Stretegies for preventing obesity and reducing inequalities: the experience in Europe

1. SCN 33rd SESSION Working Group on Household Food Security Stretegies for preventing obesity and reducing inequalities: the experience in Europe Francesco Branca Joceline Pomerleau Cecile Knai

2. The Ministerial Conference on counteracting obesity • Istanbul on 15-17 November 2006, hosted by the Ministry of Health of Turkey • Participants : Health Ministers and representatives from the agriculture, trade, transport, environment, education sectors • International partners : European Commission, Council of Europe, FAO, The World Bank, UNICEF

3. Expert consultations • Evidence of effective prevention policies – Athens, June 2005 (with EASO) • The role of physical activity – Amsterdam, June 2005 (with • The role of local governments – Bursa, Turkey, September 2006 • Inequalities and Obesity – London, 13-14 December 2005 • School policies – Florence, 11-12 March 2006 (with HBSC) • Marketing to children of food and drinks in Europe – Oslo, May 2006

4. The mothers Women’s BMI in Russia, Poland, Czech Republic By Education Obesity trends by social class in women: England 1993-2001 Health Survey for England H. Pikart: HAPIEE study, 2003/2004

5. The children ETHNICITY Germany INCOME France (2-17 y) INDEX OF MULTIPLE DEPRIVATION England (2-10 y) Jotangia et al., 2005 Kuepper-Nybelen et al (2005)

6. Policy framework - 1 • “There is a need to identify and deal with high risk environments rather than high risk […] groups” (Kuepper-Nybelen et al 2005) • The responsibility for obesity cannot rest on the shoulders of individuals • Individuals, particularly those in disadvantaged situations, face structural, social, organisational, financial and other constraints in making the healthy choice • Key considerations: accessibility, availability, affordability, practicality, relevance and attractiveness… a

7. Policy framework - 2 • Focusing on more on environmental change, and less on behavioural change, can be particularly beneficial to disadvantaged groups • addresses the underlying causes and increases the potential for true prevention; • becomes structural (e.g. local government transport policies); • helps make healthy choices the normative choices; • is most likely to be sustained, particularly if backed by strong policies; • can be benefited by all (e.g. green spaces); • is less language-dependent; • is usually cost effective, even the expensive strategies such as improving active transport; Swinburn & Egger, Obes Rev 3(4) 2002

8. Potential strategies: matrix

9. Potential strategies - 1 • Global (WHO, EU, others) • With governments, examine the role of globalization on food availability and consumption; transport and urban planning; social networks; local and national economies • Promote the importance of evidence-based, independent research in the role of diet, physical activity, economic/ psychosocial factors in reducing SE inequalities in obesity • National / local • Create funds for local authorities, voluntary organisations and community groups to deliver a range of local schemes such as safe routes to school, community regeneration projects, local coalitions to reducing health inequalities • Examine pricing policies to ensure that healthy foods are accessible to all and ensure that foods like fruit and vegetables are no longer luxury items

10. Less of this… More of this… Example 1 : Re-prioritizing access and price Junk food at school and in the curriculum School fruit tuck shop in Swansea

11. Example 2 : Programmes for vulnerable groups In Indiana, USA, the Farmer’s Market Nutrition Program provides participants in the WIC program with checks to purchase locally grown fresh fruits and vegetables at local farmers’ market.

12. Potentialstrategies - 2 • NGO • Develop programmes for low income households on how to prepare low-cost healthy meals and on how and where to access physical activity opportunities at low cost • Support local agriculture and community physical activity initiatives to promote social cohesion, sense of worth, healthier food intake and higher activity level • Food supply • Encourage more farmers’ markets and grocery stores to establish themselves in low income areas, to reduce ‘food deserts’ and provide sources of healthy food within walking distance • Increase the visibility and appeal of healthy foods in supermarkets, and those accepted by particular ethnic groups

13. Potential strategies - 3 UNDP "Teams to end Poverty" • Media • Attract celebrity role models in the promotion of healthy eating and physical activity • Promote a healthy lifestyle culture (e.g. incorporate positive behaviour change messages into television programmes and popular magazines) • Health care • Increase health professionals’ awareness of SE inequalities in obesity • Develop partnerships between health services, social services and local authority which can provide a catalyst for increased community networks to support disadvantaged groups and liaise with existing physical activity and diet initiatives

14. Potential strategies - 4 • Education sites • Improve access to pre-school education • Have school nutrition policies to ensure good nutritional quality of foods served in cafeterias • Incorporate physical activity into the school day as integrated in the curriculum • Develop clear policies about bullying related to body size • Work sites • Include healthy food choices (e.g. subsidize healthy foods in cafeterias) and physical activity options (e.g. exercise facilities and changing rooms) at the workplace • Actively address hiring discrimination and stigmatization

15. ExampleIncrease opportunities for active travel to school and work

16. Potential strategies - 5 • Communities and families • Encourage community leaders to create councils and groups that take the initiative (e.g. raise funds) and provide guidance on preventing obesity in their communities • Increase access of low income groups to healthy foods (e.g. set up neighbourhood garden programmes and food cooperatives)

17. Decision-making framework for governments • Tool to formalise decision-making as a consistent process with identifiable steps • A way to identify the important principles and values that guide decision-making • Flexible and practical approach • Appropriate to each country’s health and economic context Developed from Swinburn et al. Obes Rev 2005; 6:23-33, and Epping-Jordan et al. Lancet 2005; 366:1667-1671.

18. Research needs and future directions - 1 • Build a case for action • Develop standardised data collection methods • Identify particularly vulnerable groups • Examine changes over time • Identify contributing factors • Study the determinants of SE inequalities in obesity in the general population and in high-risk groups • Examine the pathways through which SES affects obesity • Develop surveillance systems

19. Research needs and future directions - 2 • Design potential interventions • Through intersectoral consultation, needs assessment, health impact assessment, etc • Target the individual and the environment • Evaluate these interventions • Effectiveness, cost-effectiveness, long-term impact, component analysis, etc • Use guidance from organizations and countries with best practice guidelines • Learn from other public health sectors e.g. tobacco-control campaigns

20. Nutrition and Food Security Programme Find programme information, documents to download, news and events on our web site: www.euro.int/Nutrition To receive news regarding web updates, send a blank email to: Subscribe-who_europe_nutrition@list.euro.who.int Thank you