainly look at cardiovascular disease prevalence and Source: 8 their treatment outcomes) and collected data are confined to selected regions or issues, such as in vitro fertilisation, tend to of those locally implemented and publicly populations (e.g. various age groups) command more public interest. Although financed health policy programmes, need and based on different methodologies some actions were taken in 2015 (notably, to be assessed ex-ante by a government (e.g. some use self-reported data). The the introduction of a ban on high salt, body – the Agency for Health Technology key source of information on obesity- sugar and fat (HSSF) food in schools, Assessment in Poland. This implies that related diseases is the National Health which has since been mostly withdrawn) all activities approved by the Agency are Fund (NHF), which collects data on the there is a lack of a clear strategic plan well-organised and evidence-based. provision of publicly financed health for obesity prevention. However, the services to patients with obesity-related implementation of the new Act on Public diseases. Role of public health organisations Health and its executive document (i.e. the NHP 2016 – 2020 9 ) may help to focus more In Poland, the MoH is the main authority attention on public health problems such responsible for identifying problems as obesity, physical inactivity, and tobacco and setting the agenda in the field of the and alcohol consumption. public health, including obesity. The Department of Public Health has primary obesity-related Local and regional governments and city responsibility for all activities undertaken authorities also play an important role within the NHP. The Department is goals are poorly in implementing high-quality activities also responsible for the implementation in the field of tackling obesity. They of the Public Health Act. Nevertheless, translated into mostly focus on children but some many other departments within the MoH activities are dedicated to adults, with undertake public health activities, e.g. actions some receiving financial support from the Department of Mother and Child is the NHP 2016 – 2020. Local activities responsible for preventive health care The National Health Programme included focus mostly on screening, such as the for children and pregnant women and several institutions as key leaders – as early detection of children with excess the Department of Science and Higher mentioned earlier NIPH-NIH and NFNI body mass. Different follow-up actions Education supervises the NIPH-NIH and play a key role‘‘ in this process. However, are recommended to all children/ the NFNI. their role in prevention and treatment of adolescents identified as having excess obesity is mainly limited to educational body mass, ranging from dietary The NFNI and the NIPH-NIH, both activities, provided both directly (training, consulting to long-term care by qualified subordinated to the MoH, are the two consultations) and through public health interdisciplinary teams (physicians, key national institutes that undertake media campaigns. They do not look at dieticians, psychologists, physical epidemiological research in the area other activities such as food taxation or activity trainers), that last from one to of obesity and related issues, such as media regulation. two years. Although the number of such nutrition, and provide data to support the local activities remains low (about 50 MoH in problem identification and issue Regional and local governments may local activities in 2018), they may have recognition. Both institutes undertake contribute to obesity prevention and a positive impact on reducing obesity this work independently and on behalf management at those levels. Regional and prevalence in the future. Additionally, all of the Ministry. Most of their activities local self-governments are responsible

Eurohealth — Vol.25 | No.1 | 2019 26 Eurohealth Systems and Policies

for developing their own health policies financing for research and data analysis 8 NCD Risk Factor Collaboration (NCD-RisC). and health programmes, depending on the on obesity. Unfortunately, the anticipated Worldwide trends in body-mass index, underweight, needs of their populations. These policies financial resources fall short of what was overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement and programmes are usually part of their recommended by experts and remains studies in 128.9 million children, adolescents, and wider development strategies and reflect politically dependent as the annual budget adults. Lancet 2017;390:2627 – 42. NCD RisC data. strategic national goals included in the will be determined by government. Available at: http://ncdrisc.org/

NHP. Since they are financed mainly Moreover, while many organisations are 9 National Health Programme for the years from local budgets and since developing willing to play a major role in the area of 2016 – 2020. Available at: http://dziennikustaw.gov.pl/ prevention and health promotion policies public health, none of them, including the DU/2016/1492/1 and programs is not mandatory, only a NIPH-NIH, is fully prepared to assume few self-governments have introduced a leading role. This lack of preparedness such policies and programmes in the area is due to a lack of knowledge, resources, of obesity. staff and experience. Future developments will very much depend on building a The Act on Public Health, adopted in clear mandate for the government’s new September 2015, foresaw the establishment plenipotentiary for public health, created of the Public Health Council, which will by the Act on Public Health. act as an advisory body to the MoH by providing opinions but also suggesting References new activities in the area of public health. Nevertheless, they have not yet 1 World Bank. GDP per capita (current US$). recommended any important policies to Washington: The World Bank, 2018. Available at: https://data.worldbank.org/indicator/NY.GDP.PCAP. the MoH in the field of obesity. CD

