Obesity on the move – Changing perceptions about a weighty issue

Changing perceptions about a weighty issue

Contents

Preface 5

Executive summary 6ConclusionsImplications for stakeholders

Burson-Marsteller’s approach 15An integrated approach as necessary conditionThe obesity lifecycle concept‘Honest’ or ‘false’ communication

1 Introductory overview 211.1 Whose fault is fat?1.2 Objectives1.3 Research methodology

2 The issue of overweight and obesity 242.1 The medical perspective2.2 Changes in dietary habits2.3 Physical activity2.4 A global perspective

3 Medical and expert opinions in the Netherlands 393.1 Scientifi c research3.2 Obesity and children3.3 Product modifi cation3.4 Consumer confusion, information and education3.5 Cultural differences

4 Parties within the Dutch public domain 454.1 The Dutch government4.2 Political parties4.3 Non-governmental organisations4.4 The Dutch media

5 The Dutch food industry 555.1 Policies of food industry associations5.2 Policies of food companies

6 Other industries in the Netherlands 636.1 The retail sector6.2 Eating out and the Royal Dutch Catering Association6.3 Healthcare insurers6.4 The computer industry

7 Physical activity in the Netherlands 717.1 An inactive lifestyle?7.2 Barriers to an increase in physical activity

8 Position of overweight and obesity in the issue lifecycle 758.1 The issues of smoking, alcohol and obesity compared8.2 The obesity issue lifecycle

Appendix I 79List of interviewed stakeholders

Appendix II 81List of abbreviations

Appendix III 83List of literature

Appendix IV 87Media analysis

Appendix V 89Obesity treatment fl owchart

ColofonGraphic Design Ontwerpwerk, Den HaagPrinting Drukkerij Giethoorn ten Brink, Meppel© Burson-Marsteller 2005

5

Preface

In August 2004 I started on the last leg of my Policy, Communication andOrganisation studies at the Free University of Amsterdam: a traineeship tohelp prepare the ground for writing my fi nal thesis. I was very privileged tobe taken on by the Healthcare Practice of Burson-Marsteller in Amsterdam,Burson-Marsteller being one of the world’s leading public relations fi rms. My basic premise when embarking on my traineeship was that the academic discipline of communications and issue management and thephenomenon of obesity were bound to be closely linked.

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

This report gives a comprehensive overview of the perceptions and statusof the obesity issue in the Netherlands. It will guide through the history of the issue, provides insights in various (inter)national programmes and givesan overview of the current perceptions and expectations of the various stakeholders in the Netherlands. Finally it contains an analysis of thepossible 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 eachindividual that has a stake or an interest in the obesity debate.

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

Gijs BoeijenJanuary 2005, Amsterdam

6

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 infl uential factors contributing to the overweight and obesity issue, an integrated approach to tackling the problem isparamount. 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 beactive, but if schools make little provision for physical activity and theneighbourhood has no playgrounds or sports facilities, the problem isexacerbated.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 coordi-nated activities on executive level. All stakeholders, such as local govern-ments, schools, and day care centres, should adapt their policy, based onthe same vision and direction, and work closely together. For example inSweden 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 directionof the government in solving the obesity problem. They feel thegovernment is responsible in providing direction and coordinating effortsand programmes (subsidised by the government) that combat obesity.

According to the private sector, the government should only providedirection, not legislation. Other stakeholders think that the governmentshould focus on providing direction but also legislate with regard tolabelling, 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 theMinister of Health is publicly asked to defend policies.

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NGOs are in confl ict regarding overweight and obesity.

Organisations such as the Nutrition Centre and the NISB (Dutch institute for sports and physical activity) are often in confl ict to secure their fundingfrom government and do not agree on evaluation criteria to measure theeffectiveness of their programmes. This division between physical activityand dietary patterns is detrimental to fi ghting 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. Somestakeholders 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 afocus on meeting evaluation criteria in order to secure funding, rather thantargeting the more challenging problem in lower-educated and foreigngroups 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 wrongchoices regarding diet and exercise. The food industry is blamed for stimulating ‘unhealthy’ diets. The government is blamed for doing toolittle. This game of blame and shame diverts attention from the realproblems 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 largepercentage of parents have indicated their support for measures againstadvertising directed at children, with suggestions for a ban up to either theage 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 ofa successful solution will take many years. For example, forty years agothe public knew of the damage that smoking can do to one’s health. Onlyrecently attitudes have begun to signifi cantly change; still many peoplecontinue 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 versusenergy expenditure, some stakeholders feel that when people are informed about diet and physical activity they should be able to make theright food choices.

