Obesity on the move – Changing perceptions about a weighty issue

Changing perceptions about a weighty issue

Contents Preface

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Executive summary Conclusions Implications for stakeholders

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Burson-Marsteller’s approach An integrated approach as necessary condition The obesity lifecycle concept ‘Honest’ or ‘false’ communication

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1 Introductory overview 1.1 Whose fault is fat?

1.2 Objectives 1.3 Research methodology

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2 The issue of overweight and obesity 2.1 The medical perspective 2.2 Changes in dietary habits 2.3 Physical activity 2.4 A global perspective

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3 Medical and expert opinions in the Netherlands 3.1 Scientific research 3.2 Obesity and children 3.3 Product modification 3.4 Consumer confusion, information and education 3.5 Cultural differences

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4 Parties within the Dutch public domain 4.1 The Dutch government 4.2 Political parties 4.3 Non-governmental organisations 4.4 The Dutch media

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5 The Dutch food industry 5.1 Policies of food industry associations 5.2 Policies of food companies

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6 Other industries in the Netherlands 6.1 The retail sector 6.2 Eating out and the Royal Dutch Catering Association 6.3 Healthcare insurers 6.4 The computer industry

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7 Physical activity in the Netherlands 7.1 An inactive lifestyle?

7.2 Barriers to an increase in physical activity

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8 Position of overweight and obesity in the issue lifecycle 8.1 The issues of smoking, alcohol and obesity compared 8.2 The obesity issue lifecycle

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Appendix I List of interviewed stakeholders

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Appendix II List of abbreviations

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Appendix III List of literature

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Appendix IV Media analysis

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Appendix V Obesity treatment flowchart

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Colofon Graphic Design Ontwerpwerk, Den Haag Printing Drukkerij Giethoorn ten Brink, Meppel Š Burson-Marsteller 2005

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Preface In August 2004 I started on the last leg of my Policy, Communication and Organisation studies at the Free University of Amsterdam: a traineeship to help prepare the ground for writing my final thesis. I was very privileged to be taken on by the Healthcare Practice of Burson-Marsteller in Amsterdam, Burson-Marsteller being one of the world’s leading public relations firms.

My basic premise when embarking on my traineeship was that the academic discipline of communications and issue management and the phenomenon of obesity were bound to be closely linked.

This research paper is the backbone of my thesis. (Unfortunately) scientific publications need more theoretical underground, with which I will not bother you in this report.

This report gives a comprehensive overview of the perceptions and status of the obesity issue in the Netherlands. It will guide through the history of the issue, provides insights in various (inter)national programmes and gives an overview of the current perceptions and expectations of the various stakeholders in the Netherlands. Finally it contains an analysis of the possible implications of the issue for key stakeholders.

The report is written for all audiences who are engaged or interested in the subject of obesity. I surely hope this report will be on the shelf of each individual that has a stake or an interest in the obesity debate.

For getting the chance to work with the consultants at Burson-Marsteller in Amsterdam and having the opportunity to do research in the obesity issue, I would like to express my sincere gratitude to all the respondents for investing their time and my mentor Ingmar de Gooijer, Head of the Healthcare Practice at Burson-Marsteller.

Gijs Boeijen January 2005, Amsterdam

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Executive summary Conclusions The increase in overweight and obesity is a complex issue; no stakeholder can be held solely responsible. A solution can only be reached if there is an integrated approach, with stakeholders working together.

Since there are so many influential factors contributing to the overweight and obesity issue, an integrated approach to tackling the problem is paramount. Product labelling can be improved, but if the public is not informed and educated as to caloric intake or a healthy eating pattern, efforts are wasted. Parents may be aware that their children should be active, but if schools make little provision for physical activity and the neighbourhood has no playgrounds or sports facilities, the problem is exacerbated.

The structure and organisation of society has changed in its fundaments.

Obesity is one of the results of this incremental change. To stop the rise of obesity, a vision and an integrated approach are needed, as well as coordinated activities on executive level. All stakeholders, such as local governments, schools, and day care centres, should adapt their policy, based on the same vision and direction, and work closely together. For example in Sweden it is the National Health Institute who is the coordinator of all activities whereas the government is responsible for developing an overall strategic approach.

The government is doing too little; political parties won’t ‘own’ the issue.

Most stakeholders hold strong views about the lack of vision and direction of the government in solving the obesity problem. They feel the government is responsible in providing direction and coordinating efforts and programmes (subsidised by the government) that combat obesity.

According to the private sector, the government should only provide direction, not legislation. Other stakeholders think that the government should focus on providing direction but also legislate with regard to labelling, health claims and marketing.

No political party has claimed the issue of overweight and obesity; politically speaking, it is not a very ‘sexy’ topic. Only infrequently the Minister of Health is publicly asked to defend policies.

7 NGOs are in conflict regarding overweight and obesity.

Organisations such as the Nutrition Centre and the NISB (Dutch institute for sports and physical activity) are often in conflict to secure their funding from government and do not agree on evaluation criteria to measure the effectiveness of their programmes. This division between physical activity and dietary patterns is detrimental to fighting the issue.

Overweight and obesity is a problem that has the most impact on the lives of lower-educated and foreign members of Dutch society.

Whilst stakeholders agree that the real problem is situated in these groups, many campaigns are targeted at the higher-income middle classes. Some stakeholders comment that it is not a lack of understanding of the target groups which causes this, but an inability to effectively implement successful campaigns in the Netherlands. Critics point to NGOs’ too great a focus on meeting evaluation criteria in order to secure funding, rather than targeting the more challenging problem in lower-educated and foreign groups in society.

The obesity debate is characterised by a game of ‘blame and shame’.

To an increasing extent the individual is blamed for making the wrong choices regarding diet and exercise. The food industry is blamed for stimulating ‘unhealthy’ diets. The government is blamed for doing too little. This game of blame and shame diverts attention from the real problems and prevents a united approach to tackling the issue.

Self-regulation of the food industry is not enough to prevent legislative action.

Advertising to children and in-pack product gifts will be the major subject of legislation. This has already become a reality in parts of Europe and the Minister of Health has stated that in-pack gifts should be restricted. A large percentage of parents have indicated their support for measures against advertising directed at children, with suggestions for a ban up to either the age of six or twelve.

There is no short-term solution to the problem of obesity and overweight; an effective, workable solution could take years.

Stakeholders seem to agree that the development and implementation of a successful solution will take many years. For example, forty years ago the public knew of the damage that smoking can do to one’s health. Only recently attitudes have begun to significantly change; still many people continue to smoke.

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There is too much emphasis on the responsibility of the individual.

Because overweight and obesity is seen as a process of caloric intake versus energy expenditure, some stakeholders feel that when people are informed about diet and physical activity they should be able to make the right food choices.

Political and governmental stakeholders see their primary responsibility end in providing this information. This supposes then, that if someone is overweight it means that he or she is not strong-willed enough to make the right choice concerning diet and physical activity. But because many negative health consequences of overweight and obesity (such as diabetes) are not noticeable in the short term, the real impact of obesity is underestimated by individuals.

People tend to perceive their healthcare premiums as a ‘buy off’ of their responsibility for their health status. There are stakeholders who see the weakness of individuals in making right choices and the fact they buy off their health status through premiums as morally justified reasons to charge higher health insurance premiums.

Physical activity does not necessarily have as great a role to play as expected.

The general notion is that physical activity has declined enormously.

Compared to 100 years ago this is indeed the case. However, in the last 25 years time spent in physical exercise has increased from 4 hours (1975) to 4.4 hours (2000) per week. However, there is valid concern for the future, because from 1995 the amount of exercise has decreased from 5.2 to 4.4 hours.

Because daily life and work tasks require a lot less energy expenditure, the net effect of calories burnt due to sport, exercise, work and performing daily tasks could well have decreased. Generally speaking, stakeholders believe it is easier for the food industry to reduce the amount of calories in a product than it is to get people out of their cars.

Most can be expected in the short-term from product modification.

Many stakeholders consider product modification the most promising short-term action. Small changes in products can contribute a great deal to healthier dietary patterns – and are often barely noticeable by the consumer. The introduction of new ‘light’ products receives some applause but the modification of existing foods to contain lower fat, sugar and salt is preferred.

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Education is central to the overweight and obesity debate.

All stakeholders agree that starting from primary school age, children should be educated about nutrition, a good dietary pattern and the value of physical activity. Stakeholders emphasize the disappearance of ‘housekeeping schools’ and the budgetary restrictions on school courses in subject areas such as healthcare and physical education. Schools and the Ministry of Education have primary responsibility for education, but educational programmes can also be created in cooperation with organisations such as the Nutrition Centre, the Heart Association and NISB. There is a lack of general understanding amongst stakeholders concerning the position of health insurance companies.

Many stakeholders believe it is an obligation of the healthcare insurance companies to be proactive regarding prevention. Prevention, however, is the responsibility of the government.

The obesity debate must not become a medical discussion.

The issue is inclined to become a medical discussion. However, healthcare professionals address the problem in terms of disease, epidemic, possible medication and cure. The real solutions are in the ‘prevention arena’.

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Implications for stakeholders No solution has (yet) been reached for the obesity ‘epidemic’. It is expected that the debate will continue and become more intense for all stakeholders involved. The following four possible scenarios of the development of the issue and implications for key stakeholders can be distinguished (see figure 1): status quo; boycotts; legislation; and self-regulation.

SOLU TION

Figure 1: Possible directions of the obesity issue, Burson-Marsteller 2004.

Legislation

Self-regulation

NON I N D U S T RY INTEREST ( NGOs )

INDUSTRY INTER EST Boycotts

Status quo

NO SOLU TION

Status quo When industry interest is combined with no solution to the issue, the result is status quo, meaning that no change is effected. This was the case for the first 20 years of the tobacco issue; tobacco could still be sold everywhere and there were no restrictions on marketing.

Boycotts Boycotts can result when the ‘expectations gap’ – a gap between current and expected behaviour from an organisation – remains and high pressure from stakeholders such as NGOs continues. Shell’s Brent Spar issue is an example of this. When Shell decided not to sink the oil platform despite pressure from NGOs, the oil company was boycotted in various countries.

Whilst this action presents no real solution, it forces the company to focus on a short-term fix.

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Self-regulation As an issue arises, self-regulation is often the preferred approach for industry and political stakeholders. Industry is not eager for legislative restraints and governments see such a solution as ‘next best’ solution: legislation means resistance, administrative burden, and higher costs.

The current status of overweight and obesity in the Netherlands suggests that self-regulation might not be as effective as expected. It should be noted that self-regulation is not only a solution in the best interest of the industry, it could also prove to be satisfactory for NGOs and political stakeholders. In the case of complex issues such as overweight and obesity some aspects of the issue might be solvable by self-regulation, but usually not all.

Legislation As with the tobacco issue, after a period of attempted self-regulation follows legislation.

In the Netherlands, the overall scenario seems to be moving from selfregulation towards legislation, in the footsteps of the tobacco issue.

Of course on sub levels of the problem various scenarios are probable.

As mentioned in some cases, the government will develop legislation (advertising to children). Self-regulation is probable when looking at the eating out sector regarding caloric information of menus. Boycotts as a scenario is not very realistic at this time, although the Dutch consumer association has gone its own way by not signing the National Obesity Covenant. Status quo as the fourth scenario will be the case in various terrains such as healthcare insurance. It is not probable that government will allocate more funds for the private healthcare insurers regarding prevention.

Taking the conclusions and scenarios into consideration, the following implications for key stakeholders can be defined.

- Food industry The food industry will face legislation regarding marketing, advertising and claims. They will become more pro-active regarding aspects such as product modification and labelling to prevent further legislation.

- Retail Supermarkets will face legislation regarding advertising and claims on food products (house brands). It is expected that a system (such as the traffic light system) will be introduced that will give more information on the nutritional value of food products within product categories (such as snacks and dairy).

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- National government Judging current developments, it seems that the Ministry of Public Health has now decided it will take further steps besides self-regulation and will become more active.

- NGOs NGOs will be called upon to coordinate initiatives. For instance in big public campaigns that are meant to inform consumers about obesity, organisations need to team up and report about the importance of the combination of dietary pattern and exercise instead of apart from each other. NGOs will be asked to address specific groups such as the low-educated and foreigners.

- Politics Now that obesity also affects the middle societal class, and the economical costs have been estimated, it is expected that political parties will become more active.

- Eating out industry The eating out industry will face bigger pressure from the outside world.

Eventually they will have to accept that many stakeholders find they have a responsibility regarding the issue of obesity, and will start giving information such as caloric value of menu items.

- Local governments At a local level specific policies will be constructed for ‘problem’ groups (such as the low-educated and foreigners). Long term goals will be determined and translated into policy plans. Barriers in reaching policy goals will be identified, and available knowledge will be implemented.

- Healthcare insurers It is not expected that the healthcare insurers as a group will become more active regarding obesity. Because prevention is not a formal task of the healthcare insurers and no budgets have been made available by the government, it will remain the responsibility of the individual healthcare insurers. Certain individual healthcare insurers will address the issue.

- Media The media will remain focusing on the food companies, and not on the outtake side of the problem. There also is the risk of ‘obesity overload’; too much media coverage on the subject could result in loss of interest for the subject, and also momentum for change, resulting in a status quo with all the negative consequences.

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- Medical arena The medical world is gaining influence within the obesity debate. Healthcare professionals think in terms of solving health problems, when persons are already in need of medical attention. Because most stakeholders agree that prevention is the most effective way in solving the obesity epidemic, society must be careful in ‘giving more power’ to the medical arena.

- Computer industry The pressure on industries such as the computer industry will increase steadily.

As the issue develops, more industries will be addressed, reports already mention that toy manufacturers have been asked to contribute. They could for instance focus on toys that require physical activity.

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Burson-Marsteller’s approach There is no doubt that obesity is one of the most complex global health issues at this moment. Not only are multiple stakeholders involved, the issue is also related to fundamental changes in society and the way people live. There is a continuous struggle in finding the right balance between the responsibility of the individual and the role of the private and public sector.

There is clearly no ‘one fits all’ solution for tackling the obesity problem because there are different ways of looking at the issue (see figure 2), resulting in different approaches and programmes.

Exercise

Diet

Genetics

Environment

Figure 2: The obesity puzzle, Burson-Marsteller 2004.

An integrated approach as necessary condition The obesity issue requires an overall approach, addressing the interests of all individual stakeholders. At this moment various organisations are developing and executing campaigns that address partial aspects of the obesity problem. For instance, the Nutrition Centre focuses on the intake part, whereas the Sports Association focuses on the outtake aspects. The campaigns of both organisations at this moment are not precisely fine tuned to each other. One of the campaigns of the Nutrition Centre addresses physical activity and accompanying information materials are sent to schools. The Ministry of Education and the Sports Association were not deeply involved.

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The efforts made will therefore not realise the effect that could have been accomplished if agreements had been made between the parties regarding the overall objectives and ways of collaboration.

Developing effective campaigns aimed at decreasing the obesity issue will be realised if at least the following three conditions have been met: 1. One overall vision and approach (preferably developed by the national government); 2. One institution is responsible for coordinating all campaigns and activities executed by various (semi) public organisations; 3. Objectives and evaluation criteria that are measurable and set on forehand.

The obesity lifecycle concept There are different ways to look at the obesity issue. At this moment single programmes are being executed with a focus on for instance dietary habits, physical exercise or education at schools. Burson-Marsteller prefers to look at the issue through a ‘target group’ perspective, meaning programmes should be tailored per target group and include various aspects as nutrition, exercise and education. Such a perspective can be illustrated through the obesity lifecycle (see figure 3).

Figure 3: The obesity lifecycle, Burson-Marsteller 2004.

er d

C h

CY

Dancing vs video

T

LIFE

GH

t ul

FE

Home cooking vs fast-food Moped vs bicycle

A d

El

Social life vs vslation

Ado le

EI

ild

EI

T

LI

‘ H E A LT H Y ’ LE ent sc

Butter vs becel

W

H

C

Y’

W

Play outdoors vs computer

C

E A LT H

G

Candy vs apple

YC

‘UNH E L

Only work vs exercise Red wine vs beer

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M

EN

W

h ce 0t

ur nt y

2

IN

D

G

ID

BE

The obesity lifecycle visualises moments in a person’s life that are critical in becoming overweight or obese. These moments have been coupled with lifestyle because fighting overweight and obesity inherently means making changes in one’s lifestyle. The lifecycle has been divided into four main stages in a person’s life – at every stage there are critical moments or events that will either present a risk factor for the development of overweight, or will present an opportunity that will contribute to a ‘healthy’ weight. The red cycle represents the ‘unhealthy’ weight lifecycle and the green cycle represents the ‘healthy weight’ lifecycle. Every moment representing an opportunity or threat is also a potential moment of transition from one cycle to another.

NO

Cornerstones of the obesity lifecycle include the following: - Overweight can be linked to history and culture: aspects of culture are passed on from one generation to the next; this therefore presents a cyclical process (see figure 4); - Overweight is a cyclical process that reinforces itself: when someone becomes overweight it is difficult to lose weight again. When parents are overweight, their child has an increased chance of becoming overweight itself, and eventually passing the risk to their children, thus also creating a cycle; - There are critical aspects in life that determine the chance of becoming overweight: in every stage of life one can point to developments that influence the possibility of becoming overweight. For an adult, for example, this could be just after pregnancy, or at the start of employed life. For an adolescent it could be the moment one changes from bicycle to moped, or starts to go out drinking.