2 OECD. OECD Health Statistics. Paris: OECD, Conclusion 2015. Available at: http://www.oecd.org/els/health- systems/health-data.htm The potential role of public health in 3 creating a healthy society and contributing Stepaniak U, Micek A, Was´kiewicz A, et al. Prevalence of general and abdominal obesity and to economic development remains poorly overweight among adults in Poland Results of the recognised by the majority of political WOBASZ II study (2013–2014) and comparison and government institutions in Poland. with the WOBASZ study (2003–2005). Pol Arch Med This attitude, however, seems to be Wewn. 2016; 126 (9): 662 – 71. Available at: https:// slowly changing and the importance of www.ncbi.nlm.nih.gov/pubmed/27535012 public health problems, including obesity, 4 NFNI (undated) Musimy zatrzymac´ epidemie˛ is being increasingly recognised. Yet, otyłosći (We must stop the obesity epidemic). there is still little understanding among Available at: http://www.izz.waw.pl/pl/strona- gowna/3-aktualnoci/aktualnoci/541-musimy- policymakers of the effectiveness of zatrzymac-epidemie-otylosci various policy tools that could be used to 5 tackle public health problems, in particular WHO Europe. Social determinants of health and well-being among young people. Health Behaviour with regard to legal and fiscal measures. in School-aged Children (HBSC) study: international report from the 2009/2010 survey, Health Policy Systematic monitoring of obesity for Children and Adolescents, No. 6. Copenhagen: prevalence in the population and WHO Regional Office for Europe, 2012. evaluation of implemented programs are 6 UNICEF Office of Research. Warunki i jakosć´ z˙ycia still missing. The New Public Health dzieci w krajach rozwinie˛tych. Analiza porównawcza Act states that at least 10% of resources (The conditions and quality of life of children in allocated to the implementation of the developed countries. Comparative analysis). Report Card 11, Florencja: UNICEF Office of Research, NHP will be dedicated to monitoring, 2013. Available at: https://www.unicef.pl/content/ evaluation and scientific research in download/12107/116935/file/Warunki%20i%20 the field of public health, including jako%C5%9B%C4%87%20%C5%BCycia%20 obesity. If this target is met, significant dzieci%20w%20krajach%20rozwini%C4%99tych. improvements could be made to data pdf collection and evaluation in this area. 7 Fijałkowska A, Oblacin´ska A, Stalmach M. (Polish COSI results 2016). Nadwaga i otyłosć´ The new Public Health Act promises to u polskich 8-latków w s´wietle uwarunkowan´ biologicznych, behawioralnych i społecznych. introduce many other improvements in Available at: http://www.imid.med.pl/files/imid/ the area of obesity policy: a dedicated Do%20pobrania/Raport%20COSI_kwiecie%C5%84. institution responsible for the development pdf of policies in this area and dedicated

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Monitor 27

NEW PUBLICATIONS

The role of public health organizations in addressing Averting the AMR crisis. What are the avenues for public health problems in Europe: The case of policy action for countries in Europe? obesity, alcohol and antimicrobial resistance By: M Anderson, C Clift, K Schulze, A Sagan, S Nahrgang, DA Ouakrim, E Mossialos Edited by: B Rechel, A Maresso, A Sagan, C Hernández- Quevedo, E Richardson, E Jakubowski, M McKee, E Nolte Copenhagen: World Health Organization (acting as the host organization for, and secretariat of, the European Observatory on Copenhagen: World Health Organization (acting as the host Health Systems and Policies), 2019 organization for, and secretariat of, the European Observatory on Health Systems and Policies), 2018 Observatory Policy Brief 32

Number of pages: xiii + 104 pages; ISBN: 978 92 890 5171 2 Number of pages: 38; ISSN: 1997-8073