Political and governmental stakeholders see their primary responsibility end in providing this information. This supposes then, that if someone isoverweight it means that he or she is not strong-willed enough to makethe 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 under-estimated 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 theweakness of individuals in making right choices and the fact they buy off their health status through premiums as morally justifi ed reasons to chargehigher 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) to4.4 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, stakeholdersbelieve it is easier for the food industry to reduce the amount of calories ina product than it is to get people out of their cars.

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

Many stakeholders consider product modifi cation the most promisingshort-term action. Small changes in products can contribute a great dealto healthier dietary patterns – and are often barely noticeable by theconsumer. The introduction of new ‘light’ products receives some applausebut the modifi cation of existing foods to contain lower fat, sugar and saltis 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 valueof physical activity. Stakeholders emphasize the disappearance of ‘house-keeping schools’ and the budgetary restrictions on school courses in subject areas such as healthcare and physical education. Schools and the Ministryof Education have primary responsibility for education, but educationalprogrammes can also be created in cooperation with organisations such asthe 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, possiblemedication 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 expectedthat the debate will continue and become more intense for all stakeholders involved. The following four possible scenarios of the development of theissue and implications for key stakeholders can be distinguished (see fi gure 1):status quo; boycotts; legislation; and self-regulation.

Status quoWhen industry interest is combined with no solution to the issue, the resultis status quo, meaning that no change is effected. This was the case for thefi rst 20 years of the tobacco issue; tobacco could still be sold everywhereand there were no restrictions on marketing.

BoycottsBoycotts can result when the ‘expectations gap’ – a gap between currentand 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 despitepressure 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 fi x.

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

Legislation Self-regulation

Status quoBoycotts

SOLUTION

INDUSTRY INTEREST

NONINDUSTRYINTEREST

(NGOs)

NO SOLUTION

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Self-regulation As an issue arises, self-regulation is often the preferred approach forindustry and political stakeholders. Industry is not eager for legislativerestraints 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 benoted that self-regulation is not only a solution in the best interest ofthe industry, it could also prove to be satisfactory for NGOs and politicalstakeholders. In the case of complex issues such as overweight and obesitysome aspects of the issue might be solvable by self-regulation, but usually not all.

LegislationAs with the tobacco issue, after a period of attempted self-regulationfollows legislation.

In the Netherlands, the overall scenario seems to be moving from self-regulation 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 theeating out sector regarding caloric information of menus. Boycotts as ascenario is not very realistic at this time, although the Dutch consumerassociation has gone its own way by not signing the National ObesityCovenant. 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 followingimplications for key stakeholders can be defi ned.

- Food industryThe food industry will face legislation regarding marketing, advertising and claims. They will become more pro-active regardingaspects such as product modifi cation and labelling to prevent further legislation.

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

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- National governmentJudging current developments, it seems that the Ministry of Public Health hasnow decided it will take further steps besides self-regulation and will becomemore active.

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

- PoliticsNow 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 fi nd 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 specifi c policies will be constructed for ‘problem’ groups (such as the low-educated and foreigners). Long term goals will be determined andtranslated into policy plans. Barriers in reaching policy goals will be identifi ed,and available knowledge will be implemented.

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

- Media The media will remain focusing on the food companies, and not on theouttake side of the problem. There also is the risk of ‘obesity overload’;too much media coverage on the subject could result in loss of interestfor 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 infl uence within the obesity debate. Healthcareprofessionals think in terms of solving health problems, when persons arealready in need of medical attention. Because most stakeholders agree thatprevention is the most effective way in solving the obesity epidemic, societymust 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 couldfor 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 healthissues at this moment. Not only are multiple stakeholders involved, theissue is also related to fundamental changes in society and the way peoplelive. There is a continuous struggle in fi nding the right balance betweenthe responsibility of the individual and the role of the private and public sector.

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

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 devel-oping and executing campaigns that address partial aspects of the obesityproblem. For instance, the Nutrition Centre focuses on the intake part, whereas the Sports Association focuses on the outtake aspects. Thecampaigns of both organisations at this moment are not precisely fi ne tuned to each other. One of the campaigns of the Nutrition Centreaddresses physical activity and accompanying information materials aresent to schools. The Ministry of Education and the Sports Association were not deeply involved.

Figure 2: The obesity puzzle,

Burson-Marsteller 2004.