Figure 4: The society lifecycle, Burson-Marsteller 2004.

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‘Honest’ or ‘false’ communication

1. Nordström, K.A., Ridderstråle, J. (2003). Karaoke Capatalism.

Stockholm, BookHouse Publishing.

Figure 5: The communication quadrant, Burson-Marsteller 2004.

‘ FA L S E ’ E M O TI O N AL COM M U N I C AT I O N

Based on a thought provoking model developed by Nordström and Ridderstråle1 it is possible to place the communication of companies about their products in four quadrants (see figure 5):

‘ H E A LT H Y ’ PRODUCTS

Dark Angel Enterprise

Heaven Enterprise

Becel ProAktiv

Chiquita Bananas

Hell Enterprise

Biological Eggs

Magnum ice cream

W

‘H ONEST’ EMOTIONAL COMMUNICATION

Enterprise

Red Band Liqourish

?

‘ U N H E A LT H Y’ PRODUCTS

1. Companies producing ‘unhealthy’ products that position their products through ‘false’ emotional communication can be described as ‘Hell Enterprises’. For instance the commercials of Red Band where people become happy and attractive after eating candy.

2. Companies producing ‘healthy’ products that position their products through ‘honest’ emotional communication can be described as ‘Heaven Enterprises’. For instance the commercial of biological eggs show chicken to have more living space, while pressing on the ‘ethical buttons’ of people.

3. Companies producing ‘healthy’ products that position their product through ‘false’ emotional communication can be described as ‘Dark Angel Enterprises’. For instance the commercial of Chiquita bananas shows people starting to dance and feel great after eating bananas.

4. Companies producing ‘unhealthy’ products that position their product through ‘honest emotional communication can be described as ‘White Demon Enterprises’. The commercial of Magnum ice cream in relation to the seven sins is close to a pure example of a White Demon Enterprise. It tells the consumer that the product is a ‘sin’ but it does not communicate the amount of calories and that consumption should not be on a regular basis.

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It is a hypotheses that White Demon Enterprises are the upcoming enterprises. Taking the pressure of society into consideration, such as marketing restriction towards children, products might be able to position themselves as being ‘unhealthy’ products while still being profitable. In the future we could possibly see a commercial of a ‘5000 C Hamburger’. The commercial will state that the 5000 C Hamburger has 5000 calories, is twice the recommended daily calorie intake, but is delicious and shouldn’t be eaten on a daily basis. Through this kind of communication companies remain credible.

Research has proven that current society embraces honest communication and punishes those companies that create false expectations.

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1 Introductory overview 1.1 Whose fault is fat?1

1. The Washington Post (14-07-2004). Whose fault is fat?

In today’s society this is a frequently asked question, both in Europe as well as America. People are becoming increasingly overweight and obese.

On average, 40% of the adults in the Netherlands are overweight and 10% are considered to be obese. An average of 13% of the boys and 14% of the girls are overweight. This percentage is rising and has increased the most amongst young children from the age of three. 2 Since 1980 the percentage of overweight young children has more than doubled. 3 It is expected that the percentage of adults with obesity will increase by another 50% within the next twenty years. 4 Extensive reporting by the media on the overweight and obesity issue has attracted widespread public attention. Daily media reports concentrate predominantly on the controversies of the issue and new angles, such as the discovery of genes causing obesity.

Who is responsible for the current obesity epidemic? Is becoming overweight entirely the responsibility of the individual? Whilst various stakeholders involved offer a variety of responses, these are often contradictory and non-conclusive.

Many companies within the food industry claim to be concerned with the issue of overweight and obesity, evidenced in their codes of corporate social responsibility. Such codes refer to a ‘concern for physical well-being’, the promotion of ‘an active lifestyle,’ and offer ‘products to match the heightened health awareness of customers’.

Furthermore, governments are dealing with the issue through legislation or self-regulation, both terms frequently discussed in the public arena. The various NGOs also fuel the debate with a variety of initiatives and solutions.

1.2 Objectives So when is the right time to start communicating with stakeholders about the issue of overweight and obesity? How does one best communicate one’s perspective?

2. Health Council of the Netherlands (2003). Overweight and obesity. The Hague.

3. RIVM (2004). Our food measured: Healthy and save food in the Netherlands. Houten: Bohn Stafleu Van Loghum.

4. Bemelmans et al (2004). Future developments in overweight: predictions for the Public Health.

RIVM rapport nr. 260301003.

Bilthoven.

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The aim of this report is to provide clarity to these questions, by concentrating on the following objectives: - To understand how the issue developed; - To gain insight into the differing perceptions and expectations of stakeholders; - To clarify the roles and responsibilities of these stakeholders; - To create an overview of the current drivers, barriers and potential solutions.

Chapter 2 looks at the development of the issue from a medical, dietary and global perspective. Chapter 3 presents medical research and expert opinion. Chapter 4 concentrates on the Netherlands – the public sector, governmental organisations, NGOs and the media. Chapters 5,6,7 focus on the private sector and physical activity in the Netherlands. The position of overweight and obesity within the issue lifecycle is addressed in Chapter 8.

1.3 Research methodology This desk-research report was undertaken by Gijs Boeijen, graduate student of the Vrije Universiteit Amsterdam (VU), in cooperation with Burson-Marsteller the Netherlands. Boeijen has combined this desk research with his thesis in the department of BCO (Policy, Communication and Organisation).

Research has been conducted in two parts. Desk research examined literature on the subject of overweight and obesity, including Codes of Conduct from companies within the food industry, political reports at a local, European and global level, research papers, and news reports from newspapers, magazines and the Internet.

Qualitative research involved 26 interviews with key stakeholders (see figure 6). For an extensive list of organisations including the names of the respondents see Appendix I. In the report comment from specific interviewees is anonymous – reference is made instead to ‘research respondent’.

A standardized questionnaire was used, including questions such as: - What is your perception of the issue?

- In your opinion, what impact does this issue have on your organisation?

- Which stakeholders do you consider to be taking responsibility for their part in the issue?

- Do you believe that your organisation does enough?

- How do you imagine this issue will develop in the future?

National Government

VBZ Bakery & Sweets Industry Association

WHO World Health Organisation

Media

ZonMw Research

Cancer Institute Obesity Association

Pharmaceutical companies

Consumer Association

Heart Foundation

Nutrition Centre

Non-governmental organisations

TNO Research Institute

RIVM Research Institute

Dutch Health Council

Universities

Science/knowledge institutions

Eating Out Industry

Retail (Supermarkets)

European Union

Healthcare Insurers

Supra National Institutions

Catering

Food companies

Private Domain

Sport & Exercise

NISB National Institute for

Sport Federation

NOC*NSF Olympic Commity &

Sport Federations

regarding the obesity issue

Political Parties

STAKEH O LDE R S

GGD Local healthcare service

CBL Supermarket Industry Association

NFI Soda Industry Association

Sport

Promotion and Disease Prevention

KHN Restaurant Industry Association

Local Government

NIGZ Netherlands Institute for Health

VAI / FNLI Food Industry Association

Consumers

Public Domain

Industry associations

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Fiugure 6: Overview stakeholders

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2 The issue of overweight and obesity 2.1 The medical perspective “Obesity increases a person’s risk of illness and death due to diabetes, stroke,

5. University of Maryland Medical Center, www.umm.edu/ency/ article/003101.htm

6. Bosch, J. D. et al. Psychological characteristics of obese children/ youngsters and their families: implications for preventive and curative interventions. Patient Education and Counseling (in press).

7. Nutrition Centre, www.voedingscentrum.nl

8. World Health Organisation (2003).

Integrated prevention of non-

Figure 7: BMI, Nutrition Centre.

coronary artery disease, hypertension, high cholesterol, and kidney and gallbladder disorders. Obesity may increase the risk for some types of cancer.

It is also a risk factor for the development of osteoarthritis and sleep apnoea.”5

It appears that the biggest concern for the medical world is the dramatic increase in childhood overweight and obesity. Adult obesity is difficult to treat; therefore early prevention is better than cure. The medical profession points to the importance of parents in the monitoring of, and as a role model for, children’s dietary habits. Engaging parents with the issue is key to the intervention of overweight and obesity at an early stage. 6 Overweight and obesity are not the same. Obesity is considered a chronic disease and can be defined as a form of overweight that compromises health. The Body Mass Index (BMI) is the most commonly used measurement to determine weight. BMI is determined by weight in kilograms divided by height (in meters squared). A BMI above twenty-five is considered overweight; above thirty is considered obese7 (for the BMI calculation see figure 7).

BMI =

kg/m2

Effective treatment of obesity is based on three core components: dietary therapy; physical activity and behaviour therapy. (For a more extensive view of this treatment, see Appendix V).

Medical programmes are generally for the treatment of obesity rather than for people who are overweight. Before treating an individual for obesity a risk assessment is made, taking into consideration the prevalence of co-morbidities (such as diabetes and high cholesterol), BMI and waist circumference. Fat that is positioned near the abdomen poses the greatest risk (for a risk assessment of the waist circumference see figure 8).

Figure 8: Waist circumference,

HIGH RISK

National Institute of Health.

Men > 102 cm (>40 inch)

Women > 88cm (>35 inch)

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Organisations such as The World Health Organisation (WHO) link an unhealthy diet and increasing physical inactivity to an increase in noncommunicable diseases, including certain cancers and diabetes 8 , which is considered to be the next worldwide epidemic. Diabetes Mellitus Type 2 has been considered to develop in older age, however this Type is seen ever more frequently in young people.

Overweight and obesity cannot be explained by dietary habits alone.

A large study conducted in Germany among 7,500 children compared the dietary pattern of obese children with that of children with a normal weight. The study concluded that the obese children did not have more unhealthy diets than those children with a normal weight.9 Whilst overweight and obesity cannot be explained by dietary habits alone, a change in diet is regarded by the medical profession as the most significant contributor to weight loss in the long term. Physical activity is most valuable in the prevention of regaining lost weight.10 Epstein showed that long-term effects of treatment improved when lifestyle changes focused on increasing daily physical activities as opposed to a concentrated few hours of sports per week.11 “An increase in physical activity is an important component of weight-loss therapy, although it will not lead to substantially greater weight loss over 6 months. Most weight loss occurs because of decreased caloric intake.

Sustained physical activity is most helpful in the prevention of weight regain.�12

communicable diseases: Draft global strategy on diet, physical activity and health. Geneva. p. 3

9. Mueller, M.J. et al. (2001). The Kiel Obesity Prevention Study (KOPS).

Obesity Review, vol. 2, p.15-28

10. National Institute of Health (1998). Clinical guidelines on the Identification, Evaluation and Treatment of Overweight and obesity in Adults. NIH report No. 98-4083 11. Epstein L.H. et al. in Binsbergen, J.J. & Mathus-Vliegen, E.M.H. (2003).

Dikke kinderen. Medisch contact, jaargang 58, nr. 14 12. National Institute of Health (1998). Clinical guidelines on the Identification, Evaluation and Treatment of Overweight and obesity in Adults.

NIH report No. 98-4083, p.21

One gram of fat delivers 9 kilocalories or 38 kilojoules. One gram of protein or carbohydrate delivers 4 kilocalories or 17 kilojoules. Alcohol delivers 7 kilocalories per one gram or 29 kilojoules. For age and caloric intake guidelines, see figure 9.

FEMALES

MEN

13-16 year: 2400 kcal

13-16 year: 2600 kcal

16-19 year: 2500 kcal

16-19 year: 3000 kcal

19-22 year: 2200 kcal

19-22 year: 2900 kcal

22-50 year: 2100 kcal

22-50 year: 2600 kcal

50-65 year: 2000 kcal

50-65 year: 2400 kcal

Figure 9: Age and caloric intake,

>65 year: 1900 kcal

>65 year: 2100 kcal

Nutrition Centre.

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13. Novum Nieuws, Associated Press (17-11-2004). For more information on the subject check: www.sciencenews.org/articles

Significantly, scientists from the medical field have made progress in determining two additional contributions to the development of overweight and obesity: genetic factors; and lack of sleep. According to a study in the US, a person sleeping less than four hours a night is 73% more likely to become obese than someone sleeping the recommended seven to nine hours a night. For a person sleeping five hours per night the percentage is 50%; for six hours it is 23%.13

2.2 Changes in dietary habits

14. European Commission: Health & Consumer protection DirectorateGeneral (2004). Healthy Eating for Healthy Lives: A European Contribution? Remarks by Robert Madelin. Brussels.

15 World Health Organisation (2002). The world health report: Reducing risks, promoting healthy life. Geneva.

“Today a combination of increasing calorie intake in Europe and rapidly declining levels of physical activity has lead to an unprecedented rise in overweight and obesity.”14

The WHO distinguishes four main drivers for the rapid increase in overweight and obesity in recent years (see figure 10), relating to a changing lifestyle, in which technological developments bring about a decrease in physical activity, and food is available 24 hours a day: - People consume more calories than in the past; - People burn fewer calories; - Advertising campaigns focus on energy-dense foods; - The increased number of food outlets.15 100

1980

1985

1990

1995

latest year available

30

20

10

Figure 10: Increasing percentage of people with overweight in OECD countries,Financial Times 31-08-2004.

0

Netherlands

United Kingdom

France

Japan

US

Dietary patterns 16. World Health Organisation (2002). The world health report: Reducing risks, promoting healthy life. Geneva. p.5

“Changes in food processing and production and in agricultural and trade policies have affected the daily diet of hundreds of millions of people.”16

27

Research conducted in 1994 concludes that obese people do not eat more carbohydrates than people with a healthy weight; they do, however, eat more fat.177 Whilst more saturated fat and trans-fatty acid is consumed than ever before, this is not the only dietary cause of an increase in overweight and obesity. Attention to the effects of refined carbohydrates such as simple sugars, is on the increase (see figure 11).

er

er

in

1994 - 96 total daily calories: 2,003

19. Ludwig, D.S. et al. (2001).

Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet, vol.

357, p.505-8

ce

44

ce

nta

12

p

37

19

18. See for the Netherlands: RIVM (2004). Our food measured: Healthy and save food in the Netherlands.

Houten: Bohn Stafleu Van Loghum.

g es

25

21

18

Figure 11: Caloric intake in the U.S., Financial Times 31-08-2004

Breakfast

nta

Lunch

p

24

Dinner

g es

Snacks

17. Bolton-Smith, C. & Woodward, M. (1994). Dietary composition and fat to sugars ratios in relation to obesity.

International Journal of Obesity, vol.

18, p. 820-828.

in

1977 - 78 total daily calories: 1,798

The percentage intake of food groups has changed. Consumption of snacks increases, whilst the consumption of fruit and vegetables has decreased.18 Snack foods such as confectionery and soft drinks contain a vast number of simple sugars. Harvard professor David Ludwig found that for every soft drink a child consumed a day, the chance of becoming obese increased by 50%.19 Blame for this increase within the snack category has frequently been placed with marketing by the food industry, usually directed at children.

Commercials directed specifically towards children are predominantly for food products containing high amounts of fat and sugar. 20 In the USA and the United Kingdom, for instance, children see on average ten commercials for sodas, candy and fast-food every hour. 21 About 4-10% of children within the Netherlands regularly skip breakfast 22 and children increasingly take in more calories from snacks. These deliver 28-32% of the daily caloric intake and are responsible for half of the daily intake of mono- and disaccharides. 23 Attention is also frequently drawn towards the increased consumption of both ‘quick fix’ meals and meals consumed outside of the home. In the United States, the number of take-away meals has doubled in the last twenty years; they now count for ten percent of the total caloric intake. 24 Pre-packed microwave dinners usually offer more fat and calories than home cooking of fresh foods. Research demonstrates that eating freshcooked meals at home (with the family) improves caloric intake. 25

20. Kunkel, D. et al. (2004).

Psychological issues in the increasing commercialisation of childhood.

Report of the APA Task Force on advertising and children. Young, B. (2003). Does food advertising influence children’s food choices? A critical review of some of the recent literature. International Journal of advertising, vol. 22, p. 441-459 21. Kotz, K. & Story, M. (1994) Food advertisements during children’s Saturday morning television programming: are they consistent with dietary recommendations? J Am Diet Assoc, vol. 94, p.1296-300.

Lewis, M.K. & Hill A.J. (1998) Food advertising on British children’s television: a content analysis and experimental study with nine-year olds. International Journal of Obesity, vol. 22, p. 206-14.

Taras, H.L. & Gage, M. (1995).

Advertised foods on children’s television. Arch Pediatr Adolesc Med, vol. 149, p. 649-52.

22. Brugman E. et al. (1998).

Breakfast skipping in children and young adolescents in the Netherlands. Eur J Public Health, vol.

8, p. 325-8 23. Voedingscentrum (1998). Zo eet Nederland. Resultaten van de voedsel consumptiepeiling 19971998. The Hague.

24. Lin, B.H. et al. (2001). American children’s diets not making the grade. Food Review, vol. 24, p. 8-17 25. Gillman, M. W. et al. (2000).

Family dinner and diet quality among older children and adolescents. Arch Fam Med, vol. 9, p. 235-40.

28

2.3 Physical activity

26. The World Health Organisation (2002). The world health report 2002: Reducing risks, promoting healthy life. Geneva. p. 5

27. Centraal Bureau voor de Statistiek (2002). Arbeidsomstandigheden 2002: Monitoring via personen.

Heerlen.