Available at: http://www.euro.who.int/__data/assets/pdf_ Freely available for download: http://www.euro.who.int/__data/ file/0011/383546/hp-series-51-eng.pdf?ua=1 assets/pdf_file/0005/397652/PolicyBrief_PB32_FINAL_WEB. pdf?ua=1 Growing levels of obesity, continued harmful consumption of alcohol, and the growing threat of antimicrobial resistance (AMR) This policy brief summarises some of the key policy avenues for are some of the greatest contemporary challenges to the health of tackling antimicrobial resistance (AMR). Following the widely European populations. While their magnitude varies from country accepted ‘One Health’

to country, all are looking for policy optionsCover_PB32.qxp_Cover_policy_brief to 06/02/2019 contain 10:55 Page 1 these approach to combating AMR,

World Health Organization threats to population health. It is clear thatRegional public Office for Europe health the brief aims to support the UN City, Marmorvej 51, HEALTH SYSTEMS AND POLICY ANALYSIS DK-2100 Copenhagen Ø, Denmark organisations must play a part in any response,Tel.: +45 39 17 17 17 and that implementation of national Fax: +45 39 17 18 18 E-mail: [email protected] intersectoralweb site: www.euro.who.int action beyond the action plans (NAPs) on AMR, POLICY BRIEF 32 is a 51 51 health systemThe European Observatory is needed.on Health Systems and Policies What is drawing on numerous f public y ORGANIZA e o partnership that supports and promotes evidence-based health , E ol Averting the AMR crisis

of alcohol

c i l tion The r o

mful consump d policy-making through comprehensive and rigorous analysis of

s e i r e

har ary i S dren), continued test contempor t tions hil ea e among c of the gr to health systems in the European Region. It brings together a wide e some ntry d ganiza of obesity (including (AMR) ar ies from cou levels resistance de var Growing obial heir magnitu b health or less clear,range ofhowever, policy-makers, academics and ispractitioners what to analyse role What are the avenues for policy examples of effective policies f antimicr le t o i y owing threat ulations. Wh tion health.

gr op :

P h t l a e the an p H trends in health reform, drawing on experience from across and urope eats to popula th of E B s to the heal o contain these thr sectoral e er e challeng y options t , and that int dressing public Europe to illuminate policy issues. The Observatory’s products action for countries in Europe? ooking for polic y response r in ad e l in an health n country, all ar t play a part t role public ope are available on its web site (http://www.healthobservatory.eu). mus is wha d ganizations , however, TION AND FINANCING lth or clear hea t is less R ems in Eur clear that public needed. Wha obl is is e public health organisations implemented by European It system ems. health obl c beyond the ts from nine health pr tion essing these pr por h ac y play in addr d country re entl ile , e tions curr sed on deta Netherlands cohol Michael Anderson organiza . It is ba va, the l , al to fill Moldo , aims lic of g f obesity lume epub essin E that this vo y, Italy, the R tions in addr the gap German rganiza l The case o is e, o k This gland, Franc public health fluence of esistance Charles Clift (En of d in e n countries nvolvement he power an obial r pea e i e t currently play in addressing Union Member States and ro th lor u n e J E d Sweden) o e reports exp e policy cycl a an hes of th a and antimicr and, Sloveni resistance. T the stages Kai Schulze ol al of n, k P antimicrobi tors in each plementatio and ac g, im u sity, alcohol vis other key cision-makin obe is-a- , de b anizations v y formulation y: rg lic o blic health o cognition, po Edited b Anna Sagan pu d issue re w ntification an nine (problem ide . tions in the s nd Rechel tion) organiza k Ber these problems. involving the human, animal valua health lores Saskia Nahrgang oring and e of public nd exp i and monit ement nses, a , involv respo esso assesses the es the policy M Anna Mar comparison blem, describ hallenges. pro a A cross-country e scale of the Driss Ait Ouakrim outlines th ee public health c r covered. It dressing these thr Systems t Anna Sagan edo untries Health i v co tions in ad y on n z-Que ganiza n Observator It nánde Elias Mossialos ropea alth. e OF u M the role of public health or etween the E and Public H Cristina Her and environmental health llaboration b alth Systems s co He ice c sult of close e, Division of c health serv hardson udy is the re e for Europ cing of publi K Erica Ric This st al Offic d finan PUBLIC HEAL ion an e the WHO Reg : Organization try reports. ies and cations e: coun e wski This volume provides detailed nd Polic ry publi in Europ Jakubo a ervato rvices , Elke er Obs alth se o oth ic he E companies tw ncing of publ ac and fina l ee nization l tin McK rga e Mar Europe and O sectors. in n