Diet

Environment

Exercis

e

Genetic

s

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

Developing effective campaigns aimed at decreasing the obesity issue willbe 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 singleprogrammes are being executed with a focus on for instance dietaryhabits, physical exercise or education at schools. Burson-Marsteller prefersto look at the issue through a ‘target group’ perspective, meaning programmes should be tailored per target group and include variousaspects as nutrition, exercise and education. Such a perspective can be illustrated through the obesity lifecycle (see fi gure 3).

LIFE

CY

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HTC

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Adolescent

AdultEld

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CYCLE ‘UNHEALTHY’ WEIGHT

Home cooking vs fast-food Moped vs bicycle

Dancing vs video

Candy vs apple

Play outdoors vs computer

Only work vs exercise

Red wine vs beer

Butter vs becel

Social life vs vslation

Figure 3: The obesity lifecycle,


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The obesity lifecycle visualises moments in a person’s life that are criticalin becoming overweight or obese. These moments have been coupledwith lifestyle because fi ghting overweight and obesity inherently meansmaking 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 momentsor 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 momentrepresenting an opportunity or threat is also a potential moment oftransition from one cycle to another.

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 fi gure 4);

- Overweight is a cyclical process that reinforces itself: when someone becomes overweight it is diffi cult to lose weight again. When parents are overweight,their child has an increased chance of becoming overweight itself, andeventually 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 thatinfl uence 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,


2

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‘Honest’ or ‘false’ communication

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 fi gure 5):

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

2. Companies producing ‘healthy’ products that position their productsthrough ‘honest’ emotional communication can be described as ‘Heaven Enterprises’. For instance the commercial of biological eggs show chicken tohave 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 AngelEnterprises’. For instance the commercial of Chiquita bananas shows peoplestarting to dance and feel great after eating bananas.

4. Companies producing ‘unhealthy’ products that position their productthrough ‘honest emotional communication can be described as ‘White Demon Enterprises’. The commercial of Magnum ice cream in relation to theseven 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.

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

Dark AngelEnterpriseChiquita Bananas

HeavenEnterprise

Biological Eggs

Enterprise?

Hell EnterpriseRed Band Liqourish

‘HEALTHY’ PRODUCTS

‘UNHEALTHY’ PRODUCTS

‘HONEST’EMOTIONALCOMMUNICATION

‘FALSE’EMOTIONAL

COMMUNICATIONWW

BecelProAktiv

Magnumice cream

Figure 5: The communicationquadrant, Burson-Marsteller 2004.

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It is a hypotheses that White Demon Enterprises are the upcoming enter-prises. Taking the pressure of society into consideration, such as marketingrestriction towards children, products might be able to position themselvesas being ‘unhealthy’ products while still being profi table. In the future wecould possibly see a commercial of a ‘5000 C Hamburger’. The commercial will state that the 5000 C Hamburger has 5000 calories, is twice the recom-mended daily calorie intake, but is delicious and shouldn’t be eaten on adaily basis. Through this kind of communication companies remain credible. Research has proven that current society embraces honest communicationand punishes those companies that create false expectations.

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1 Introductory overview

1.1 Whose fault is fat?1

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 thatthe percentage of adults with obesity will increase by another 50% withinthe next twenty years.4

Extensive reporting by the media on the overweight and obesity issue hasattracted widespread public attention. Daily media reports concentrate predominantly on the controversies of the issue and new angles, such asthe 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 theheightened health awareness of customers’.

Furthermore, governments are dealing with the issue through legislationor self-regulation, both terms frequently discussed in the public arena. Thevarious 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 aboutthe issue of overweight and obesity? How does one best communicateone’s perspective?

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

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 Stafl eu 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 concen-trating 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 onthe private sector and physical activity in the Netherlands. The position ofoverweight and obesity within the issue lifecycle is addressed in Chapter 8.

1.3 Research methodology

This desk-research report was undertaken by Gijs Boeijen, graduatestudent 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, Communicationand 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 (seefi gure 6). For an extensive list of organisations including the names of therespondents see Appendix I. In the report comment from specifi c inter-viewees 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?