“Changes in living and working patterns have led to less physical activity and less physical labour. The television and the computer are two obvious reasons why people spend many more hours of the day seated and relatively inactive than a generation ago.”26

Reports from the WHO, the European Commission (EC) and other institutions conclude that a disturbed balance between dietary habits and physical activity – intake versus outtake – exacerbates the issue of overweight and obesity. Work nowadays demands less physical activity thanks to ongoing computerisation and the development of new technology.

For example, in the Netherlands almost half of the workforce regularly works at a computer (this figure has increased by 5% from 1997 to 2002.) 27 The increase in cars has also reduced physical activity (see figure 12); so too has the widespread increase in home computer usage and television viewing.

Company cars

10.000.000

Family cars

7.000.000 6.000.000 5.000.000 4.000.000 3.000.000 2.000.000

Figure 12: Increasing number of cars in the Netherlands, RAIAutovak, November 1998.

1.000.000 0

years 28. Robinson, T.N. (1998). Does television cause childhood obesity?

Journal of the American Medical Association (JAMA), vol. 279, p. 95960.

29. Health Council of the Netherlands (2003). Overweight and obesity. The Hague.

30. Social and Cultural Planning Office (SCP) (2004). Trends in time, The use and Organisation of time in The Netherlands, 1975-2000. The Hague.

60 65 70

75

80

85

90

95

Research shows that for every hour of television watched by children, the chance of obesity increases by 12%. 288 In the Netherlands, people watch more television than ever before. Between 1975 and 2000 the number of hours spent watching television (aged twelve or above) increased from 10.2 hours per week to 12.4 hours per week. 29 Computer and internet usage in the Netherlands increased between 1985 and 2000 from 0.1 to 1.8 hours per week 30 .

29

2.4 A global perspective “Today more people than ever before are exposed to products and patterns of living imported or adopted from other countries that pose serious long-term risks to their health. The fact is that so-called ‘Western’ risks no longer exist as such. There are only global risks and risks faced by developing countries.”31

THE ‘OBE S E ’ E NV I RONM E NT Sports & leisure

High energy food

Lack of school facilities Few global playing areas Widely available indoor passive entertainment Unsafe streets Few cycle routes

Family

31. World Health Organisation (2002). The world health report, 2002: Reducing risks, promoting healthy life. Geneva. p.5

promoted via Advertising Favourable pricing School-based marketing Snacks, soft drinks Sponsorships Eating out

GL OB& E S IT Y Education Information

Genetic predisposition Excess weight in parents Breast feeding practices Parent‘s health Knowledge and budgeting, shopping Cooking skills

School lessons; Lifestyles; Nutrition; Cooking; Media messages; Fashions; Body image; Cultural beliefs

Figure 13: The obese environment, CIAA, 2004.

The development of the overweight and obesity issue in the Netherlands appears to be twenty years behind that in the USA. By drawing parallels between the two countries and looking at the global impact of the issue – from the perspective of the World Health Organisation, the USA, European Commission (EC) and a cross-section of European countries – this section offers a broad overview of the issue, its development, steps taken to counter an ‘epidemic’, and challenges faced by specific countries and organisations.

The World Health Organisation (WHO) “There are more than one billion adults worldwide who are overweight and at least 300 million who are clinically obese. Among these, about half a million people in North America and Western Europe die from obesity-related diseases every year.”32

The World Health Report 2002 had a significant impact on all stakeholders, resulting on many occasions in the formulation of local policy. After the publication of the report, the WHO began formulating a Global Strategy on Diet, Physical Activity and Health which identified four main objectives33 :

32. World Health Organisation (2002). The world health report, 2002: Reducing risks, promoting healthy life. Geneva. p. xiv

33. World Health Organisation (2003). Integrated prevention of non-communicable diseases: Draft global strategy on diet, physical activity and health. Geneva. p. 5

30

1. To reduce the risk factors for non-communicable diseases that stem from unhealthy diets and physical inactivity by means of essential public health action and health-promoting and disease-preventive measures.

2. To increase the overall awareness and understanding of the influences of diet and physical activity on health and of the positive impact of preventive measures.

3. To encourage the development, strengthening and implementation of global, regional, national and community policies and action plans to improve diets and increase physical activity that are sustainable, comprehensive, and actively engage all sectors, including civil society, the private sector and the media.

4. To monitor scientific data and key influences on diet and physical activity; to support research in a broad spectrum of relevant areas, including evaluation of interventions; and to strengthen the human resources needed in this domain to enhance and sustain health.

The WHO takes an integrated inclusive approach to the overweight and obesity issue:

34. World Health Organisation (2002). The world health report, 2002: Reducing risks, promoting healthy life. Geneva. p. x

35. World Health Organisation (2004). Children Environment and health Action Plan (CEHAP). Geneva. p. 4

36. World Health Organisation (2003). Integrated prevention of non-communicable diseases: Draft global strategy on diet, physical activity and health. Geneva. p. 11-12

“We are developing new guidelines for healthy eating. When these are complete, key players in the food industry will be invited to work with us in combating the rising incidence of obesity, diabetes and vascular diseases in developing countries.”34

At the 2004 WHO conference in Budapest, entitled The Future For Our Children, Ministers from 52 European states adopted an action plan to reduce the impact of the environment on health, children’s health in particular. Ministers committed to bring about a reduction in the prevalence of overweight and obesity by implementing health promotion activities in accordance with both the WHO Global Strategy on Diet, Physical Activity and Health and the WHO Food and Nutrition Action Plan for the European Region, 2000-2005. The plan further commits to promoting the benefits of physical activity in children’s daily life by providing information and education, as well as pursuing opportunities for partnerships and synergies with other sectors with the aim of ensuring a child-friendly infrastructure.35 Initiatives endorsed by the WHO include tax policies and other fiscal measures, such as subsidies to influence the consumption of food and access to sporting facilities, and strict rules for marketing directed at children. 36

31

The United States “In the US there are twice as many overweight children and three times as many overweight adolescents as in 1980.”37

In 2000, 56% of the adult population in the United States was overweight, 19.8% of those adults were obese. 388 From 1960 to 2000 the prevalence of overweight adults aged 20 to 74 increased from 31.5% to 33.6%.

The prevalence of obese adults more than doubled during this time, from 13.3% to 30.9%; the prevalence of extreme obesity (BMI of 40 or higher) increased from 2.9% to 4.7%. 39 The USA is considered to have the long-standing highest percentage of citizens suffering from overweight and obesity. It is also in America that various stakeholders first paid serious attention to the issue. In March 2004 a legislative Act was approved by the Senate sardonically referred to as ‘the Cheeseburger Bill’. 40 The Personal Responsibility in Food Consumption Act, was essentially created to halt overweight and obese people taking food companies to court, holding their food products accountable for personal overweight and obesity problems.

Evidence in the US points to the opinion that personal responsibility and a collective approach to the issue from all stakeholders is the best solution, rather than legislation (see figures 14 & 15). However, many NGOs and politicians support the view that legislation is indeed part of the solution, as cited in newspaper reports: a group of members of parliament in the US lobby fast-food chains to list the calories in their menus41 ; and in Los Angeles educational authorities have banned the sale of carbonated soft drinks in schools. 42

VI E W S O N OBE S I T Y I N T H E U . S .

Whatever the causes of obesity, please tell me whether you think each group bears a great deal of responsibility for the nations obesity problem…

Individual Americans in their choice of diet and lack of exercise

87%

Fast-food restaurants

64%

Schools that allow high-calorie snack and sweets

64%

Manufacturers of high-calorie packaged and processed foods Marketers and advertiser of high-calorie packaged and processed foods Government policies and laws on food content and marketing

61% 60%

41%

percentage saying "great deal" or "good amount" of responsibility

37. U.S centres for Disease Control and Prevention (2000).

38. Health Council of the Netherlands (2003). Overweight and obesity.

The Hague.

39. The National Institute of Diabetes, Digestive and Kidney Diseases of the National Institutes of Health (2003).

40. Brown, P. (01-06-2004). Big food and drink bites back. Management Today.

41. Reformatorisch Dagblad (11-112003). Fastfoodketens VS moeten aantal calorien op menu vermelden.

42. Nederlands Dagblad (29-082002). Verbod op verkoop frisdrank in scholen Los Angeles.

Figure 14: Views on obesity in the U.S., Time/ABC news poll, 10-16 may 2004 among 1,202 adult Americans.

32 Figure 15: What is the best obesity solution?, www.mallenbaker.com 26/08/04.

43. CSPI Newsroom (14-02-2003).

Maine Legislation Tackles Obesity.

44. CNN.com International (12-032004). White house takes aim at obesity.

45. www.commercialalert.org/ bushadmincomment.pdf

46. Commercial Alert (15-01-2004).

Secret document shows Bush Administration Effort to Stop Global Anti-Obesity Initiative. www. commercialalert.org

THE RISING OBESIT Y PROBLEMS IN MANY COUNTRIES WILL BEST B E S O LV E D BY: New legislation to force food companies to reform their ways

59 (12.45%)

People taking personal responsibility for themselves and their families – we don’t need people telling us how to live our lives

167 (35.23%)

All organisations, public and private sector, working together voluntarily to change behaviour

248 (52.32%)

Further laws are expected, including the nation’s first comprehensive AntiObesity Package. 43 The package consists of bills that would ban sales of soda and junk-food in schools, require calorie labelling on chain restaurant menus and promote transportation policies that encourage walking, biking and other forms of exercise. Public health advocates, including the Washington DC-based Centre for Science in the Public Interest (CSPI) herald the legislation as the nation’s first comprehensive anti-obesity effort and a model that should be replicated both in other states and in Congress.

But what of a nationwide plan? Similar to the EU, the USA lacks coordination. This is due to federal policy making and numerous initiatives from NGOs. The Bush administration has announced a nationwide campaign to combat the epidemic of obesity in the United States through improved product labelling, health education, and a partnership with restaurants to steer consumers toward healthier menu options. 44 However, this effort was contradicted by negative reports in the media that in January 2004 the Bush Administration’s Department of Health and Human Services had taken a stand against the World Health Report, 455 to stop the global antiobesity effort.

The Bush Administration’s reaction to the WHO’s Global Anti-Obesity effort seems clear: “The assertion that heavy marketing of energy-dense food or fast-food outlets increases the risk of obesity is supported by almost no data.

In children, there is a consistent relationship between television viewing and obesity. However, it is not at all clear that this association is mediated by the advertising on television. Equally plausible linkages include displacement of more vigorous physical activity by television viewing, as well as consumption of food while watching television. No data has yet clearly demonstrated that the advertising on children’s television causes obesity.”46

33

In the fight against overweight and obesity the Bush Administration appears to focus on self-responsibility and an increase in physical exercise.

It seems unlikely that legislation will be presented at a national level which stimulates change in the food industry.

In February 2005 the Bush administration announced a substantial cutback in healthcare expenditure. Programmes aimed at reducing obesity will be dropped from the budget. 47

47. Spits (07-02-2005). Bush cuts in healthcare expenditures (ANP).

The European Commission (EC) “The obesity epidemic is a serious health issue; its multi-causal character calls for multi-stakeholder approaches. Action at all levels, including the European Union level, is required to address this issue.”48

0 - 10%

48. European Commission: Health & Consumer protection DirectorateGeneral (2004). Summary Report Roundtable on Obesity, 20-07-2004.

Brussels. p.2

13

11 - 15% 16 - 20% 21 - 30% > 30%

18

9

14

20

15

14

14

14

13 9 19

24 23 36

15 18

27

27 35 39

24

Robert Madelin, Director General for Health and Consumer Protection of the European Commission, states that eating is primarily a matter of individual responsibility. Because information alone is considered insufficient in empowering consumers to change behaviour, education is the key process and central objective of the EC. 49 “Many studies looking at health promotion and social marketing activities tell us that merely getting the message across about the risks of a particular activity or lifestyle is not enough. Knowledge of risk does not always lead to a change of behaviour. So it is not just about empowering consumers with the facts, it is about going one stage further and empowering them to make a positive change in their eating habits.”50

Figure 16: Percentage of overweight children (6-17) years in different European countries, International Obesity Taskforce IOTF, 2003.

49. European Commission: Health & Consumer protection DirectorateGeneral (2004). Healthy Eating for Healthy Lives: A European Contribution? Remarks by Robert Madelin. Brussels. p.4

50. European Commission: Health & Consumer protection DirectorateGeneral (2004). Healthy Eating for Healthy Lives: A European Contribution? Remarks by Robert Madelin. Brussels. p.4

34

Robert Madelin points to the need for a coordinated approach in building a general policy framework that wins consumer trust. This, within an EU where there is no typical European diet or consumer.

The European Commission also predicts an increase in European level litigation, which could bring both positive and negative effects.

Overweight and obesity could be fought on a wider scale, giving companies a unified set of rules to combat the issues. On the other hand, litigation at a European level could actually be both ‘softer’ and slower than on a national level, therefore potentially lagging behind real-time European issues development.

51. European Commission: Health & Consumer protection DirectorateGeneral (2004). Healthy Eating for Healthy Lives: A European Contribution? Remarks by Robert Madelin. Brussels. p.4

52. European Commission: Health & Consumer protection DirectorateGeneral (2004). Healthy Eating for Healthy Lives: A European Contribution? Remarks by Robert Madelin. Brussels. p.4

53. Reuters (30-01-2005). EU warns food industry on junk food advertising.

54. Rigby N. et al. International Obesity Task Force (2004). Seeking bold solutions for Britain’s runaway obesity epidemic. www.iotf.org/ media/IOTFNov11briefing.pdf 55. Statement by Melanie Johnson (4-07-2003). http://www.parliament. be

“Diagnosis and education apart, the public authorities can and must continue to set the framework in order to ensure that no inappropriate encouragement is given by the food chain to patterns of consumption that will make the obesity problem worse rather than better.”51 Madelin believes that increased governmental interference could be costly and slow, causing conflict. The private sector has a significant role to play, but is not widely trusted to do the job properly. To increase trust the private sector should take note: - Economic operators have to commit to a measurable and sustained increase in the amount of staff, time and money that they put into good nutrition activities.

- The processing and retail arms of the food chain have to agree to sit with all other interested parties in drawing up bench-marks for their healthy eating campaigns.

- The economic operators will have to accept non-profit interested parties as part of a process to verify that the promised private actions really are taking place.52 In January 2005 Health and Consumer Affairs Commissioner Markos Kypriano said: “I would like to see the [food] industry not advertising [junk food] to children anymore. The signs from the industry are very encouraging. But if this doesn’t produce satisfactory results, we will proceed to legislation.”53 United Kingdom “Current UK obesity trends imply that 34% of men and 38% of women will be obese by 2020.”54

According to government figures in the UK, nearly 16% of children between the ages of 6 to 15 can be defined as obese, three times as many as 10 years earlier.55

35

The UK takes second place in the global overweight and obesity epidemic.

The National Audit Office Report on Tackling Obesity in England (2001) gives an overview of the manner in which overweight and obesity is viewed and debated in the UK: Promotion of physical activity - The Ministry of Health should lead the development of a new cross government strategy to promote the health benefits of physical activity.

- The Ministry of Health and Ministry of Environment, Transport and Regions should continue to adopt local targets for cycling and walking. It should also work with local agencies to help develop targets to increase the number of school journeys undertaken by bicycle, on foot or on public transport.

- The Ministry of Education and Employment should continue to encourage all schools to achieve the stated aspiration of at least two hours of physical activity a week for all pupils, and a joint advisory and coordinating group, such as the School Sports Alliance, should monitor the success of initiatives to increase physical activity in schools.

Promotion of a healthy diet - The Ministry of Health should give a high priority to implementing the initiatives on nutrition listed in the National Health Service (NHS) Plan, working with the food industry, including manufacturers and caterers, to improve the balance of diet.

- The Ministry of Health and the Ministry of Education and Employment should work together, seeking the technical advice and support of the Food Standards Agency where appropriate, to establish ways to monitor the overall impact of initiatives to improve the nutritional quality of food provided in schools.

Leading UK supermarket chain Tesco, made a significant announcement in May 2004, introducing a labelling scheme that uses images of traffic lights to indicate the fat, sugar and salt content of its products. The initiative was applauded by many NGOs and the government, but not all comment was in praise of the scheme: “The fact that some of its supposedly healthy food offerings may attract amber or red labels under regulatory guidelines suggests that Tesco still has work to do before consumers get food label clarity.”56 Using the Food Standards Agency (FSA) rating criteria the medical profession rated a sample of the company’s products, including dairy, meat, cereal and dessert products. “Many of them would have to be coloured with amber warnings and more than a few would have to carry a red danger signal – somewhat undermining the label’s claim to be healthy.”57

56. Datamonitor (29-07-2004).

Tesco meeting guidelines the key to informative labelling. www.just-food.com/news

57. Medical News Today (27-07-2004).

Trafic light labelling scheme to indicate levels of fats sugar and salt in products UK. www.medicalnewstoday.com/medicalnews

36

58. Westminster watch (16-11-2004).

White paper on Public Health.

Alongside initiatives from the private sector and NGOs, British Parliament has proposed legislation, including a ‘fat tax’ and the banning of commercials for junk food directed at children. The recent White Paper on Public Health588 outlines: - Introduction by 2006 of a traffic light system for processed food, indicating fat, sugar and salt content to allow for a more informed choice.

- Campaigns to increase awareness and activities both at school and work.

- Increased number of school nurses and the introduction of NHS ‘health trainer’ lifestyle gurus.

- School inspection agency Ofsted to include school meal nutrition guidelines in its assessments.