e N en Nolt , Ell tems and Policies o s l

t country reports from nine rs tory on Health Sy he edito e T t the European Observa esearch Officer a . d Rechel is R Tropical Medicine Policies. Bern hool of Hygiene & Systems and ondon Sc tory on Health based at the L pean Observa , t the Euro olicies TH SER arch Officer a stems and P aresso is Rese tory on Health Sy European countries (England, This policy brief was Anna M opean Observa ch Officer at the Eur . Sagan is Resear olitical Science lth Systems Anna hool of Economics and P tory on Hea t the London Sc opean Observa In support of the Romanian Council Presidency based a ch Officer at the Eur . do is Resear olitical Science FcaUb]UbDfYg]XYbWmcZh\Y7cibW]`cZh\Y9ifcdYUbIb]cb ueve VICE Hernández-Q f Economics and P Cristina ondon School o stems and France, Germany, Italy, ISSN prepared to support the , based at the L tory on Health Sy and Policies opean Observa h Officer at the Eur . 1997–8065 son is Researc Tropical Medicine Erica Richard hool of Hygiene & stems S IN EUROPE t the London Sc f Health Sy Policies, based a ategy at the Division o or Policy and Str Copenhagen. is Senior Advisor f ope, based in the Republic of Moldova, Romanian EU Council bowski or Eur ropical Elke Jaku egional Office f f Hygiene & T or the WHO R ondon School o . and Public Health f t the L olicies opean Public Health a stems and P ofessor of Eur tory on Health Sy n McKee is Pr opean Observa Marti ector at the Eur as previously hub esearch Dir esearch and w . Medicine and R stems R stems and Policies the Netherlands, Poland, Presidency, which hosted a ofessor of Health Services and Sy tory on Health Sy Ellen Nolte is Pr f the European Observa or the London hubs o coordinator f

. 51 9 Slovenia and Sweden) on the conference on ‘Next Steps to Making the EU a Good Practice olicy Series No 7 Health P 8 9 .eu 2 tory 8 www.healthobserva 9 051712 involvement of public health in Combating Resistance to Antimicrobials’ (Bucharest, organisations in addressing 1 March 2019). It draws significantly on a forthcoming study, obesity, alcohol and antimicrobial Challenges in Tackling Antimicrobial Resistance: Economic resistance. These reports explore the power and influence of and Policy Responses, being co-produced by the Observatory public health organisations vis-a-vis other key actors in each of and the Organisation for Economic Co-operation and the stages of the policy cycle (problem identification and issue Development (OECD). recognition, policy formulation, decision-making, implementation, Contents: Foreword; Acknowledgments / Acronyms; List of and monitoring and evaluation). tables, figures and boxes; Key messages; Executive summary; A cross-country comparison assesses the involvement of public Introduction; The health and economic impact of AMR; Global health organisations in the nine countries covered. It outlines action to date; What are the options? Essential AMR policies the scale of the problem, describes the policy responses, and and priority interventions; Facilitating successful implementation explores the role of public health organisations in addressing of ‘One Health’ AMR NAPs: governance is key; Discussion; these three public health challenges. Appendix; References.

Contents: Cross-country analysis: Introduction, Obesity, Alcohol, Antimicrobial resistance, Key policy lessons; Country reports.

Eurohealth — Vol.25 | No.1 | 2019 28 Eurohealth Monitor

HSPM COUNTRY NEWS

The Observatory’s Health Systems handed over to GPs based on individual follow chronically ill and complex patients and Policy Monitor platform provides agreements between the GP and the identified by GPs or specialists with whom systematic descriptions of country treating oncologist and by an explicit they will collaborate directly in primary care health systems and features up- approval of the patient. Professional teams or within hospital and social care to-date information on ongoing associations believe that GPs are easier institutions. Advanced nursing practices will health reforms and policies. See to reach for the majority of patients and cover prevention and screening activities, the individual country pages for will enhance access to care. Monitoring of prescription of complementary exams, these news items and more: patients at a high risk of disease relapse and renewal or adjustment of medical http://www.hspm.org will however remain the responsibility of prescriptions. Advanced nurses will first be oncologists. Oncologists estimate that two introduced for chronic diseases managed thirds of specialised oncology centres’ in primary care (e.g. diabetes or epilepsy), patients will be affected by this care oncology, haemato-oncology and chronic delivery change. GPs will be paid for this renal disorders, before being extended to Compiled by Gemma Williams, based new task through fee-for-service, additional other clinical areas. on July – December 2018 reform logs. to general capitation payments.