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Fiugure 6: Overview stakeholders

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2.1 The medical perspective

“Obesity increases a person’s risk of illness and death due to diabetes, stroke, 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 dramaticincrease in childhood overweight and obesity. Adult obesity is diffi cult to treat; therefore early prevention is better than cure. The medicalprofession points to the importance of parents in the monitoring of, and asa role model for, children’s dietary habits. Engaging parents with the issueis key to the intervention of overweight and obesity at an early stage.6

Overweight and obesity are not the same. Obesity is considered a chronicdisease and can be defi ned as a form of overweight that compromiseshealth. The Body Mass Index (BMI) is the most commonly used measurement to determine weight. BMI is determined by weight inkilograms divided by height (in meters squared). A BMI above twenty-fi ve is considered overweight; above thirty is considered obese7 (for the BMI7

calculation see fi gure 7).

BMI = kg/m2

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

Medical programmes are generally for the treatment of obesity rather thanfor people who are overweight. Before treating an individual for obesitya 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 fi gure 8).

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

Figure 7: BMI, Nutrition Centre.

HIGH RISK

Men > 102 cm (>40 inch) Women > 88cm (>35 inch)

Figure 8: Waist circumference,

National Institute of Health.

2 The issue of overweight and obesity

6. Bosch, J. D. et al. Psychological characteristics of obese children/youngsters and their families: impli-cations 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-

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Organisations such as The World Health Organisation (WHO) link anunhealthy diet and increasing physical inactivity to an increase in non-communicable diseases, including certain cancers and diabetes8, 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 seenever 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 comparedthe dietary pattern of obese children with that of children with a normalweight. The study concluded that the obese children did not have moreunhealthy diets than those children with a normal weight.9

Whilst overweight and obesity cannot be explained by dietary habitsalone, a change in diet is regarded by the medical profession as the mostsignifi cant contributor to weight loss in the long term. Physical activity ismost valuable in the prevention of regaining lost weight.10 Epstein showedthat long-term effects of treatment improved when lifestyle changesfocused 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

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

FEMALES

MEN

13-16 year: 2400 kcal 13-16 year: 2600 kcal





>65 year: 1900 kcal >65 year: 2100 kcal

Figure 9: Age and caloric intake,

Nutrition Centre.

9. Mueller, M.J. et al. (2001). The Kiel Obesity Prevention Study (KOPS). Obesity Review, vol. 2, p.15-28

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

10. National Institute of Health (1998). Clinical guidelines on the Identifi cation, Evaluation and Treatment of Overweight and obesity in Adults. NIH report No.98-408311. 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 Identifi cation, Evaluation and Treatment of Overweight and obesity in Adults. NIH report No. 98-4083, p.21

26

Signifi cantly, scientists from the medical fi eld have made progress in deter-mining two additional contributions to the development of overweight and obesity: genetic factors; and lack of sleep. According to a study in theUS, a person sleeping less than four hours a night is 73% more likely tobecome obese than someone sleeping the recommended seven to ninehours a night. For a person sleeping fi ve hours per night the percentageis 50%; for six hours it is 23%.13

2.2 Changes in dietary habits

“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 inoverweight and obesity in recent years (see fi gure 10), relating to a changing lifestyle, in which technological developments bring abouta 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

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

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

0

10

20

30

100

Netherlands UnitedKingdom

France Japan US

latest year available1995199019901985198019801980

14. European Commission: Health & Consumer protection Directorate-General (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.

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

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

27

Research conducted in 1994 concludes that obese people do not eat morecarbohydrates than people with a healthy weight; they do, however, eatmore fat.17 Whilst more saturated fat and trans-fatty acid is consumed than7

ever before, this is not the only dietary cause of an increase in overweightand obesity. Attention to the effects of refi ned carbohydrates such assimple sugars, is on the increase (see fi gure 11).

The percentage intake of food groups has changed. Consumption of snacksincreases, 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 softdrink a child consumed a day, the chance of becoming obese increased by50%.19

Blame for this increase within the snack category has frequently beenplaced with marketing by the food industry, usually directed at children.Commercials directed specifi cally 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 commercialsfor sodas, candy and fast-food every hour.21

About 4-10% of children within the Netherlands regularly skip breakfast22

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 dailyintake of mono- and disaccharides.23

Attention is also frequently drawn towards the increased consumption ofboth ‘quick fi x’ meals and meals consumed outside of the home. In theUnited 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 fresh-cooked meals at home (with the family) improves caloric intake.25

18. See for the Netherlands: RIVM (2004). Our food measured: Healthy and save food in the Netherlands. Houten: Bohn Stafl eu Van Loghum.

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

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 infl uence 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 1997-1998. 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.