- The government will consult with the food and advertising industry to introduce a voluntary code on food promotion. If the industry has not brought in an adequate code by 2007, the government is committed to introducing legislation forcing the food industry to conform. One option canvassed in the White Paper is banning ‘unhealthy’ food advertising before 9 pm.

- Continued work with industry to develop ‘voluntary’ targets for reducing sugar and fat levels in foods, building on the FSA framework for salt reduction and the development of guidance on portion sizes.

Other countries

59. Business Respect Newsletter (2410-2004). Vending machines in schools barred in fight on obesity. www.mallenbaker.net

60. Science Generation (03-2004).

Diet and Health. http://en2.sciencegeneration.com

“Vending machines in schools barred in fight on obesity. The legislation stopped short of banning advertisements for fast food, but manufacturers will be hit by extra tax equivalent to 5 percent of their annual advertising budget if they do not include health warnings in their adverts.”59

Because overweight and obesity is a global issue, almost all countries in the EU experience problems in effectively coordinating the fight against it.

Countries differ in their opinions on who is responsible for the epidemic, however it appears that the most vulnerable segments of a country’s population remain difficult to reach.

In France legislation has already been implemented, with schools the first to encounter legislative measures. In response to the question in Science General, “In your country, could we say that obesity has reached epidemic proportions?”,60 Arnaud Basdevant, professor of Nutrition at University of Paris, and head of the Nutrition ward at Hotel-Dieu Hospital in Paris, responds: ”If we are talking about an increase in the frequency and spread of obesity in the different regions and countries of Europe, then I would have to say yes. WHO speaks of an obesity epidemic. France is actually only at the initial stage of the phenomenon, but the obvious increase in obesity in France is clear. The frequency of obesity doubles every 15 years in children.

37

In other words, 12 to 14% of children are affected by obesity today whereas there were only 6% 15 years ago and 3% 30 years ago. As for adults, the figure is around 11% as opposed to 8% six years ago.”

Professor Basdevant and colleagues have participated in debates regarding advertising on French television aimed at children, and on school vending machines: “The problem is to carry out effective campaigns that target the most vulnerable segments of the population and that are the most difficult to reach. This is one of the major challenges facing us at this time.”61 In the same article from Science Generation, Nicola Sorrentino, nutritionist and professor at the University of Pavia, Italy, comments on Italian public health campaigns:

61. Science Generation (03-2004).

Diet and Health. http://en2.science-generation.com

“The Ministry of Health recently proposed to create a commission with the aim of preparing an agreement with food production and packaging companies and restaurants concerning portion sizes. Other public health initiatives require greater clarity in labelling.”

It appears that campaigns in Italy to encourage better eating habits are organised by many bodies, including government agencies, the Ministry of Health and Agricultural Policy, Italian regions, provinces, municipalities, universities, and private companies.

“The problem is that there is no central coordination and no common objective. There is a lack of communication and coordination for public health campaigns related to food.”62 Despite a common belief in Italy that overweight and obesity is not an issue due to a Mediterranean diet, problems are on the increase. Studies show that among the adult population in Italy, four million people are obese and 16 million are overweight, which represents a 25% increase in 10 years.

For the entire adult population, 9.2% of men and 8.8% of women are obese, 42.4% of men and 26% of women are overweight.

Some governments have already taken more drastic measures and have implemented some form of regulation. The British Medical Association has endorsed a plan to impose a 17.5 per cent value-added-tax on fatty food, except for takeaway meals which are already taxed. In Sri Lanka, a similar tax has successfully been introduced on unsaturated fat.63 Belgium is also seriously considering legislative measures. The Belgian Minister Demotte for Public Health is considering a ban on commercials for candy.64

62. Science Generation (03-2004).

Diet and Health. http://en2.sciencegeneration.com

63. Free republic (6-08-2003) Fat tax to fight obesity. www.freerepublic. com/focus/f-news 64. Adformatie (19-01-2004). België overweegt verbod op snoepreclame.

38

65. Global study conducted by Universal McCann in July 2004

66. Weber Shandwick survey amongst European consumers, October 2003

Research shows a distinct difference between the American and British view of food companies and government agencies’ responsibility towards the obesity epidemic. 26% of those surveyed in the USA said they blamed food companies for obesity problems, compared to 42% in the UK. When asked whether or not the government and health authorities were to blame for the problem of overweight and obesity, 22% in the USA said yes, compared to 39% in the UK.65 A European survey displayed a similar distortion, with 37% of consumers in favour of self-regulation among food industries, versus 30% in favour of a specific regulation constraining those industries. European consumers were mainly hostile towards coercive measurements such as prohibition of publicity directed at children (62% against) and taxation on junk food (58% against.) Consumers’ expectations of food industries’ actions point towards nutritional information (58%) and developing healthy products (57%).66

39

3 Medical and expert opinions in the Netherlands In the Netherlands, both the government and food companies work in cooperation with knowledge institutions such as the RIVM (National Institute of Public Health and Environment) and TNO (Research Institute for Health Prevention) for specific research into the issue of overweight and obesity.

3.1 Scientific research Medical research published in 2004 identifies a second influence on appetite of a certain brain protein. The protein was already known to play a central role in the ‘feast or fast’ signalling that controls the urge to eat. It appeared that the discovery had potentially identified a new target for drugs against obesity.67 The research stated: “Earlier research has shown that this protein, called MC4R, is a receptor or neuron in the hypothalamus region of the brain and receives signals through at least two pathways about the status of the body’s fat reserves. If fat stores are increasing, these signals stimulate MC4R, triggering physiological responses that decrease appetite. If fat reserves are decreasing, these signals turn off, deactivating MC4R and increasing appetite.”

Medical research continues to make important discoveries regarding genomic causes of the issue, such as that of the hormone Leptin. Leptin helps regulate appetite; when it is absent patients have a continual craving for food. Predominantly, those who benefit from treatment suffer from obesity rather than overweight.

A better understanding of the risks that are attributed to overweight and obesity not only helps to design effective treatments, it also aids in determining the enormous cumulative costs involved. The sum of these extensive costs seems to peak political interest in the issue.

Caloric intake and social groups Professor Han Kemper (Vrije Universiteit Amsterdam, Medical Centre) believes that lack of physical exercise is more to blame for an increase in overweight and obesity than the intake of food and drinks68. He cites research proving that caloric intake of Dutch consumers has dropped in recent years and goes on to suggest that a decline in physical exercise has distorted the balance between caloric intake and expenditure of energy.

67. Vidyya Medical News (16-102004). Scientists identify new cause of obesity. Vidyya Medical News, vol. 6, Issue 290 68. VAI/SMA symposium (4-06-2004).

Obesitas, een gewichtig probleem.

40

69. Voedingscentrum (1998).

Resultaten van de voedselconsumptie peiling 1997-1998. The Hague.

70. Hulshof, K.F.A.M. et al. (2004).

Resultaten van de Voedselconsumptie peiling 2003. RIVM rapport 350030002/2004.

Bilthoven.

According to a 1998 report from the Nutrition Centre, the Hague, daily energy intake has declined from 2300 kcal in 1988 to 2190 kcal in 199869.

Surprisingly, the percentage of fat has also declined from 38.7% in 1988 to 35.9% in 1998. Since 2003 this food consumption overview is conducted every year. The first, in 2003, focused on 19-30 year olds. On average caloric intake measured 2328, with fat contributing to 34.4 percent of the daily intake.70 It seems that whilst the percentage of fat intake is lower, total caloric intake is higher.

Respondents from the medical profession interviewed for the purposes of this research believe that the results published by the Nutrition Centre are questionable, due to the limited number of people involved and the composition of the group. Some social groups are more likely to suffer from overweight and obesity – specifically the lower-educated – and this would have an impact on results where a range of social health groups are not accurately represented.

Research respondents have suggested that the Nutrition Centre targets campaigns towards social groups that are more likely to yield required results – white, higher educated, middle classes – whilst the real problem lies with foreigners and the lower educated classes. Information available to these groups is inadequate. In the last twenty years physical energy expenditure has dropped most significantly in the lower-educated section of the Dutch population. This can be seen most obviously in retirement.

Higher-educated people usually lose weight when they retire; the lowereducated section of the population usually gains weight due to decreased physical activity.

71. VAI/SMA symposium (4-06-2004).

Obesitas, een gewichtig probleem.

Professor Jaap Seidell (Vrije Universiteit Amsterdam, Faculty of Medicine, Food & Health), emphasises the complexity of the problem. He references genetics, individuals’ willpower and numerous societal factors which impact on overweight and obesity, namely: television viewing; computerisation of the workplace; safety concerns raising the use of cars for personal use; the 24 hour availability of low-cost food; advertising; and other forms of commercial persuasion.71

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3.2 Obesity and children Another medical respondent suggested that overweight and obesity issues may start before birth: the dietary pattern of the mother may influence the possibility of the child becoming overweight in later life. Certainly, dietary intake is important from the youngest age: “When the child goes to day-care they preferably move as little as possible, when they move around there is the chance the child hurts itself. If one of the children cries he or she gets a little fruit-juice, from the understanding that this is good for the child. When trying to prevent overweight and obesity, aspects such as day-care centres should also be included. It is a complex problem so all stakeholders should be included.”

Children and junk food Michiel Korthals, Professor of Applied Philosophy, Universiteit Wageningen, and author of the book ‘Before Dinner: Philosophy and Ethics of Food’, believes that the private sector and the government should work together to reduce the amount of salt, sugar and fat in food products.

“What is not a question but a fact, is that obesity increases rapidly where fast-food and junk-drinks are dominant. It is amazing that, regardless of the existence of obvious connections, it is often stated that the individual consumer is responsible for his or her overweight.”72 He goes on to say that since the seventies there has been an increase in sugar, fat and salt in processed foods. People become addicted to these tastes, even though they are perhaps individually difficult to recognise. He believes this makes it difficult to become used to lower salt and sugar levels.

Marketing to children Children are targeted every day by an enormous number of advertisements, mainly for unhealthy food products. Research in 2003 conducted by the University of Strathclyde, Scotland, has shown that because advertising shapes the preferences of children, they should live in a ‘marketing mild environment’ – the age of twelve is frequently cited.73 Research conducted

by Intomart suggests that a large part of the Dutch population would agree with such measures: 55% is in favour of a ban on advertising directed towards children until the age of six; 45% would like to see a ban until the age of 12; 46% would like to see advertising banned in schools.74 Professor Seidell draws attention to the marketing of healthy products: “Marketing for wholemeal bread and fruit is practically zero. The advertisement noise for candy, sodas and ice cream is a thousand times stronger.”75 See figure 17 for an example of marketing healthy foods, in which Dutch asparagus producers are intending to make their product more desirable for children.

Figure 17: Flippo’s (goodies to collect for children) with asparagus, Telegraaf, 25-11-2004.

72. NRC Handelsblad (17-02-2004). Te dikke kinderen zijn niet schuldig aan hun eetgedrag.

73. See: University of Strathclyde (2003). Review of research on the effects of food promotion to children. www.foodstandards.gov.uk

74. Voedingsmiddelentechnologie nr. 20 (24-09-2004). Reclame voor kids en jongeren kan niet meer.

75. Financieel Dagblad (08-09-2004).

De dikmakers tegen volksvijand no. 1

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3.3 Product modification The RIVM published a report in 2004 entitled ‘Our Food Measured: Healthy Food and Safe Food in the Netherlands’, which emphasised that the largest changes to be made towards healthier food are in the hands of the private sector. The report ‘Longer Healthy Living’ from the Ministry of Health also makes suggestions for change within the private sector. Product modification, for example, towards a healthier composition of food could enable a less rigorous change in consumers’ dietary behaviour. Less expensive healthy food products could also have a positive influence on social economic health changes.

76. Financieel dagblad. (08-09-2004).

De dikmakers tegen volksvijand no. 1

Experts on the issue of overweight and obesity tend to agree that the private sector is not doing enough. Professor Seidell again: “Replace ordinary potato chips with ‘light’ variations without calling them so.

That has also been done with mayonnaise. I have not heard any consumer complain about it.”76

3.4 Consumer confusion, information and education Research respondents and experts from the medical field agree: there is a need for clarity within the private sector. Food companies follow trends such as ‘low fat’ or ‘low carb,’ which confuse consumers (see figure 18).

An increase in health claims on products also adds to the confusion. One research respondent comments: “Real fruit juice usually means that the product contains just 1% juice. Some messages from companies also tell parents that children need sugar because they are so active! Such messages do not fit in our modern society where most kids are not very active.”

Figure 18; Companies producing or planning to produce low carbohydrate products, Obesity, Low-Carb Diets and the Atkins Revolution: Healthy profits from big issues in food and drinks, 2004.

100%

How many companies are manufacturing products marketed or sold as low-carbohydrate or are planning to launch products in the future?

60 50 40 30 20 10 0

5%

21%

22%

55%

Yes, but we are not developing any more in the near future

Yes, we are developing more for the near future

Considering it

no

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New research, media comment and other forms of information are published every day, is often contradictory. This makes for a complex situation in which it is difficult to find a solution. Whilst much research and expert comment points to snack foods playing a significant role in the increasing overweight epidemic, Fox News reported a different conclusion, based on Harvard University research: ‘Snack Foods Don’t Fatten Kids’.77 The report published online in 2004 in the International Journal of Obesity stated: “Our results suggest that although snack foods may have low nutritional value, they were not an important independent determinant of weight gain among children and adolescents.”

77. Fox news (24-09-2004). Snack Foods Don’t Fatten Kids. www.foxnews.com/story

Experts and research respondents alike are not particularly positive concerning the numerous organisations responsible for public information on physical activity, dietary patterns and food. There is little steering of the process and organisations such as the Nutrition Centre and the Netherlands Institute for Sports and Physical Activity (NISB) are not working together as efficiently as they could. This hinders effective dissemination of useful information to the right sections of the public.

Research respondents stress the importance of education for young people on both the need to be physically active and sensible dietary patterns. It is believed that responsibility for this education lies with parents and schools.

One respondent comments: “Maybe parents are not able to take this responsibility because they are not well enough informed themselves?”

School swimming lessons are diminishing and the teaching of food and diet within the school curriculum is subject to heavy budgetary criticism.

3.5 Cultural differences Local government sometimes lacks knowledge and understanding of cultural differences amongst various ethnic groups in society. In Amsterdam, for example, free swimming was made available for foreigners new to the Netherlands. This was not a success, however, because women with certain cultural backgrounds would not attend if there were men also present.

In some cultures, being overweight is still a sign of good health. One research respondent comments: “Telling a Turkish mother that her baby is a little chubby and that that is unhealthy goes against her cultural beliefs.”

An article in the Wall Street Journal illustrated that in the Arab world, a preference for larger women drives obesity.788 In Mauritania plump women are assumed to be both wealthy and more likely to bear healthy children.

78. Wall Street Journal (29-12-2004).

Arab’s World’s Preference For Larger Women Fuels An Explosion of Obesity.

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There are concerns amongst overweight and obesity issue experts that the government and health insurers will attempt to make overweight and obesity socially unacceptable, much the same as has been done with smoking. According to one research respondent: “Because overweight inevitably is seen as a process of intake and outtake, the government feels that when people are informed about diet and physical activity they should be able to make the right choice. This means that when people have the information they need, people are responsible themselves for the choices they make. The conclusion is then that if someone is overweight it means that he or she is not strong-willed enough to make the right choices concerning diet and physical activity.

This weakness makes it morally justified to charge people higher premiums for their insurance.� Figure 19 represents a potential process.

Figure 19: Undesirable potential development of overweight solution, Burson-Marsteller 2004.

Intake-outtake

Informing

Selfresponsibility

Insurance premiums

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4 Parties within the Dutch public domain “Minister Hoogervorst from Public Health wants a restriction on toys added to potato chips.”79

The issue of overweight and obesity has undoubtedly become a public and political issue in the Netherlands. Legislation has been proposed and every political party recognises the importance of tackling the epidemic before the situation takes on American proportions. By addressing the issue of overweight and obesity from the perspective of the government, the wider political arena, NGOs and the media, this chapter aims to determine which stakeholders within the Netherlands hold a prominent place in the debate, stakeholders’ vision of the issue, potential solutions and the barriers to overcome in order to implement them.

79. Algemeen Nederlands Persbureau (25-11-2004). Hoogervorst wil speeltjes chips aan banden.

4.1 The Dutch government “The private sector is being more and more addressed on its social responsibilities concerning public health. The government stimulates self-regulating initiatives (healthy food, smoke-free restaurants, marketing directed at children) and will come with appropriate regulation if these do not work.”80

The most prominent stakeholder in the Netherlands is the Ministry of Public Health. Due to the complexity of the overweight and obesity issue, an integrated approach is required. Ministries such as Spatial Planning (are there enough outdoor play areas for children), Justice (is it safe enough to play on the streets) and Education (physical education and dietary knowledge) also play an important role. It is the responsibility of local authorities to translate national policies to the local situation.

The RIVM’s report ‘Our Food Measured, Safe Food in the Netherlands’ gives a summary of the Dutch government’s role regarding the issue of overweight and obesity.

“The Dutch government has set a goal from the beginning to establish healthy consumer choice. In this it has distinguished for attention the consumer, the general public, the private sector and vulnerable groups.

Regarding the promotion of a healthy dietary pattern, the government has taken a reserved position. From the understanding that the consumer should be able to make a free choice from the assortment of food products, the government sees a facilitating, informing and stimulating role for itself.

80. Ministerie van VWS (2003). Nota gezond leven, POG/OGZ/2.424.450.

The Hague. p. 4.