Germany: HPV vaccination for boys will Croatia: Adoption of a national plan for Estonia: Health workers’ collective be covered by statutory health insurance the development of hospitals agreement for the next two years agreed Statutory sickness funds will pay In September 2018, the government Representatives from provider associations for the human papillomavirus (HPV) adopted the new National Plan for the and health professionals’ unions signed vaccination to be extended to boys. Development of Clinical Hospital Centres, a collective agreement for the next two The Joint Federal Committee decided Clinical Hospitals, Clinics and General years in November 2018. The minimum on 20th September 2018 to include Hospitals in the Republic of Croatia hourly wages for doctors, nurses and other the HPV vaccination for all children (2018 – 2020). The plan is a continuation health care professionals will increase up between 9 and 14 years in the statutory of an earlier plan that was in place for to €13.30, €8.00 and €5.00 respectively health insurance benefit catalogue. The the 2015 – 2016 period. Its main goals are to by 2020. This translates into an increased decision is based on a recommendation increase access to hospital care, improve minimum wage of 18.1% for doctors, of the Standing Vaccination Commission quality of hospital care, and increase 16.8% for nurses and 19.0% for other (STIKO) based at the Robert-Koch-Institute efficiency of care delivery in hospital. health professionals. In addition, night (RKI) for this age group. The vaccine has The implementation of these goals will and weekend shift allowances, compared been recommended for girls to prevent be guided by two principles described in to the minimum required by the law, will cervical cancer since 2007. In June 2018, the plan: the principle of subsidiarity and gradually be introduced. These negotiations the STIKO recommended extending functional integration of hospitals. The plan received relatively little public attention vaccination coverage to boys. will also help steer the implementation of compared to previous negotiations, in part EU funded investments projects in the area due to a strong economic environment of hospital infrastructure. which supported a positive approach Ireland: The public health alcohol towards negotiations. act 2018

Czech Republic: Strengthening primary The Public Health Alcohol Act came into care physicians’ competencies for France: The introduction of advanced law on 3 October 2018. The law is historic oncology patients nursing practice as it is the first time the Irish government has used legislation as a public health As part of primary care reforms, Advanced nursing practice was introduced measure in relation to alcohol and because primary care physicians (GPs) will be in France in July 2018 to improve access it introduces restrictions on alcohol not able to gain new competencies as of to care and management of chronic in place in other countries. The wide- January 2019 to treat patients following diseases. Nurses with at least three years ranging piece of legislation supports successful oncological treatment that of experience can now complete two years implementation of a minimum unit price of require specialised regular checkups of additional training at Master’s level to €0.10 per gram of alcohol; restrictions on and examinations, but are not in need of undertake tasks formerly completed by advertising and warning labels on alcohol further therapeutic treatment. Monitoring medical doctors. According to the new products including cancer warnings; the of recovered oncology patients will be legislation, trained nurses will be able to separation and reduced visibility of alcohol