Snacks Dinner BreakfastLunch

1994 - 96total daily calories:

2,003

1977 - 78total daily calories:

1,798

37

18

24 21

4419

25 12

in

perc

entages

inperc

entages

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

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.

28

2.3 Physical activity

“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 habitsand physical activity – intake versus outtake – exacerbates the issue of overweight and obesity. Work nowadays demands less physical activitythanks to ongoing computerisation and the development of new technology.

For example, in the Netherlands almost half of the workforce regularlyworks at a computer (this fi gure has increased by 5% from 1997 to 2002.)27

The increase in cars has also reduced physical activity (see fi gure 12); so too has the widespread increase in home computer usage and televisionviewing.

Research shows that for every hour of television watched by children, the chance of obesity increases by 12%.28 In the Netherlands, people watch 8

more television than ever before. Between 1975 and 2000 the number ofhours 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 1985and 2000 from 0.1 to 1.8 hours per week30.

0

1.000.000

2.000.000

3.000.000

4.000.000

5.000.000

6.000.000

7.000.000

10.000.000 Family cars Family cars Company carsCompany cars

years 6560 70 75 80 85 90 95

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.

28. Robinson, T.N. (1998). Does television cause childhood obesity? Journal of the American Medical Association (JAMA), vol. 279, p. 959-60.

29. Health Council of the Netherlands (2003). Overweight and obesity. The Hague.30. Social and Cultural Planning Offi ce (SCP) (2004). Trends in time, The use and Organisation of time in The Netherlands, 1975-2000. The Hague.

Figure 12: Increasing number ofcars in the Netherlands, RAI-Autovak, November 1998.

29

Figure 13: The obese environment, CIAA, 2004.

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 development of the overweight and obesity issue in the Netherlandsappears to be twenty years behind that in the USA. By drawing parallelsbetween 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 sectionoffers a broad overview of the issue, its development, steps taken tocounter an ‘epidemic’, and challenges faced by specifi c 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 signifi cant impact on all stakeholders,resulting on many occasions in the formulation of local policy. After thepublication of the report, the WHO began formulating a Global Strategyon Diet, Physical Activity and Health which identifi ed four main objectives33:

Education & Information

School lessons; Lifestyles; Nutrition; Cooking;

Media messages; Fashions;Body image; Cultural beliefs

High energy foodpromoted via

AdvertisingFavourable pricing

School-based marketingSnacks, soft drinks

SponsorshipsEating out

Family

Genetic predispositionExcess weight in parentsBreast feeding practicesParent‘s healthKnowledge and budgeting, shoppingCooking skills

Sports & leisure

Lack of school facilities Few global playing areasWidely available indoor passive entertainmentUnsafe streetsFew cycle routes

THE ‘OBESE’ ENVIRONMENT

GLOB-ESITY

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

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 fromunhealthy diets and physical inactivity by means of essential public healthaction and health-promoting and disease-preventive measures.

2. To increase the overall awareness and understanding of the infl uences ofdiet and physical activity on health and of the positive impact of preventive measures.

3. To encourage the development, strengthening and implementation ofglobal, regional, national and community policies and action plans toimprove 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 scientifi c data and key infl uences 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 andobesity issue:

“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 OurChildren, Ministers from 52 European states adopted an action plan toreduce the impact of the environment on health, children’s health inparticular. Ministers committed to bring about a reduction in thepre valence 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 topromoting the benefi ts of physical activity in children’s daily life byproviding information and education, as well as pursuing opportunitiesfor partnerships and synergies with other sectors with the aim of ensuringa child-friendly infrastructure.35

Initiatives endorsed by the WHO include tax policies and other fi scal measures, such as subsidies to infl uence the consumption of food andaccess to sporting facilities, and strict rules for marketing directed atchildren.36

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

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.38 From 1960 to 2000 the prevalence of 8

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 ofcitizens suffering from overweight and obesity. It is also in America thatvarious stakeholders fi rst paid serious attention to the issue. In March 2004 a legislative Act was approved by the Senate sardonically referred to as ‘theCheeseburger 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 personaloverweight and obesity problems.

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

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

VIEWS ON OBESITY IN THE U.S.

87%

64%

64%

61%

60%

41%

Individual Americans in their choice of diet and lack of exercise

Fast-food restaurants

Schools that allow high-calorie snack and sweets

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

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

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

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 (11-11-2003). Fastfoodketens VS moeten aantal calorien op menu vermelden.42. Nederlands Dagblad (29-08-2002). Verbod op verkoop frisdrank in scholen Los Angeles.