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81. RIVM (2004). Our food measured: Healthy and safe food in the Netherlands. Houten: Bohn Stafleu Van Loghum. p.103.

Government wants to tempt the consumer to make a healthy choice and chooses more than ever to do so in cooperation with other stakeholders.

The responsibility of the consumer to make that healthy choice is increasingly emphasised.�81 This view was confirmed in an interview with the Ministry of Public Health, which sees itself as having a facilitating, informing and encouraging role.

The preferred solution is an integrated approach, all parties working together. The ultimate goal is to raise the public’s consciousness of the necessity for a healthy lifestyle. In the end the consumer itself has to make that healthy choice.

Policy The government endorses a number of initiatives on the subject of diet and physical activity which act as vital discussion and policy platforms for the issue of overweight and obesity. According to the Ministry of Public Health this activity demonstrates its responsibility to provide direction to stakeholders.

82. Nederlands Dagblad (06-052004). De ziekte van Welvaart.

83. Ministerie van VWS (2004).

Bos Impuls: stimulans voor samenwerking buurt, onderwijs en sport.

The Hague.

- The Ministry of Public Health presides over the ROW (discussion platform on consumer goods). Specifically, part of this platform is the ROO (discussion platform on the topic of overweight and obesity).

- The Ministry of Public Health has involved stakeholders such as the VAI (Dutch Food Industry Association) and Unilever to a new covenant on the topic of overweight and obesity, with a task to design a programme of activity involving all participants. Eventually as many as twenty stakeholders are expected to take part. The programme intends to outline the contribution every interest group can make to the issue, with a central goal of stabilising the growing number of people affected by overweight and obesity.

- The government finances the Nutrition Centre, which is tasked with informing the public on the subjects of food and dietary health.

- A specialist research institute on the subject of overweight and obesity has been founded. One specific aim of the institute is to create initiatives which discourage the consumption of junk food and unhealthy snacks.82 - The government has initiated the BOS project (project to give education and sport in the local neighbourhood an impulse). Over the following six years (starting October 2004) â‚Ź80 million will be invested in after-school sport activities.83 - The government is making a concerted effort to support the promotion of more physical activity with the FLASH programme (referring to biking, walking, active playing, sports and housekeeping), via both radio and television commercials and programming, and local campaigns.

Besides stimulating the private sector to contribute, the main instrument the government uses to combat overweight and obesity is the dissemination of information.

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This is achieved by way of public campaigns and institutions such as the Nutrition Centre. Subsidy has also financed preventive activities and research undertaken by third parties. 84 With regard to the food industry, the government believes the first course of action should be self-regulation. Legislative measures could be enforced, however, if the private sector is not seen to comply with this course of action. Research in 2004 855 identifies support from the Dutch population for government involvement when it comes to the promotion of a healthy lifestyle choice: 64% of young people (aged 18-34) and 51% of elderly people (55+ years) agree.

84. RIVM (2004). Our food measured: Healthy and save food in the Netherlands. Houten: Bohn Stafleu Van Loghum.

85. TNS NIPO (2004). Helft Nederlanders: Overheid moet ingrijpen bij ongezonde levensstijl.

Furthermore, of those individuals who applauded government interference, the same research showed the following support for possible government measures: - Making healthier products cheaper (87%); - Availability of information on negative consequences of unhealthy foods (83%); - Subsidy for healthy food in school canteens (71%); - Making health and fitness centre subscriptions tax deductible (64%); - A ban on advertising encouraging ‘unhealthy’ nutritional behaviour (49%); - A tax on unhealthy food products (34%).

As on a global level, the health of people with a lower income and lower education is a major concern in the Netherlands. This phenomenon, known as the ‘social economical health difference’ is recognised by the Dutch government; concentrated effort is spent on reducing the health risks within the lower income and education social groups. 866 With this in mind, the State, together with local government, has undertaken two main initiatives: 87 1. A strive to include health as an issue in the upcoming policy framework ‘Large City Policy 2005-2009’, which allocates national budget for specific subjects in large cities. Foreigners to the Netherlands and people with lower level income and education are concentrated in the larger cities.

2. Development of a programme for a directed focus on the main areas of larger cities that require extra attention.

One barrier exemplified by research respondents is the difficulty in reaching young people and lower income groups by more traditional means of health promotion. Reaching these groups specifically could be achieved more efficiently through schools, recreation and work within the groups’ environments. 88

86. Programmacommissie SEGV-II (2001). Sociaal-economische gezondheidsverschillen verkleinen: Eindrapportage en beleidsaanbevelingen van de Programmacommissie SEGV-II. 87. Ministerie van VWS (2003).

Beleidsnota: Langer gezond leven.

The Hague.

88. Ministerie van VWS (2003).

Beleidsnota: Langer gezond leven.

The Hague.

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Criticism from research respondents Three main points of criticism have been identified, shared by a number of experts, NGOs and research respondents alike.

1. The government does not provide the leadership, direction or facilitation that is expected or required. There seems to be enormous differentiation of unaligned initiatives from stakeholders within the field. Whilst the Ministry of Health pointed at the new covenant as an expression of clarity and good intent, stakeholders within the food industry appear to have little faith in it, one going so far as to comment: “A covenant is just a statement of good intent; anyone can express such a statement.”

Meetings of the ROO have been described as ‘polder meetings’ by one NGO during research: each stakeholder has an opportunity to comment, however this results in fragmentation of initiatives rather than a cohesive plan of action.

89. NRC (27-01-2005) Convenant overgewicht slappe hap

The Ministry of Health presented the national obesity covenant in January 2005. Co-signers were the food industry association, eating out industry association, employers’ federation, retail association, catering association, healthcare insurance association, sport federation and the Ministry of Education. The consumer association refused to co-sign the covenant: “Signing the covenant is out of the question. If the covenant does not address the fact that the food industry is also responsible for the problem of obesity, the concrete measures flowing from the covenant will not be very promising.”89 2. NGOs point to the slowness of the government to affect change.

The Ministry of Public Health believes that the new covenant had been established in just three months, exemplifying speed and efficiency. NGOs on the other hand believe it could be years before any results are expected.

3. Many stakeholders call for the Dutch government to task companies more directly in working towards a solution to the overweight and obesity issue.

4.2 Political parties

90. Stenogram, wetsvoorstel Vaststelling van de begrotingsstaat van het Ministerie van VWS voor het jaar 2005, p. 12

“Minister Hoogervorst from the Ministry of Public Health, do you share the opinion that it takes more to fight the problem of overweight and obesity, and that the State secretary – because she is responsible for youth policy – should develop an action plan, and formulate a level of ambition?”90 (Ms. Arib, PVDA, Socialist Party)

Overweight and obesity has become a political issue; the Minister for Public Health is regularly asked to defend policy decisions. Is there political support for legislation from parties including the PVDA, CDA and VVD? If so, what form could legislation take in the Netherlands? After interviewing stakeholders from the PVDA, CDA and VVD, it appears that attention is concentrated in the following areas.

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Informing the public There is widespread belief across parties that raising public awareness by providing better information on the necessity of a healthy lifestyle is key.

Without this the consumer cannot effectively take individual responsibility by making an informed and educated choice.

An integrated approach Political parties see the Ministry for Public Health as responsible for directing an integrated approach involving all stakeholders at a national level. There is a need for a setting of common goals and targets which can be evaluated and adopted at a local level within a long-term planning framework. Local government also plays a role in combating overweight and obesity by its more precise understanding of local community needs. In the Hague, for example, funds available for the local promotion of physical activity have been directed towards the continuation of school swimming.

Self-regulation In order to reduce administrative burden resulting from governmental legislation, self-regulation appears to be the preference. Interestingly, not all legislation is viewed negatively by political parties. Legislation concerning the ban on some food products from schools and the restriction of marketing directed at children, for example, receives general applause: “No ban on advertising for confectionery: Parliament urges for a ban on advertising directed at children. PVDA, Groenlinks and SP are in favour, and the CDA called the position ‘sympathetic’. Public Health Minister Hoogervorst, for now, opts for self-regulation.”91 Cutbacks on the national budget Due to cutbacks in the national budget, restricted funds have been made available for the promotion of physical exercise in the Netherlands. Political parties disagree as to whether budgets have been adequately allocated to the development of physical education in schools, or the improvement of professional advice at sports clubs. Various political research respondents nodded to the possibility for sporting clubs to receive additional funding, for instance from the private sector.

Overweight and obesity have not been high on the political agenda It is only in the last two years that the issue of overweight and obesity has secured a more prominent position on the political agenda. It remains to be seen whether any one political party will truly claim the issue. Some stakeholders interviewed point to the fact that politically, overweight and obesity is not a ‘sexy’ issue to lay claim to.

91. Marketing Online (17-02-2004).

Minister wil snoep en snack reclame beperken.

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4.3 Non-governmental organisations

92. De Telegraaf (30-01-2004).

Dikmakers krijgen rood van Consumer Association.

“The Consumer Association wants to help consumers in the supermarket by way of using the colours red, yellow and green on packages to distinguish the ‘fat-makers’ from more healthy products.”92 There is a wide spectrum of non-governmental organisations in the Netherlands which regularly participate in the public debate on overweight and obesity. Organisations include the Consumer Association, the Dutch Heart Association, and the Dutch Obesity Association. The Nutrition Centre, whilst partially funded by the government, sits most comfortably in this section on NGOs. NGOs have the responsibility to question the policies of both the government and the private sector – putting pressure on both to take responsibility and act in the public’s best interests.

93. De Telegraaf (16-02-2004).

Reclamegeld tegen overgewicht.

For this reason NGOs often take on the role of devil’s advocate. The Consumer Association does this frequently on the subject of overweight and obesity and has proposed the traffic light system which is intended to inform on ‘healthy’ and ‘unhealthy’ foods. The Nutrition Centre has suggested that food companies could use one percent of their marketing budgets for public information campaigns about a healthy dietary pattern.93 Labelling of food products Labelling is a way of informing the public about the nutritional value of that product. On the basis of this information, the consumer can then decide whether the product fits in their dietary pattern and how much of it could be consumed. Packaging claims are a subject of marketing as well as labelling. The NGOs seem to agree that labelling is of major importance, however product labelling is still often unclear.

The Consumer Association proposes the implementation of the traffic light system on product labelling, to guide consumers towards healthier eating options. Success of such a scheme would be dependent on an effective public information campaign to support the labelling. Without it, consumers may find it difficult to understand whether red signifies ‘never eat’ or ‘once a week’.

NGOs agree that labelling of ingredients such as fat and sugar requires standardisation and regulation. Currently this is not the case; claims in use are open to interpretation and misunderstanding:

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“Some consumer organisations in the European Union consider products that do not have a ‘desirable’ nutritional profile, such as candies, high salt and high fat snacks or high fat and sugar biscuits and cakes, should not to be allowed to bear claims. For example, a ‘low fat’ claim should only be allowed if the product does not contain high quantities of sugar or salt; or a ‘high calcium’ claim should not be used on a product with a high fat content.”94 Marketing practices of the food industry Most NGOs feel strongly about limiting the marketing practices of food companies, especially towards children. According to research respondents, current intensive marketing practices undermine parental authority. It could also be claimed, however, that “Parents are the ones that ultimately buy ‘unhealthy’ products – the problem is not so much the number of commercials but the choices the parents make.”

94. Commission of the European Communities (2003). Regulation of the European parliament and of the council on nutrition and health claims made on foods, 2003/0165 (COD). Brussels.

Content of food products The content of food products also receives a great deal of attention from NGOs. General opinion states that whilst a few companies are making an effort to address the issue, the majority of food companies make minimal effort. Opinion amongst NGOs is split.

The majority of NGOs surveyed believe that the introduction of ‘low fat’ and ‘light’ variations of products is a positive initiative, by providing additional consumer choice. One NGO stressed the importance of concentrating first on a change in existing products, as an extended product range could lead to yet more confusion. As with the introduction of smaller portion sizes, if new products are offered alongside current products they may well be left on the shelf due to small perceived price and value differentiation.

As yet, the restaurant and catering business has barely entered the debate.

This is something that NGOs would like address in the near future.

To give an impression of campaigns from NGOs in the Netherlands, figures 20 and 21 are shown here below.

Figure 20: SIRE campaign, Source Adformatie, 23-12-2004.

O R G A N I S AT I O N

C A M PA I G N

SIRE

Parents, say no more often! See figure 20

Nutrition Centre

Don’t get fat!

- 2000 cal for women / 2500 for men - New disc of five (food pyramid in the form of a disc)

Heart Association

Kids, kilo’s and overweight!

Consumer Association

Association chooses health!

Figure 21: Overview of campaigns from NGOs on the subject of obesity, Burson-Marsteller 2004

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95. CIAA 2003). CIAA position on com. (2003) 424 Final: Proposal for a Regulation of the European Parliament and of the Council on Nutrition and Health Claims made on Foods. Brussels.

Categorisation of food products The Confederation of Food and Drink Industries of the EU (CIAA) states: “The basic principle in nutrition is that there are no ‘good’ or ‘bad’ foods but rather ‘good’ or ‘bad’ diets. CIAA can therefore not agree with the concept of undesirable nutritional profiles and the consequent prohibition of any claim on those foodstuffs.”955 This is the proffered reasoning as to why concepts such as ‘nutritional profiles’ are not generally endorsed.

Here NGOs disagree. If it is a common fact that some foods are not healthy, “Why shouldn’t you be able to talk about ‘unhealthy’ products?”

Research respondents question the principles upon which certain foods are evaluated. Under the traffic light system where red is ‘halt/bad’ and green is ‘go/healthy’ one respondent questioned: “Is cheese red or amber? Oily fish is normally positioned as a healthy food – is it red or is it green?” The private sector stakeholders were keen to point out that provision of public information in support of such a scheme does not necessarily influence behaviour. After all, after 40 years of debate and health education, the public is clear on the dangers of smoking – and yet people still do so.

4.4 The Dutch media The Dutch media play a vital role in reporting on developments concerning the overweight and obesity issue. But are news reports objective? Does the media provide a balanced picture of the issue from the perspective of all stakeholders? Are the true motives for stakeholder action accurately portrayed?

Media analysis There is a wealth of media coverage on the subject of overweight and obesity within the Dutch media. A media analysis was undertaken for one month from 30 October – 30 November 2004, involving local and national newspapers, in order to ascertain the breadth and depth of reportage.

The search words used were ‘overweight’ and ‘obesity’.

Fourteen articles were discovered in local newspapers throughout the country for the given time period; in national newspapers the search resulted in six articles. These appeared in Algemeen Dagblad, de Volkskrant (twice), Trouw (twice) and NRC Handelsblad (see Appendix IV.) On closer examination a number of themes can be seen:

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- The lower-educated sections of the population suffer the greatest problems concerning overweight and obesity; - Sugar and fat are not ‘bad’ per se; - Not only consumers and the private sector, but also schools should take greater responsibility for their role in the issue; - The decline in physical activity in schools and disappearance of playgrounds; - The private sector’s marketing of food products to children.

By writing headlines such as de Volkskrant’s ‘Fat People Visit Doctor More’, industry experts believe the Dutch media are adding to the stigma attached to overweight and obesity (being overweight is socially unacceptable). On the other hand, medical conditions such as Type 2 diabetes and poor joints are more prevalent in those individuals suffering from overweight and obesity.

From an analysis of 2,300 articles across European and American media (2004) 96 , it appears that the Dutch media places responsibility for overweight and obesity mainly with the food industry and the general public. This is in contrast to other European countries, where the government is predominantly held responsible; English and American media point towards the individual.

Objectivity within the media Certain research respondents from the food industry were wary of giving media interviews, citing a distrust of objective journalism in the Netherlands. Does this concern come from a journalist’s deliberate manipulation of the truth or a basic misunderstanding of the overweight and obesity issue? One research respondent from the food industry questioned whether food companies themselves had fully educated the media on the complexities of the issue.

Criticism of journalistic integrity also comes from within the profession.

One research respondent drew attention to opportunistic journalism, whereby every new research finding is reported on, whether it is verifiable, respected, objective or otherwise. Such professional eagerness could be said to contribute to public confusion. Some stakeholders go so far as to question the level of media interest in the issue, suggesting that public interest will decrease and momentum for change weaken if the population tires of extensive media exposure.

96. Carma International commissioned by Edelman, the Netherlands (2004).

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5 The Dutch food industry “Unilever CEO Niall Fitzgerald expects that the food industry will discuss means to regulate itself, otherwise rules will be imposed upon it.”97

The food industry in the Netherlands has faced criticism regarding the overweight and obesity issue, with its response to product labelling and marketing practices subject to public debate. NGOs and the media are the harshest critics.

97. Financieele Dagblad (26-012004). Top-Unilever: voedingsindustrie moet actie tegen toename overgewicht.

5.1 Policies of food industry associations “The VAI adheres to the point of view that enough exercise and a responsible, varied dietary pattern are of the utmost importance for weight management and the prevention of overweight.” 98

In April 2004 the VAI (Dutch Food Industry Association) presented a report to the Minister for Public Health, entitled ‘Policy of the Dutch Food Industry Concerning the Reduction of Overweight’. As a member of the Confederation of the Food and Drink Industries of the EU (CIAA), the VAI’s report incorporated CIAA research findings.99 The report of the VAI states that the food industry already took responsibility at an early stage in the overweight and obesity issue.100 Surprisingly, a lot of the NGOs agree, pointing to developments in the US as preceding the situation in the Netherlands; with this in mind the VAI could be seen to be taking preventative measures. Research respondents cited the VAI as proactive compared to the response of the government.