Eurohealth — Vol.25 | No.1 | 2019 Eurohealth Monitor 29

products in mixed trading outlets; and the treatment for Hepatitis C has been Switzerland: Six groups of surgical regulation of the sale and supply of alcohol extended since 2016, when an innovative interventions to be moved to outpatient in certain circumstances. interferon-free treatment was made care available to 5,860 patients with advanced stage of fibrosis (F4). In 2017 treatment was From 1 January 2019, six groups of surgical Lithuania: Locations for the sale of offered to almost 10,000 patients, including interventions will only be reimbursed if selected medicines to be expanded those in stages F3 and F2. Prevalence of undertaken on an outpatient basis in Hepatitis C virus infection stands at 3.3% an effort to create uniform regulations Starting from January 2019, certain non- of the Romanian population (over 660,000 for all insured individuals in Switzerland prescription medicines are available for people), which is the highest rate in the EU. who undergo these procedures. The sale not just in pharmacies, but also in The measures described above are meant interventions affected are: 1. unilateral stores, petrol stations, and other retail to contribute to the WHO and EU efforts to varicose vein surgery of the legs; points. Approximately 50 medications will eliminate Hepatitis C by 2030. 2. haemorrhoid procedures; 3. unilateral be available for sale outside of pharmacies, inguinal hernia surgery; 4. examinations/ mostly those used to treat mild disorders in interventions on the cervix or uterus; children over the age of 12 and in adults, for Poland: Piloting of comprehensive care 5. knee arthroscopy, including arthroscopic example those containing paracetamol or for people with heart failure surgery on the meniscus; 6. tonsil and ibuprofen. The medicines must be sold in adenoid surgery. Criteria are being packaging containing the smallest available In November 2018 the Minister of Health developed to determine exceptional cases quantities, while only adults over 16 years initiated a two-year pilot of Comprehensive in which inpatient treatment can continue of age can purchase no more than one Care for People with Heart Failure to be reimbursed. pack of the same medicine. The prices (Kompleksowa Opieka Nad Osobami z of medicines sold in retail points cannot Niewydolnos´cia˛ Serca, KONS). The pilot exceed the price of equivalent medicines will be implemented by six coordinating sold in pharmacies. centres and will cover over 5,000 patients. KONS comprises ambulatory, hospital and home care. Care will be coordinated Portugal: Increased availability of HIV by a team consisting of a family doctor, self-testing kits nurse, cardiologist and other specialists. Telemedicine will be used to improve HIV self-testing, as well as Hepatitis B and coordination between the family physician Hepatitis C self-testing, will be available and the cardiologist. Patients with the over the counter in Portugal, following most advanced form of heart failure will government approval of their sale in be referred to educational and advisory community pharmacies without the need centres where they (and their families) will for a medical prescription (Decree-Law receive diet and psychological advice. No. 79/2018, of 15 October 2018). Tests are already available in community pharmacies in Cascais (since 10 October 2018), and will Spain: Extension of the common health be gradually expanded to other pharmacies benefits package throughout the country. The decision follows 2016 WHO guidelines on HIV self- In November 2018, the Ministry of Health testing which recommend that: “HIV self- and the regional health representatives testing should be offered as an additional approved a revision to the common approach to HIV testing services”, aiming to health benefits package. New benefits reduce late HIV diagnosis and eliminate HIV covered include both areola and nipple epidemics by 2030. micropigmentation techniques as part of breast reconstruction, new models of external prosthesis for breast implants, Romania: Improved access to innovative facial restoration and eye readers for treatment for Hepatitis C motor neurone disease and hearing aids for older people. In addition, the screening In September 2018, the National Health programme for cervical cancer will become Insurance House (NHIH) announced that population-based, while five patient groups Hepatitis C treatment will be made available with Type I diabetes requiring more than six to 13,000 patients in all stages of fibrosis. glycaemic controls per day will benefit from The number of contracted providers was the use of flash glucose monitors. also increased. Access to innovative

Eurohealth — Vol.25 | No.1 | 2019 13th OBSERVATORY VENICE SUMMER SCHOOL 2019

Skill-mix innovation in primary and chronic care: mobilizing the health workforce

21 – 27 July 2019 San Servolo, Venice, Italy.

The Observatory Venice Summer School is a short, intensive course. It is a week of learning, interacting, studying, debating, and sharing experiences with other policy makers, planners and professionals to understand, discuss and improve skill- mix strategies and policies.

Objectives • Understanding definitions of skill-mix innovation and analysing skill-mix trends, drivers and outcomes in countries • Reviewing policy and other governance approaches for creating and How to apply Twitter account: implementing skill-mix innovation (e.g. @OBSsummerschool regulation, education, payment policies) Submit your CV, photo and application form before 31 May 2019. • Assessing skill-mix innovation for integrated care (including the hospital Summer School’s fee: €2,260 (includes interface) teaching material, social programme, transfer from/to the airport to/from the • Preparing for future challenges island, boat to Venice, accommodation and trends. and meals). PLACES ARE LIMITED therefore early applications Accreditation are strongly encouraged. Additional information available at: The Summer School has applied to www.theobservatorysummerschool.org the European Accreditation Council WE AWAIT YOU IN VENICE! for Continuing Medical Education and or email: it is expected that participation will [email protected] count towards ongoing professional development in all EU Member States.