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

32

THE RISING OBESITY PROBLEMS IN MANY COUNTRIES WILL BEST

BE SOLVED 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%)

Figure 15: What is the best obesitysolution?, www.mallenbaker.com26/08/04.

Further laws are expected, including the nation’s fi rst comprehensive Anti-Obesity 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, bikingand other forms of exercise. Public health advocates, including the Washington DC-based Centre for Science in the Public Interest (CSPI) heraldthe legislation as the nation’s fi rst comprehensive anti-obesity effort and amodel that should be replicated both in other states and in Congress.

But what of a nationwide plan? Similar to the EU, the USA lacks coordi-nation . This is due to federal policy making and numerous initiatives fromNGOs. The Bush administration has announced a nationwide campaignto combat the epidemic of obesity in the United States through improved product labelling, health education, and a partnership with restaurants tosteer consumers toward healthier menu options.44 However, this effort wascontradicted by negative reports in the media that in January 2004 theBush Administration’s Department of Health and Human Services had taken a stand against the World Health Report,45 to stop the global anti-5

obesity 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, aswell as consumption of food while watching television. No data has yetclearly demonstrated that the advertising on children’s television causesobesity.”46

43. CSPI Newsroom (14-02-2003). Maine Legislation Tackles Obesity.

44. CNN.com International (12-03-2004). 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

33

In the fi ght against overweight and obesity the Bush Administrationappears 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 bedropped from the budget.47

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

Robert Madelin, Director General for Health and Consumer Protection ofthe European Commission, states that eating is primarily a matter ofindividual responsibility. Because information alone is considered insuffi -cient in empowering consumers to change behaviour, education is the keyprocess and central objective of the EC.49

“Many studies looking at health promotion and social marketing activitiestell us that merely getting the message across about the risks of aparticular activity or lifestyle is not enough. Knowledge of risk does notalways 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 empow-ering them to make a positive change in their eating habits.”50

0 - 10%

11 - 15%

16 - 20%

21 - 30%

> 30%

27

19

20

18

14

13

9

15

13

24

9

23

1518

1414

14

36

35

27

39 24

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

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

48. European Commission: Health & Consumer protection Directorate-General (2004). Summary Report Roundtable on Obesity, 20-07-2004. Brussels. p.2

49. European Commission: Health & Consumer protection Directorate-General (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 buildinga 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, givingcompanies a unifi ed set of rules to combat the issues. On the other hand,litigation at a European level could actually be both ‘softer’ and slowerthan on a national level, therefore potentially lagging behind real-timeEuropean issues development.

“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 thatwill make the obesity problem worse rather than better.”51

Madelin believes that increased governmental interference could be costlyand slow, causing confl ict. The private sector has a signifi cant role to play,but is not widely trusted to do the job properly. To increase trust theprivate sector should take note:

- Economic operators have to commit to a measurable and sustained increasein 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 allother interested parties in drawing up bench-marks for their healthy eatingcampaigns.

- The economic operators will have to accept non-profi t interested parties as part of a process to verify that the promised private actions really are takingplace.52

In January 2005 Health and Consumer Affairs Commissioner MarkosKypriano 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 willproceed 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 fi gures in the UK, nearly 16% of children between the ages of 6 to 15 can be defi ned as obese, three times as many as 10 years earlier.55



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

54. Rigby N. et al. International Obesity Task Force (2004). Seeking bold solutions for Britain’s runaway obesity epidemic. www.iotf.org/media/IOTFNov11briefi ng.pdf

55. Statement by Melanie Johnson (4-07-2003). http://www.parliament.be

35

The UK takes second place in the global overweight and obesity epidemic. The National Audit Offi ce 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 benefi ts 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 alsowork with local agencies to help develop targets to increase the number ofschool journeys undertaken by bicycle, on foot or on public transport.

- The Ministry of Education and Employment should continue to encourage allschools 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 toincrease 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 theFood Standards Agency where appropriate, to establish ways to monitorthe overall impact of initiatives to improve the nutritional quality of foodprovided in schools.