In conversation with research respondents, there were a number of points taking central stage: public information (e.g. about sensible dietary habits); education (e.g. children regarding diet and the role of marketing); physical activity; marketing practices of the food industry; labelling of food products and the content of food products.

The following six aspects can be seen as the fundament on which policies of the food industry association are developed.

98. VAI (2004). Policy of the Dutch food industry concerning the reduction of overweight. The Hague. p.4

99. VAI (2004). Policy of the Dutch food industry concerning the reduction of overweight. The Hague. p.3 100. VAI (2004). Policy of the Dutch food industry concerning the reduction of overweight. The Hague. p. 3

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1. Responsibility of the consumer Similar to other stakeholders, research respondents from the food industry believe that a workable solution to the overweight epidemic can only be achieved if all stakeholders cooperate in sharing responsibility – this includes the private sector, the government, consumers, the retail industry, education and insurance companies. There has been insufficient dialogue between stakeholders to align different policies.

Whilst there are external factors influencing the decision, respondents believe it is the consumer’s end responsibility to choose healthy eating and physical activity. The CIAA states that the objective of any nutrition policy should be to facilitate free and informed choice by ensuring the following:

101. CIAA (1992). Nutrition policy: views and role of the food and drink industry. Brussels. p.3

- The provision of a safe and varied food supply in sufficient quantity, including varied portion sizes and a product range incorporating ‘light’ and ‘snack’ choices; - The provision of information about those foods, containing clear labelling of nutritional information; - Nutrition and health education, including the meaning of a varied diet and the importance of physical exercise, which takes cultural context into consideration.101 2. Caloric intake and physical exercise According to research respondents, the food industry has initiated projects to stimulate physical activity, especially in schools. These range from financial support to the distribution of pedometers and organisation of sports tournaments.

One stakeholder comments: “Being physically active should be made as much fun for children as playing computer games. Why does physical education at schools have to be graded? When something is an obligation, it is not fun anymore to most people.”

It is in the promotion of physical activity, where the food industry expects the most success in combating overweight and obesity in the Netherlands.

According to one research respondent: “People will simply have to learn the value of physical activity and a balanced dietary pattern.”

3. Clear communication Transparent communication – labelling, marketing and advertising – of food products are a major concern for the food industry. The 2004 VAI report goes on to outline the importance of clear product labelling, the provision of specific information concerning the place a product has in a responsible dietary pattern, and the establishment of an Advertising Code.

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In a 1992 nutrition policy document, the CIAA firmly states that the introduction of mandatory nutrition labelling for food products would be inappropriate: “The practicalities of compelling its provision for all food products would be out of all proportion to the possible benefits. But in view of the average level of the European consumer’s nutritional education, it is often difficult for the consumer to understand absolute information concerning a given nutrient; he needs a reference to give meaning to the information. Such a reference would be to use European-wide recommended dietary amounts for at least all relevant vitamins and minerals and maybe even for proteins.”102 The CIAA goes on to welcome an agreement by member states on a community scheme for presenting a product’s energy and nutrient content information in a standardised format.

4. Nutritional profiles, no food is ‘good’ or ‘bad’ The European Commission’s viewpoint on the matter of nutritional profiles is clear: “The concept of prohibiting the use of claims on certain foods on the basis of their ‘nutritional profile’ is contrary to the basic principle in nutrition that there are no ‘good’ and ‘bad’ foods. Nutritional advice certainly recommends judicious food choices and moderation in consumption of certain products but accepts that, in a long-term varied diet, all foods could be included in appropriate frequency and quantities. This argument, although scientifically valid, should be considered in the appropriate context.”103 The same report goes on to state: “Foods baring claims are presented by the food operators as products whose consumption would provide a benefit, which is as ‘good’ or ‘better’ products. In most cases, influenced by the promotional campaigns, consumers perceive them as such. This potential bias should be avoided in order to prevent negative effects.

Therefore some restrictions on the use of claims on foods based on their nutritional profile should be foreseen.”

The VAI supports the principle that there are no ‘good’ or ‘bad’ foods, much to the discontent of most NGOs, who believe it is clear that some products are less healthy than others. The Ministry for Public Health went so far as to say that it could not agree 100% with the VAI’s statement that there are no ‘bad’ foods.

102. CIAA (1992). Nutrition policy: views and role of the food and drink industry. Brussels. p.2

103. Commission of the European Communities (2003). Regulation of the European parliament and of the council on nutrition and health claims made on foods. Brussels.

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5. Advertising Code According to Jan Droogh, Secretary to the VAI, an experiment with commercial-free youth programming demonstrated that children are only minimally less exposed to advertising than usual. Recommendations from the report include a ban on celebrities to promote products and no volume-driven campaigns. NGOs believe that such a Code is not specific enough. The private sector may no longer be able to use celebrities in commercials, but what about on-pack advertising? Months after submission, the VAI’s suggested Code of Advertising still has not been approved by the Advertising Code Committee.

104. Twentsche Courant (25-092004). Te dikke burger is ook zaak overheid.

Instead, the VAI believes it is better to support initiatives such as ‘reclamerakkers’,104 a cooperative initiative between the Ministry of Education, the advertising and media industries, universities and NGOs, to educate children up to the age of twelve on the role marketing plays in society.

The target is to anchor the subjects of marketing and advertising within the primary school curriculum.

Making children more resilient against marketing is “nonsense” according to some stakeholders. A political stakeholder said: “When we make kids resilient against marketing, new ways of marketing are invented, then we have to make kids resilient against those as well; this results in a never ending cycle.”

105. Nutrition Centre (1998). That’s the way the Dutch eat. Results from the Food consumption overview 1997-1998. The Hague.

Whilst a food consumption overview (1997-1998) published by the Nutrition Centre1055 indicates that 90% of the time, parents determine the food intake of their children, the ‘pester power’ phenomenon cannot be underestimated.

NGO research respondents purport that commercials such as those for Chupa Chups candy continue to mislead. In the commercials large pieces of fruit are seen going into the product; in reality the product contains a very small amount of real fruit. The product also claims a ‘no fat’ content which caused one respondent to declare: “McDonalds can also claim that their burgers contain no sugar!”

106. Het Parool (5-01-2004). Tot brugklas geen frisdrank op school.

107. NRC Handelsblad (5-01-2004).

Playstation slechter dan Coca-cola.

6. Self-regulation One of the most recent developments in the overweight and obesity debate is the decision of the soda industry to stop selling drinks in Dutch primary schools. This decision is in advance of agreements that the food industry has made with the Minister for Public Health.1066 The NRC Handelsblad newspaper reports that the Public Health Minister will propose a new policy, effective from July 2005, bringing changes in the advertising industry, and banning soft drinks and confectionery in primary schools. Limitations will also be set on the sale of these products in secondary education.107

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7. Product modification & research The report of the VAI mentions the following points108 : - Guarantee freedom of choice by offering a varied assortment of food products; - Optimal product composition on the basis of scientific research; - Research about the prevention of overweight and informing the public about possibilities.

108. VAI (2004). Policy of the Dutch food industry concerning pushing back overweight. The Hague.

The industry association underlines the fact that most food organisations have introduced new or altered products containing less fat, sugar and salt. Introducing light products increases the choices consumers have.

Also, according to these respondents, the industry is working hard to decrease the amount of trans-fats.

Some stakeholders have a concern regarding the provision of ‘light’ product alternatives because research suggests that ‘light’ products can increase overweight and obesity, perhaps just in more indirect ways.

Mechanisms in the human body can be disrupted when products with artificial sweeteners are consumed. When ‘light’ products containing these artificial alternatives are consumed the body learns that no calories are associated with a sweet taste; when real sugar is consumed the body therefore still believes it is not receiving many calories. This stimulates the body to signal for additional food intake, leading people to consume more.109

5.2 Policies of food companies “Portion sizes will be cut as the food giants sign a seven step manifesto to tackle the sensitive food and health debate.”110

Many food companies feel themselves threatened by changes in the industry brought about by a response to the overweight and obesity issue (see figure 22). Food industry research respondents have emphasised the dynamics of competition whereby marketing is intended not to drive people to over-consume, but to differentiate companies and their products from one another: “When a customer wants to choose what product to buy, we want him to buy ours.”

109. Vidyya Medical News (01-072004). Study: Artificial sweetener may disrupt body’s ability to count calories. Vidyya Medical News, vol. 6, Issue 182. www.vidyya.com/vol6

110. Diary reporter.com (27-092004). Food Industry manifesto targets obesity. http://dairyreporter.com/news

60 C O M PA N I E S M O S T AT R I S K I N T H E O B E S I T Y D E B AT E

Figure 22: Companies most at risk in the obesity debate, JP Morgan, 2003.

1. Hershey

95

2. Cadbury

88

3. Coca-Cola

76

4. PepsiCo

73

5. Kraft

51

6. Kellogg

38

7. Wrigley

35

8. General Mills

35

9. H.J. Heinz

32

10. Campbell

23

However, other respondents have struck a more positive ‘seize the day’ attitude, viewing a call for new product ranges as an opportunity for further differentiation within the marketplace. For companies that are likely to benefit from the overweight and obesity issue see figure 23.

C O M PA N I E S M O S T L I K E LY T O B E N E F I T FROM THE RISE IN OBESITY 1. Danone 2. Campbell 3. Nestle 4. H.J. Heinz 5. Reckitt 6. Sara Lee 7. Wrigley 8. General Mills Figure 23: Companies most likely to benefit from the obesity debate, JP Morgan, 2003.

9. Kellogg 10. Unilever

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Initiatives of food companies to reduce overweight and obesity can be placed in four categories: 1. Product modifications Changes being embraced by some of the larger food companies include the introduction of smaller portion sizes, new food product composition, ‘light’ variations on popular lines and functional foods. Some product lines face barriers to modifications, such as chocolate. In light of EU regulations, using lower fat vegetable oil instead of ingredients higher in fat contravenes codes outlining what constitutes ‘chocolate.’

2. Product information Some companies have introduced caloric values for a portion size on food labels; many more companies plan to do the same. Also more products are getting labels, including candy-bars. However, barriers arise – particularly for smaller companies – when a product is sold in multiple countries; food companies encounter both cost issues for label changes and diverse labelling regulations.

Problems remain when a product is bought in a restaurant or from a vending machine. One research respondent suggested a resourceful solution: “Maybe it would be a good idea to mention the caloric value when the button for the product is pressed on a vending machine?

This way people know the value of the product before buying it and it is also possible to make a comparison between products before the product is bought.”

3. Responsible marketing Primary schools allow no marketing on the premises other than nonbranded sponsorship of events such as sports activities; this is usually referred to as ‘soft’ branding. Food industry research respondents questioned whether NGOs would appreciate that without income from sponsorship opportunities, many sporting events would not take place.

4. Stimulating physical activity During the interviews, respondents accentuated diverse initiatives that food companies have taken to promote physical activity. In their view physical activity is more important than food. After many interviews, the message from the private sector is clear. They have a responsibility and will continue to contribute in finding a solution but physical activity has declined more than the caloric intake has increased.

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6 Other industries in the Netherlands There are a number of private sector stakeholders besides the food industry who are involved: the retail industry; restaurants, cafes and other businesses involved in the catering industry; health insurance companies; and the computer industry. The latter is thought of as a stakeholder due to its influence on decreasing physical activity.

6.1 The retail sector “Supermarkets are also looking for measures to fight obesity in consumers.

They will soon communicate with the Department of Public Health about an approach together with the food producers.” 111

In accordance with the report of the VAI, the 2004 policy document of the CBL (industry body for supermarkets) ‘Plan for the prevention of overweight’ emphasises that the consumer is largely responsible for the issue of overweight and obesity.112 According to retailers the primary focus for the retail sector is on providing information about healthy dietary patterns, publishing health information in consumer magazines, stimulating the consumption of vegetables and fruit, and offering a variety of product choice. A CBL 2003 policy document states: “Freedom of choice is the central point of departure for supermarkets. The consumer has to decide for himself what to buy and make a choice in the store.”113 Freedom of choice According to one research respondent, consumer choice drives product development: “The consumer has the strongest voice, the consumer comes first. They do not always share the same opinion as the NGOs would like you to believe.” As long as customers make demand for a product it has a place on the shelves – this includes products across all categories.

Labelling Labelling receives more customer attention than ever before. One research respondent has introduced the caloric value of portion sizes on labels of its own house brand; it is expected that others will follow. Retailers also confirmed the intention to increase information on healthy dietary patterns in store brochures.

111. Telegraaf (12-05-2004).

Ook supermarkten in actie tegen overgewicht.

112. CBL (2004). Plan for the prevention of overweight.

Leidschendam.

113. CBL (2003). Annual report: 2003. Leidschendam

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Shelf space Supermarkets try to position products in a way that shoppers find most logical. Surveys show that ‘healthy’ aisles are not necessarily a logical store layout for consumers. Rather, it seems that shoppers prefer to be able to compare similar products. A ‘light’ product should therefore be offered next to similar products within the same range. The same is true, incidentally, for vegetarian products.

114. VARA-KASSA (12-07-2004).

Supermarkten gaan verantwoordelijkheid nemen in strijd tegen overgewicht. http://kassa.vara.nl

115. Obesity debate at Nieuwspoort, November 22, The Hague.

The retail industry does however, have power to steer people’s choices by use of shelf space and position. The Nutrition Centre suggests the placement of ‘healthy’ products at eye level.114 A number of research respondents were of the opinion that ‘unhealthy’ products are given the most prominent shelf space. Placement of confectionery at checkout counters has been stigmatised by certain stakeholders as a clear sign that the retail sector has not taken the issue seriously enough. At a 2004 debate on overweight and obesity in the Hague, one stakeholder commented: “As long as [supermarkets] keep offering those products at the counters, they cannot genuinely say that they are taking responsibility.”115 Many stakeholders from outside the food industry seem to agree.

A research respondent outlined a shopping scenario familiar to many parents: “Imagine people standing in line with their child and he or she begins to whine about one of those products. You cannot just walk away, people are looking and they feel uncomfortable. How many times do those parents give in? Of course ultimately it is the responsibility of the parents, but these tactics make it very difficult for parents to stay strong.”

Price Price is a major influence on consumer choice (see figure 24). Various research respondents (non-retail industry) perceive that supermarket brochures predominantly advertise high fat, high sugar products and concentrate on marketing initiatives from producers of ‘unhealthy’ foods, such as towers of confectionery in the middle of supermarket aisles. Respondents from the retail industry disagree, citing regular offers on lower fat products and vegetables.

6.2 Eating out and the Royal Dutch Catering Association The Royal Dutch Catering Association (KHN) also has a part to play in the overweight and obesity debate. Research respondents, however, have heard little from the eating out and catering industry regarding plans and some stakeholders referred to the KHN as the most stubborn of stakeholders to talk with regarding this issue.

65 H O W M A N Y T I M E S D O YO U PAY AT T E N T I O N T O T H E F O L L O W I N G WHEN BUYING FOOD IN THE SUPERMARKET? Aspects

N eve r

Sometimes

A l way s / a l m o s t a l way s

Shelf-life

1%

7%

92%

Price

2%

13%

85%

Special Offering

2%

14%

84%

Ingredients

14%

35%

51%

Brand

10%

40%

50%

Method of preparation

11%

41%

48%

Time of preparation

22%

50%

28%

Package

32%

41%

27%

Hallmark present or not

36%

41%

23%

Addition of not-natural substances

43%

34%

23%

Country of origin

44%

37%

19%

Genetically modified substances

55%

26%

19%

Biological or not

40%

42%

18%

According to the KHN their first responsibility is to support variety on the menu so people can determine for themselves whether to eat more or less healthy. Some members see this issue as an opportunity and believe that much has already changed: “You can see a big difference when you compare a modern menu card with one from ten years back.”

The general feeling among stakeholders from the food industry, politics and NGOs is that the eating out sector does little in the way of combating overweight and obesity: “It seems that the only thing they communicate is that people do not want to be confronted with the issue in restaurants and pubs. Eating out is a moment to enjoy.”

Members of the KHN have gone so far as to criticise the association’s lack of action - the Association represents such a vast number of small food outlets, that an industry-wide approach is unachievable. The Ministry of Health pointed out that the eating out industry will be a focal point in the near future. After the industry association of food companies, the industry organisation of the retail business was asked to produce a Code of Conduct and the next focus could well be the KHN.

Figure 24: Which aspects do customers pay attention to when buying food in the supermarket, Erasmus Food Institute Rotterdam, 2003.

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116. Algemeen Dagblad (1-12-2004).

Veel profijt van ijdelheid.

Not all companies in the catering business remain silent, however. Dutch newspaper Algemeen Dagblad reported in 2004 on catering company Albron: “Fatima Moreira de Melo started a campaign this week from catering giant Albron to stimulate people to take up a healthier life and eating pattern.”116 Catering businesses hold essentially the same opinion as other stakeholders: they do not see themselves as primarily responsible; the issue is complex; it is a matter of caloric intake versus expenditure of physical energy; the consumer is ultimately responsible.

According to one respondent from the catering industry, the issue is actually new to the sector. The KHN received its first invitation to the Regional Discussion of Overweight (ROO) in 2004 - it attended the second.

Product information The sector shares a common belief that major barriers exist to accomplishing widespread product information. One research respondent comments: “It is very difficult to put the caloric value on a glass of cola in a bar.” But not all respondents agree. The Nutrition Centre is designing a computer system for the Eating out sector that should make ‘more or less’ accurate caloric calculations per menu item straightforward. Such a step has already been taken in the USA.