Leading UK supermarket chain Tesco, made a signifi cant announcement inMay 2004, introducing a labelling scheme that uses images of traffi c lightsto indicate the fat, sugar and salt content of its products. The initiative wasapplauded by many NGOs and the government, but not all comment was inpraise 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 medicalprofession 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 tocarry a red danger signal – somewhat undermining the label’s claim tobe 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). Trafi c light labelling scheme to indicate levels of fats sugar and salt in products UK. www.medicalnew-stoday.com/medicalnews

36

Alongside initiatives from the private sector and NGOs, British Parliamenthas proposed legislation, including a ‘fat tax’ and the banning of commer-cials for junk food directed at children. The recent White Paper on Public Health58 outlines:8

- Introduction by 2006 of a traffi c light system for processed food, indicatingfat, 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 intro-ducing legislation forcing the food industry to conform. One option canvassedin the White Paper is banning ‘unhealthy’ food advertising before 9 pm.

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

Other countries“Vending machines in schools barred in fi ght 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 inthe EU experience problems in effectively coordinating the fi ght 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’spopulation remain diffi cult to reach.

In France legislation has already been implemented, with schools the fi rst to encounter legislative measures. In response to the question in ScienceGeneral, “In your country, could we say that obesity has reached epidemicproportions?”,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 obesityin the different regions and countries of Europe, then I would have to sayyes. WHO speaks of an obesity epidemic. France is actually only at theinitial stage of the phenomenon, but the obvious increase in obesity inFrance is clear. The frequency of obesity doubles every 15 years in children.

58. Westminster watch (16-11-2004). White paper on Public Health.

59. Business Respect Newsletter (24-10-2004). Vending machines in schools barred in fi ght on obesity. www.mallenbaker.net

60. Science Generation (03-2004). Diet and Health. http://en2.science-generation.com

37

In other words, 12 to 14% of children are affected by obesity todaywhereas there were only 6% 15 years ago and 3% 30 years ago. As foradults, the fi gure is around 11% as opposed to 8% six years ago.”

Professor Basdevant and colleagues have participated in debates regardingadvertising on French television aimed at children, and on school vendingmachines: “The problem is to carry out effective campaigns that target themost vulnerable segments of the population and that are the most diffi cultto reach. This is one of the major challenges facing us at this time.”61

In the same article from Science Generation, Nicola Sorrentino, nutritionistand professor at the University of Pavia, Italy, comments on Italian publichealth campaigns:

“The Ministry of Health recently proposed to create a commission with theaim of preparing an agreement with food production and packagingcompanies and restaurants concerning portion sizes. Other public healthinitiatives require greater clarity in labelling.”

It appears that campaigns in Italy to encourage better eating habits areorganised 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 commonobjective. There is a lack of communication and coordination for publichealth campaigns related to food.”62

Despite a common belief in Italy that overweight and obesity is not an issuedue to a Mediterranean diet, problems are on the increase. Studies showthat 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 areobese, 42.4% of men and 26% of women are overweight.

Some governments have already taken more drastic measures and haveimplemented some form of regulation. The British Medical Association hasendorsed 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 similartax has successfully been introduced on unsaturated fat.63 Belgium is alsoseriously considering legislative measures. The Belgian Minister Demottefor Public Health is considering a ban on commercials for candy.64



63. Free republic (6-08-2003) Fat tax to fi ght obesity. www.freerepublic.com/focus/f-news64. Adformatie (19-01-2004). België overweegt verbod op snoepreclame.

38

Research shows a distinct difference between the American and British viewof food companies and government agencies’ responsibility towards theobesity 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 forthe problem of overweight and obesity, 22% in the USA said yes, comparedto 39% in the UK.65

A European survey displayed a similar distortion, with 37% of consumers infavour of self-regulation among food industries, versus 30% in favour of aspecifi c regulation constraining those industries. European consumers weremainly 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 towardsnutritional information (58%) and developing healthy products (57%).66

65. Global study conducted by Universal McCann in July 2004

66. Weber Shandwick survey amongst European consumers, October 2003

39

3 Medical and expert opinions in the Netherlands

In the Netherlands, both the government and food companies work incooperation with knowledge institutions such as the RIVM (National Institute of Public Health and Environment) and TNO (Research Institutefor Health Prevention) for specifi c research into the issue of overweightand obesity.

3.1 Scientifi c research

Medical research published in 2004 identifi es a second infl uence on appetiteof a certain brain protein. The protein was already known to play a centralrole in the ‘feast or fast’ signalling that controls the urge to eat. It appeared that the discovery had potentially identifi ed a new target for drugs againstobesity.67

The research stated: “Earlier research has shown that this protein, called MC4R, is a receptor or neuron in the hypothalamus region of the brainand receives signals through at least two pathways about the status of thebody’s fat reserves. If fat stores are increasing, these signals stimulate MC4R,triggering physiological responses that decrease appetite. If fat reserves aredecreasing, these signals turn off, deactivating MC4R and increasingappetite.”