6.3 Healthcare insurers 117. Nederlandse Obesitas Vereniging (22-12-2004). Ziektekostenverzekeraars VGZ en CPG starten overgewicht offensief. www.dikke-mensen.nl

118. Zorgverzekeraars Nederland (2212-2004). Dutch Healthcare system. www.zn.nl

“Healthcare Insurers VGZ and CPG start overweight offensive.”117

Political stakeholders in particular question the responsibility of health insurance companies to be more proactive and properly enter the overweight and obesity debate.

Health insurance companies are responsible for providing insurance for everyone in the Netherlands. This is achieved by implementing a system consisting of public and private insurance. According to the industry organisation for healthcare insurers in the Netherlands (ZN) the Dutch system incorporates three parts: 118 1. Long-term care and uninsurable risks: financed by the AWBZ (General Law on Special Medical Care). The government is responsible for cost control; no competition or operation of market forces; 2. Curative care: this care package is determined by the government and insured via the health insurance fund, medical insurance access act (WTZ) or private insurance. A limited market operation by means of insurers’ budgeting constraints and the freedom of healthcare insurers to contract healthcare providers;

67

3. Additional care: offered by the insurance company to the individual in supplementary policies. Cost control and monitoring of quality is in the hands of the healthcare insurers themselves.

Although this does not formally fall within their jurisdiction, healthcare insurers feel that they not only have curative but also preventive responsibilities. Because prevention is not mentioned in point 2, if insurance companies want to address and act on the issue they must do so without financial support of the government. For this reason the curative component receives the most attention from health insurers; according to research respondents this is due to preventive healthcare being seen for the most part as responsibility of the government.

The general opinion within the health insurance sector is that the government should provide the resources necessary to support the prevention of overweight and obesity. In other words, this cost should be integrated into point 1 with the AWBZ. One research respondent observed that so long as the government gives no financial contribution to this, there is little incentive for healthcare insurance companies to act collectively. In the short term, the results of preventive measures are therefore unclear.

High risk groups and long-term investment Central to the way insurance companies work are methods of risk selection and damage control. The former refers to the marketing of health insurance products to the young, active and healthy; the latter refers to methods of screening potential consumers for conditions such as diabetes, providing health information in marketing literature, and developing health programmes designed to raise physical activity. Attracting ‘safe bet’ consumers does much the same thing.

Investment in his form of prevention is thought to save costs in the longer term; experts and research respondents accuse insurance companies of focusing too heavily on short-term gain.

Respondents from the health insurance sector went on to say that if an organisation is high profile about the issue of overweight and obesity, it runs the risk of attracting more members of the public from high risk groups. This effects ‘damage control’. There is also a concern that by becoming actively financially involved in this issue, it will send signals to the government that health insurance companies should take responsibility for resourcing additional preventive health issues.

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Use of available data Research respondents share a belief that the general public does not want interference from the government or health insurance companies concerning their weight – this is seen by many as a private issue.

Health insurance companies are prevented from using personal health details in ‘preventive measure’ marketing campaigns. For example, using available data it is possible to construct a list of people who use insulin.

With this list healthcare insurance companies could send specific information to those clients with diabetes. Instead, when companies want to provide clients with information regarding diabetes they are required to contact all clients, asking whether they have diabetes and whether they would like to receive additional information.

119. Nederlandse Obesitas Vereniging (22-12-2004) Ziektekostenverzekeraars VGZ en CPG starten overgewicht offensief www.dikke-mensen.nl. Zie ook: www.natuurlijkafvallen.nl

Taking initiative Whilst the health insurance system does not perhaps stimulate the public to become more concerned about their health, some healthcare insurers do take the initiative. Insurer VGZ began an offensive in January 2005 against obesity specifically, together with Collective Preventive Health (CPG). The preventive programme, called ‘Natural Weight Loss, Healthy Lifestyle’ consists of four goals :119 1. To increase insight into an individual’s own lifestyle in relation to the healthy norm; 2. To increase knowledge of healthy nutrition, physical reactions to nutrition, physical exercise and self-motivation; 3. To increase FLASH moments (physical activity through biking, walking and activities in the housekeeping); 4. To continue stimulating motivation to work on a healthy lifestyle and achieve results.

The industry association of healthcare insurers intends to sign an agreement with the Ministry of Health. The next steps would be the instalment of a study group on the issue of overweight and obesity.

Research respondents highlighted two practical solutions coming from this: it would stimulate the development of guidelines for general practitioners and the allocation of 3% of healthcare insurance mutual funds towards prevention. This is an individual rather than a collective approach. According to most respondents this is not a realistic option, because it is forbidden to have a mutual target (such as prevention of obesity) for the funds.

69

Significantly, respondents pointed out that people are responsible for buying their own healthcare premiums. These premiums are ‘non-active’, meaning they offer no real incentive for people to improve their health.

The system could be made more pro-active according to these respondents, meaning that action from the individual could be stimulated by way of economical bonuses.

6.4 The computer industry As this research report has shown, many stakeholders point towards increasing computer use as a significant contribution to the decrease in physical activity.

Computer and internet use during leisure time has increased between 1985 and 2000, from 0.1 to 1.8 hours per week.120 As figure 25 illustrates, males use the computer more than females in their leisure time; the increase is most dramatic in the 12-19 age group.

120. Social and Cultural Planning Office (2004). Trends in time: The use and Organisation of time in The Netherlands, 1975-2000. The Hague.

The computer industry, however, sees itself as having no responsibility for overweight and obesity. Indeed, there has been no direct scientific link made between the computer industry and overweight. There has also been no real pressure from the media, politics, NGOs or other stakeholders towards the computer industry. The general notion among respondents from various stakeholder sectors was that the computer industry would only enter the debate if the issue was seen as an opportunity. Exposure at this stage would mean linking a company to a negative issue.

COMPUTER USE

COMPUTER USE 2000

19 8 5

Population

19 9 0

19 9 5

2000

Inter-

Other

net

use

! 12 years

0.1

0.5

0.9

1.8

0.5

1.3

male female

0.3 0.0

0.8 0.1

1.5 0.4

2.5 1.0

0.7 0.3

1.8 0.7

12-19 years

0.4

0.8

1.9

3.4

0.7

2.7

20-34 years

0.1

0.5

1.3

1.6

0.6

1.0

35-49 years

0.1

0.5

0.8

2.0

0.6

1.4

50-64 years

0.1

0.5

0.5

1.7

0.5

1.2

! 64 years

0.0

0.1

0.3

0.6

0.1

0.5

Sex

Age Figure 25: Computer and internet use, population aged 12 and over, 1975-2000 in hours per week, SCP ‘Trends in time, the use and Organisation of time in the Netherlands 1975-2000’ September 2004.

70

71

7 Physical activity in the Netherlands The importance of physical activity in combating overweight and obesity has been noted throughout the report. A few physical education initiatives such as the BOS impulse (increase education and sport in the local neighbourhood) and FLASH campaign (physical activity through biking, walking and activities in the housekeeping) have been mentioned earlier.

This chapter takes a closer look at levels of physical activity in the Netherlands: do people participate in sports less and if so, why?

7.1 An inactive lifestyle?

“Between 1975 and 2000 both men and women spent more time on sport.

Women doubled their sport time, while among men the increase was not quite so marked.”121

According to experts across all sectors, society in the Netherlands is designed more and more towards inactivity. Between 1975 and 2000, television viewing by people aged 12+ increased from 10.2 to 12.4 hours per week.122 Modes of transport – and time spent using them – have also changed (see figure 26).

Total travel

1975

19 8 0

19 8 5

19 9 0

19 9 5

2000

6.6

6.8

7.2

7.9

8.5

8.4

121. Social and Cultural Planning Office (2004). Trends in time: The use and Organisation of time in The Netherlands, 1975-2000. The Hague. p.120 122. Social and Cultural Planning Office (2004). Trends in time: The use and Organisation of time in The Netherlands, 1975-2000. The Hague

Reason for travel school/work

2.2

1.9

2.2

2.5

2.5

2.9

household activities

1.8

2.5

2.1

2.5

2.8

2.5

leisure

2.6

2.3

2.9

2.9

3.2

3.0

car

2.9

3.3

3.5

3.8

4.2

4.7

Transport mode public transport

1.0

0.9

0.9

1.2

1.1

1.0

cycle/moped, scooter or on foot

2.8

2.5

2.8

2.9

3.1

2.7

Figure 26: Travel by reason and transport mode, population aged 12 and over, 1975-2000 in hours per week, SCP ‘Trends in time, the use and organisation of time in the Netherlands 1975-2000’ September 2004.

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123. Social and Cultural Planning Office (2004). Trends in time: The use and Organisation of time in The Netherlands, 1975-2000. The Hague. p.125 124. Social and Cultural Planning Office (2004). Trends in time: The use and Organisation of time in The Netherlands, 1975-2000. The Hague. p.120

Figure 27: Sport and daily physical activity, population aged 12 and over, 1975-2000 in hours per week, SCP ‘Trends in time, the use and organisation of time in the Netherlands 1975-2000’ September 2004.

According to the Dutch Health Enhancing Physical Activity Guideline (NNGB) people should spend at least half an hour a day (one hour a day for young people) performing moderately intensive physical exercise to reap real health benefits. Physical exercise refers to sports and other daily activities such as walking and cycling123 (see figure 27). It appears that sporting activity itself has increased (hours per week) between 1975 and 2000, from 0.7 to 1.2. This increase, however, can be almost entirely accounted for by an increase in the general number of people participating in sport. The amount of time spent on sport individually did not rise substantially.124 1975

19 8 0

19 8 5

19 9 0

19 9 5 2 0 0 0 I N D E X

Time spent on sport

0.7

1.0

1.2

1.2

1.4

1.2

91

Walking and cycling as a goal in itself

0.8

0.6

0.8

0.6

0.7

0.5

73

Walking and cycling to get about

2.5

2.5

2.7

2.9

3.1

2.6

85

Total exercise

4.0

4.0

4.8

4.7

5.2

4.4

85

Share of sport in exercise pattern

18

24

26

26

26

28

108

73

Figure 28 outlines that people who are studying exercise more than those in employment. Whilst average total exercise time is 4.4 hours per week, this figure increases to 8.3 hours for 12 -19 year olds. This could be explained by additional time spent cycling due to lack of other transport possibilities at that age.

Figure 28 also shows that between 1975 and 2000 the number of hours exercised per week has actually increased; between 1995 and 2000, however, it has decreased.

Population ! 12 years

1975

19 8 0

19 8 5

19 9 0

19 9 5 2 0 0 0 I N D E X

4.0

4.0

4.8

4.7

5.2

4.4

85

Sex male

4.2

4.4

5.1

4.8

5.5

4.5

82

female

3.7

3.7

4.4

4.5

4.9

4.4

88

12-19 years

6.6

7.4

8.3

7.8

8.2

8.4

103

20-34 years

3.7

3.9

4.3

4.6

4.6

4.1

89

Age

35-49 years

3.0

3.0

3.9

4.1

4.9

3.9

80

50-64 years

3.3

3.1

3.8

4.0

4.9

3.9

79

! 64 years

3.2

2.9

4.3

3.7

4.7

3.7

78

living with parents

6.1

6.8

7.4

6.9

7.2

7.5

105

Family position living alone

3.1

3.4

4.4

4.6

5.0

5.0

100

with partner without children

3.3

3.1

4.4

4.1

4.9

3.5

72

parents with child/ children livind at home

3.1

3.2

3.7

4.0

4.6

3.6

79

primary/junior secundary

3.7

3.8

4.5

4.2

4.9

3.8

78

senior secundary

5.5

5.8

5.3

5.1

5.4

4.7

87

tertiary

3.7

4.1

4.9

5.1

5.4

4.9

90

Level of education

Labour market position at school/studying

7.2

7.6

8.3

7.9

7.9

8.3

104

employed

3.3

3.4

3.7

3.9

4.3

3.7

86

houshold activities

3.0

2.8

4.0

3.9

5.1

4.0

78

unemployed/incapacitated

4.0

3.5

4.5

4.7

5.0

4.2

84

retired

4.1

3.9

5.1

4.5

5.4

4.1

75

Figure 28: Time spent on exercise, population aged 12 and over, 1975-2000 in hours per week, SCP ‘Trends in time, the use and organisation of time in the Netherlands 1975-2000’ September 2004.

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7.2 Barriers to an increase in physical activity In addition to influences already discussed, research respondents across all sectors point to the following when considering barriers to physical activity in the Netherlands: - Government subsidy: the government makes less provision of subsidy for sport, suggesting an increase in financial contribution from the public.

This development has a negative effect for those with a lower income – the section of the population most in need of tackling overweight and obesity.

- Sports associations: with a change in people’s choice of sporting activity (towards fitness or skating, for example) sports associations are seeing fewer members and reduced subsidies. In this environment sports associations need to change and professionalise. A respondent pointed out the larger role played by the private sector (including food companies.) Sport associations need financial support from this sector, given, for example, in the form of sponsorships.

- Geographical location: sports clubs have been increasingly developed in the outer regions of cities, to the detriment of inner-city provision of facilities.

The NOC*NSF would like to see location of some clubs and facilities back in city centres.

- Playing outside: respondents remark that little thought has been given to outdoor sport and exercise areas in the design of new residential areas.

Sometimes areas are not considered safe for children to play outdoors.

Bicycle lanes should be provided with adequate illumination.

- Cultural divergence: national organisations such as the Netherlands Institute for Sport and Physical activity (NISB), and local organisations for public health (GGDs) display little awareness of how to promote physical activity in an increasingly culturally diverse population. The NOC*NSF, however, believes that time and financial resourcing regarding research, development and implementation should be split in a ratio of 1:3:9; in the Netherlands this ratio is more realistically 1:3:3.

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8 Position of overweight and obesity in the issue lifecycle It seems that the issue of overweight and obesity follows the same route as alcohol and smoking. Will its development result in the same kind of legislation and litigation?

8.1 The issues of smoking, alcohol and obesity compared “Tobacco and obesity epidemics: not so different after all?”125

At a first glance, the consumption of food is very different from that of tobacco: food after all, must be eaten from a physiological viewpoint, while tobacco consumption is not necessary for survival. Tobacco is also bad for people other than the smoker, inciting people to fight smoking because they have a right to clean air. These differences make it difficult to submit food companies to the same policies faced by the tobacco industry.

However, both issues follow a similar path. Smoking, obesity and alcohol abuse are all issues causing health problems and pose an enormous cost to society. Industry reaction is essentially the same: the individual is primarily responsible themselves; they are intelligent enough to make their own choices; and people have a right to smoke, drink or eat as they like.126 Connection between the products – foods, cigarettes, alcoholic drinks – and an unhealthy effect was denied in the earlier phase of all three issues.

The tobacco industry denied all links between smoking and certain diseases, arguing that they were not based on sound scientific research127, while the food industry proclaims, as previously discussed, that there are no ‘bad foods’.1288 Some accuse the three industries of having pointed to conflicting scientific data – is this to encourage a ‘smoke-screen’ effect?

For example, reports have said that sugars can help children to concentrate more, or that alcohol is good for widening the blood vessels, resulting in lower blood pressure.

In 1996 President Clinton launched a US campaign against the use of tobacco.129 Key initiatives were to: - List some tobacco substances as controlled substances due to their addictive effect; - Restrict children’s exposure to cigarette advertising; - Restrict points of sale for tobacco products.

125. Chopra M. & Darnton-Hill, I. (2004). Tobacco and obesity epidemics: not so different after all?

British Medical Journal, vol. 328, p.

1558-60

126. Post, J.E. (ed.) (2002). Business and society, Corporate strategy, public policy, ethics. New York, McGraw-Hill, p. 40

127. Heath, R.L. (1997). Strategic issues management. London: Sage publications. p.78 128. See for example: VAI (2004) policy of the Dutch food industry concerning pushing back overweight.

The Hague.

129. Heath, R.L. (1997). Strategic issues management. London: Sage publications. p.78

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For the food industry very similar measures are being proposed: banning of trans-fats and others from food products; changing guidelines of advertising to children; and more accessibility of healthy rather than ‘unhealthy’ food.

130. Adformatie (17-02-2004).

Minister wil snoep en snackreclame beperken.

131. Management today (01-062004). Big food and drink bites back.

In February 2004 the Dutch Minister for Public Health spoke of expectations of a firm approach from the food industry, referring to the tobacco industry’s refusal to make firm agreements; the tobacco industry is nowadays extremely limited in its ability to advertise.130 Management Today went further in saying: 131 “It is all horribly reminiscent of the tobacco business, decimated by the verdict of a Miami jury in 1999, which found manufacturers guilty of conspiring for years to hide the dangers and addictive properties of cigarettes. The tide has turned against tobacco; last year, its advertising and promotion was banned in Britain, weeks later New York outlawed smoking in public places and Dublin soon followed. Could the same bludgeon of litigation be directed at food companies? The threat is so real that public-liability insurance for fast-food and other restaurants rose by 35% last year, with further hikes expected.”

132. Zie bijvoorbeeld de Keuringsdienst van Waarde. www. rvu.nl/kvw/index 133. New York Times (14-05-2003). A Suit Seeks to Bar Oreos as a Health Risk.

It is difficult to implement effective legislation for something that people already know is ‘bad’ for them. What does seem better possible is legislation regarding information. People have a right to know when food is ‘bad’ for them, recommended amounts for consumption and what exactly is in a food product. Litigation could become a reality for the food and drinks industry if stakeholders believe that they have been misinformed and misled regarding potentially harmful food and ingredients. This has already been suggested concerning trans-fats and E-numbers such as E621 (monosodium-glutamate).132 In the USA Kraft is facing a lawsuit for ‘hiding’ trans-fats in their Oreo cookies.133 During research one respondent from a political party suggested that this issue should be directed only at foods deemed ‘unhealthy’ from a physiological point of view. Essentially, smoking, alcohol and ‘unhealthy’ foods are all stimulants. From this perspective it would appear that the same policies could be implemented.

The private sector is in agreement that there is a resemblance between the development of smoking and obesity issues. However, one fundamental difference is that the food industry believes it took responsibility at an early stage, in contrast to the tobacco industry.

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8.2 The obesity issue lifecycle Issues usually follow a certain lifecycle where the attitude of stakeholders towards the issue takes a different form. The issue lifecycle can be generally distinguished by five key stages: birth; growth; development; maturity; and post-maturity (see figure 29).

Birth

Growth

Development

Maturity

Postmaturity

Identification

Increasing attention NGOs

Attention Media & Public

Political attention

Legislation

Europe Netherlands r

New balance

United States

P r o - a c t iv e

R ea c tive

(opportunities)

(damage control)

Post, Lawrence and Weber134 suggest an alternative model with four stages: - Phase 1: changing stakeholder expectations; - Phase 2: political action; - Phase 3: formal government action; - Phase 4: legal implementation.

The two models are comparative. One can state that when stakeholder expectations change, an issue is born. When an issue grows and develops it becomes part of the political agenda. An issue is mature when more people are drawn into the political arena, ideas emerge about how to use laws or regulations to solve the issue, and when legislative proposals or draft regulations emerge.

Global evaluation of the overweight and obesity issue makes it clear that the issue has reached the political arena of various countries, including those in Asia and Africa (for example, Sri Lanka and Mauritania). The issue has become public with many stakeholders debating potential solutions.

But is the issue in the maturity stage?

Figure 29: Issue Lifecycle, Burson-Marsteller 2004.

134. Post, J.E. (ed.) (2002). Business and society, Corporate strategy, public policy, ethics. New York, McGraw-Hill.

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Theoretically yes, because in almost every country legislation has been proposed. However, articles and reports on the subject of overweight and obesity express the expectation that the issue will become much larger, suggesting that the issue is still in its development stage.

135. American Heart Association (07-01-2004). American Senate introduces obesity-fighting legislation. http://www.americanheart.org.

136. See the summary of the debate between Minister Hoogervorst and parliament on 16 February 2004

For some nations the issue seems to have reached the formal government phase and perhaps even the stage of legal implementation. In the US legislation has been issued in several states. For example, the American Heart Association speaks of the US Senate introducing obesity-fighting legislation.135 In the Netherlands the issue hit the political arena in 2001 when the Minister of Health stated a belief that obesity was becoming an epidemic. The ‘Don’t Make Yourself Fat’ campaign of 2002 implies that the government was beginning to invest in the issue since 2000.

Attention of the overweight and obesity issue was particularly intensified after the subject of ‘fat-tax’ came up in the report of the Council of Public Health, November 2002. From this moment on, politicians have been talking about regulation. In the political debate that followed the diplomatic paper Longer Healthy Living (October 2003) 136 , numerous questions regarding the possibility of regulation were posed to the Health Minister.

Many were disappointed by ‘just self-regulation’ and referred to the Belgian Minister of Health who was considering a ban on advertising for candy and junk food.

An issue usually advances to the growth phase when attention is drawn by certain events – the issue becomes part of public debate. In the Netherlands, this could be the media attention for Morgan Spurlock’s documentary ‘Super Size Me’ and the reaction from Dutch journalist Wim Mey who repeated the experiment and reviewed it in the national newspaper Algemeen Dagblad. However, when an issue reaches the development phase, stakeholders are pressing companies for change; this is the more accurate situation in the Netherlands. In countries such as France and the UK, debate on possible legislative measures and policies is more advanced. In contrast, research respondents point to a lack of significant political interest in the Netherlands.

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Appendix I List of interviewed stakeholders Public domain 1. Drs. S. Buijs, Member of Parliament CDA 2. Ms. M. van Dijken, Member of Parliament PVDA 3. J. Rijpstra, Member of Parliament VVD 4. Ms. Dr. C.E.J. Cuijpers, Policy Officer, Ministry of Health 5. Drs. J.A.J. Krosse, Director NIGZ 6. Drs. R. Kramer, r Senior Consultant NIGZ 7. W. Meij, Chief Editorial Office ‘Diagnosis’ Algemeen Dagblad Private domain 8. G. van Alphen, Corporate Relations Manager Coca-Cola 9. Dr. Ir. G. de Bekker, r Nutrition Manager Danone-LU 10. L. Blommaert, General Manager Kraft Foods 11. J.M. van Boxtel, Franchise-Manager FEBO 12. F. de Jonge, Issue PR Media Manager Unilever Bestfoods 13. H. Scholten, Sr. Marketing Manager Smiths Food Group B.V. 14. M. Simonis, Communication Coordinator McDonalds r Head of Quality Albert-Heijn 15. Ms. Dr. S. A. Hertzberger, 16. K. van den Hoven, Head of Communication and Promotion Schuitema N.V. 17. F. Rittinghaus, Marketing Manager Nintendo Benelux B.V. Industry associations 18. Drs. J.A.M. Droogh, Secretary of the VAI (FNLI) 19. M. Klok, Policy Officer Royal Dutch Catering (KHN) 20. A.L.J.E. Martens, Policy Officer sector organisation of healthcare insurers (ZN) 21. J.W. Schouten, Policy Officer sector organisation of healthcare insurers (ZN) NGOs 22. Ms. K. Bemelmans, Policy Officer Project Overweight Nutrition Centre 23. Ms. I. van Dis, Heart Foundation 24. Ms. A.M. van der Laan, Policy Officer Consumer Association 25. Ms. M. van Spanje, President Dutch Obesity Association (NOV) Science / knowledge institutions 26. Prof. Dr. M. Korthals, Applied Philosophy University Wageningen (WUR), Author of the book “Before dinner, philosophy and ethics of nutrition” 27. Prof. Dr. J. Seidell, Prof. Nutrition and Health, Director Institute for Health Sciences Free University Amsterdam (VU) Sport 28. Ms. H. Mulder, r Senior Project Manager NOC*NSF

80

81

Appendix II List of abbreviations AWBZ

General Law Special Health Costs

BMI BOS

Body Mass Index Impulse Neighbourhood, Education and Sport

CBL CDA CIAA CPG CSPI

Industry Association of Supermarkets Christian Democrat Party Confederation of the Food and Drink Industries of the EU Collective Preventive Health Centre for Science in the Public Interest

EU

European Union

FNLI FLASH FSA

New name for the VAI and SMA after merging Government campaign stimulating physical activity by way of Biking, Walking, Active playing, Sports and Housekeeping Food Standards Agency

GGD

Institutions for Public Health on a local level

Kcal KHN

Kilocalories Royal Dutch Catering Association

NGO NHS NIGZ NISB NNGB NOC*NSF

Non-Governmental Organisation National Health Service Netherlands Institute for Health Promotion and Disease Prevention Dutch Institute for Sports and Physical activity Dutch Health Enhancing Physical Activity Guidelines National Olympic Comity and Sport Federation

OC&W OECD

Ministry of Education, Culture and Science Organisation for Economic Co-operation and Development

PVDA

Labour Party

RIVM ROO ROW

National Institute of Public Health and Environment Discussion platform on the topic of overweight Discussion platform on consumer-goods

82

SIRE SMA SP

Foundation of Ideological Advertising Association for the interests of producers and importers of fast consumer goods Socialist Party

TNS NIPO

Dutch Research Institute of Public Opinion

UK US

United Kingdom United States

VAI VROM VU VVD VWS

Dutch Food Industry Association Ministry of Spatial Planning Free University Amsterdam Liberal Party Ministry of Health

WHO WTZ WUR

World Health Organisation Law for the access to healthcare Insurances University Wageningen

ZN

Sector organisation representing the providers of care insurance in The Netherlands

83

Appendix III List of literature - Bemelmans, W.J.E et al (2004). Toekomstige ontwikkelingen in overgewicht: Inschatting effecten op de volksgezondheid. RIVM rapport nr. 260301003. Bilthoven.

- Binsbergen, J.J. & Mathus-Vliegen, E.M.H. (2003). Dikke kinderen.

Medisch contact: jaargang 58 nr. 14.

- Burson-Marsteller (2001). Public affairs in de 21e eeuw. The Hague.

- Centraal Bureau Levensmiddelenhandel (2004). Plan van aanpak preventie overgewicht. Leidschendam.

- Chopra, M. & Darnton-Hill, I (2004). Tobacco and obesity epidemics: not so different after all? British Medical Journal. Vol. 328, p.1558-60.

- ClĂŠmence Ross Van Dorp, staatssecretaris van VWS (2003). Toespraak ter gelegenheid van het in ontvangst nemen van het advies Overgewicht en obesitas van de Gezondheidsraad. The Hague.

- Confederation of the Food and Drink Industries of the EU (1992).

Nutrition Policy: Views and role of the food and drink industry. Brussels.

- Elkington, J. (1997). Cannibals with forks. Oxford: Capstone Publishing.

- Erasmus Food Management Instituut Rotterdam (2003). CBL debat voedselveiligheid Nationale food week. Rotterdam.

- European Commission; Health & Consumer Protection DirectorateGeneral (2004). Summary Report; Roundtable on Obesity. Luxembourg.

- European Commission; Health & Consumer Protection DirectorateGeneral (2004). Healthy Eating for Healthy Lives: A European Contribution? Remarks by Robert Madelin. Brussels.

- Gezondheidsraad (2003). Overgewicht en obesitas. The Hague.

- GFK (2004). Overgewicht de nieuwste bedreiging voor volksgezondheid.

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- Heath, R.L. (1997). Strategic issues management. London: Sage publications.

- Hulshof, K.F.A.M. et al. (2004). Resultaten van de Voedselconsumptie peiling 2003. RIVM rapport 350030002/2004. Bilthoven.

- Janssen Groesbeek, M. (2001). Maatschappelijk ondernemen. Amsterdam: Business Contact.

- Leyer, J. (1997). Brede maatschappelijke overeenstemming als managementvraagstuk. Nijenrode management review. Nr. 3, pp. 36-48.

- Ministerie van Volksgezondheid, Welzijn en Sport (2003). Preventienota; Langer gezond leven. The Hague.

- Ministerie van Volksgezondheid, Welzijn en Sport (2003). Kabinetsnota; Gezond leven. The Hague.

- Ministerie van Volksgezondheid, Welzijn en Sport (2004). Stenogram behandeling wetsvoorstel. Vaststelling van de begrotingsstaat van het Ministerie van Volksgezondheid, Welzijn en Sport voor het jaar 2005.

The Hague.

- Nederlandse Public Health Federatie (2004). Samenvatting overleg minister Hoogervorst en de Tweede Kamer i.v.m bespreking nota Langer gezond leven. The Hague.

- Nederlandse Voedingsmiddelen Industrie. Beleid van de Nederlandse Voedingsmiddelen Industrie inzake het terugdringen van overgewicht.

The Hague, 21 april 2004.

- Peper, B. (1999). Op zoek naar samenhang en richting. Essay 12 juli 1999.

Petracca.

- Pijnenburg, A.A.G. (1998). Reader “PAM en pressiegroepenpolitiek�.

Erasmus Universiteit Rotterdam.

- Post, J.E. (ed.) (2002). Business and society, Corporate strategy, public policy, ethics. New York, McGraw-Hill.

- Public Affairs Consultants (1992). Gewogen belangen: Public Affairs in theorie en praktijk. Deventer: Kluwer Bedrijfswetenschappen.

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- Reuters Business Insights (2004). Obesity, Low-Carb Diets and the Atkins™ Revolution: Healthy profits from big issues in food and drinks.

- Rijksinstituut voor Volksgezondheid en milieu (2004). Van Kreijl, C.F. & Knaap, A.G.A.C. (eindredactie). Ons eten gemeten: Gezonde voeding en veilig voedsel in Nederland. Houten: Bohn Stafleu Van Loghum.

- Schendelen, M.P.C.M. van, Pauw, B.M.J. (1998). Lobbyen in Nederland.

The Hague: Sdu Uitgevers.

- Schendelen, M.P.C.M. van (red.) (1994.). Politiek en Bedrijfsleven.

Amsterdam: Amsterdam University Press.

- Schendelen, M.P.C.M. van (2002). Machiavelli in Brussels. Amsterdam: Amsterdam University Press.

- Smith, E.A. & Malone, R.E. (2003). Thinking the ‘unthinkable’: why Philip Morris considered quitting. Tobacco Control. Vol.12, p. 208-213.

- Sociaal en Cultureel Planbureau (2003). Rapportage jeugd 2002.

The Hague.

- Sociaal en Cultureel Planbureau (2004). Trends in time: The use and organisation of time in the Netherlands, 1975-2000. The Hague.

- Steiner, G.A., Steiner, J.F. (2000). Business, Government and Society.

Boston: Irwin McGraw-Hill.

- Tulder, R. van, Zwart, A. van der (2003). Reputaties op het spel. Utrecht: Uitgeverij Het Spectrum.

- Tweede Kamer der Staten Generaal. Preventiebeleid voor de volksgezondheid: Motie van de leden Tonkens en Arib. Vergaderjaar 2003-2004, 22 894, nr. 27.

- Nutrition Centre (1998). Resultaten van de voedselconsumptie peiling 1997-1998. The Hague.

- World Federation of Advertisers (2004). Statutory and self-regulatory regulation on food and beverage advertising aimed at children in EU member States.

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- World Health Organisation (2002). The World Health Report 2002: Reducing risks, promoting healthy life. Geneva.

- World Health Organisation (2003). The World Health Report 2003: Shaping the future. Geneva.

- World Health Organisation (2004). Global strategy on diet, physical activity and health. Geneva.

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Appendix IV Media analysis Local newspapers 1. Dagblad van het Noorden, November 11, 2004, Centre for heavy weights in hospital; Emmer surgeon Reijnen offers help for overweight people.

2. Dagblad van het Noorden, November 12, 2004, Fatties lose weight in Emmen; Surgeon starts centre for heavy people in hospital.

3. Dagblad van het Noorden, November 13, 2004, Medicine against obesity with children; AZG closely involved in research.

4. Dagblad Tubantia / Twentsche Courant, November 19, 2004, Sugar and fat not always bad, the reality behind unhealthy fat bellies is…

5. De Standaard, November 23, 2004, Lack of sleep makes fat.

6. Eindhovens Dagblad, November 24, 2004, Lighter through light?

7. Rijn en Gouwe, November 24, 2004, Worries for overweight; GGD starts campaigns for children.

8. Goudsche Courant, November 24, 2004, low-educated have more problems. ... more often have overweight, drink more and ...

9. Amersfoortse Courant / Utrechts nieuwsblad, November 25, 2004, Schools must play role in the battle against overweight.

10. Rotterdams Dagblad, November 25, 2004, Dieticians go to work with overweight children.

11. Eindhovens Dagblad, November 27, 2004, sticker doesn’t make apple more exciting.

12. Rotterdams Dagblad, November 27, 2004, Sponge Bob doesn’t make an apple more exciting; Minister in action against toys with potato chips.

13. Haagsche Courant, November 27, 2004, The proposition- ‘removing playgrounds is idiotic’.

14. De Standaard, November 29, 2004, Chocolate against coughing…

Goodbye cough, hello obesity!

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National newspapers 15. De Volkskrant, October 30, 2004, Fat people visit doctor more.

16. Algemeen Dagblad, November 17, The scale of five (food pyramid shaped as a disc) is back.

17. De Volkskrant, November 24, 2004, Big Mac with cola becomes yoghurt with muesli; McDonald’s gets through health hype successfully.

18. Trouw, November 27, 2004, Hamburger-giant against overweight; not everybody happy with money McDonalds.

19. Trouw, November 27, 2004, Does McDonald’s money stink?

20. NRC Handelsblad, November 27, 2004, Physical education at school?

Treatment

Examination

Yes

No

Hx BMI ≥ 25?

No

Yes Assess risk factors

Advise to maintain weight/address other risk factors

13

Yes

6

Periodic Weight Check

16

Brief reinforcement / educate on weight management

15

14

BMI ≥ 25 or waist circumference > 88 cm (F) > 102 cm (M)

5

No

• Dietry therapy • Behavior therapy • Physical activity

Maintenance counseling

11

No

Does patient want to lose weight?

12

Yes

BMI ≥ 30 OR {[BMI 25 to 29,9 OR waist circumference Yes > 88 cm (F) >102 cm (M)] AND ≥ 2 risk factors}

7

Treatment Algorithm*

10

Yes

Assess reasons for failure to lose weight

No

Progress being made / goal achieved?

9

Clinican and patient devise goals and treatment strategy for weight loss and risk factor control

8

Obesity treatment flowchart

• Calculate BMI

• Measure weight, height, and waist circumference

BMI measured in past 2 years?

No

Hx of ≥ 25 BMI?

Patient Encounter

Appendix V

* This algorith applies only to the assessment for overweight and obesity and subsequent decisions based on that assessment. It does not include any initial overall assessment for cardiovasculair risk factors or diseases that are indicated.

4

3

2

1

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91

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Notes

93

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94

Notes

95

Notes

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