Medical research continues to make important discoveries regardinggenomic causes of the issue, such as that of the hormone Leptin. Leptinhelps regulate appetite; when it is absent patients have a continual cravingfor food. Predominantly, those who benefi t from treatment suffer fromobesity rather than overweight.

A better understanding of the risks that are attributed to overweight andobesity not only helps to design effective treatments, it also aids in deter-mining the enormous cumulative costs involved. The sum of these extensivecosts seems to peak political interest in the issue.

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

67. Vidyya Medical News (16-10-2004). 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

According to a 1998 report from the Nutrition Centre, the Hague, dailyenergy 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 to35.9% in 1998. Since 2003 this food consumption overview is conductedevery year. The fi rst, in 2003, focused on 19-30 year olds. On average caloricintake 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 ofthis research believe that the results published by the Nutrition Centre are questionable, due to the limited number of people involved and the compo-sition of the group. Some social groups are more likely to suffer fromoverweight and obesity – specifi cally the lower-educated – and this would have an impact on results where a range of social health groups are notaccurately represented.

Research respondents have suggested that the Nutrition Centre targetscampaigns towards social groups that are more likely to yield requiredresults – white, higher educated, middle classes – whilst the real problem lies with foreigners and the lower educated classes. Information availableto these groups is inadequate. In the last twenty years physical energyexpenditure has dropped most signifi cantly in the lower-educated sectionof the Dutch population. This can be seen most obviously in retirement. Higher-educated people usually lose weight when they retire; the lower-educated section of the population usually gains weight due to decreased physical activity.

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

69. Voedingscentrum (1998). Resultaten van de voedselconsumptie peiling 1997-1998. The Hague.

71. VAI/SMA symposium (4-06-2004). Obesitas, een gewichtig probleem.

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

41

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

3.2 Obesity and children

Another medical respondent suggested that overweight and obesity issuesmay start before birth: the dietary pattern of the mother may infl uence thepossibility of the child becoming overweight in later life. Certainly, dietaryintake 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 understandingthat 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 acomplex problem so all stakeholders should be included.”

Children and junk foodMichiel 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 togetherto reduce the amount of salt, sugar and fat in food products.

“What is not a question but a fact, is that obesity increases rapidly wherefast-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 insugar, fat and salt in processed foods. People become addicted to thesetastes, even though they are perhaps individually diffi cult to recognise. He believes this makes it diffi cult to become used to lower salt and sugar levels.

Marketing to childrenChildren are targeted every day by an enormous number of advertisements,mainly for unhealthy food products. Research in 2003 conducted by theUniversity of Strathclyde, Scotland, has shown that because advertisingshapes 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 theage 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 adver-tisement noise for candy, sodas and ice cream is a thousand times stronger.”75 See fi gure 17 for an example of marketing healthy foods, in which Dutch asparagus producers are intending to make their productmore desirable for children.

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 modifi cation

The RIVM published a report in 2004 entitled ‘Our Food Measured: HealthyFood and Safe Food in the Netherlands’, which emphasised that the largestchanges to be made towards healthier food are in the hands of the privatesector. The report ‘Longer Healthy Living’ from the Ministry of Health alsomakes suggestions for change within the private sector. Product modifi -cation , for example, towards a healthier composition of food could enable aless rigorous change in consumers’ dietary behaviour. Less expensive healthyfood products could also have a positive infl uence on social economic healthchanges.

Experts on the issue of overweight and obesity tend to agree that theprivate sector is not doing enough. Professor Seidell again: “Replaceordinary potato chips with ‘light’ variations without calling them so. That has also been done with mayonnaise. I have not heard any consumercomplain about it.”76

3.4 Consumer confusion, information and education

Research respondents and experts from the medical fi eld agree: there isa need for clarity within the private sector. Food companies follow trendssuch as ‘low fat’ or ‘low carb,’ which confuse consumers (see fi gure 18). An increase in health claims on products also adds to the confusion. Oneresearch respondent comments: “Real fruit juice usually means that theproduct contains just 1% juice. Some messages from companies also tellparents that children need sugar because they are so active! Such messagesdo not fi t in our modern society where most kids are not very active.”

0

10

20

30

40

50

60

100%How many companies are manufacturing productsmarketed or sold as low-carbohydrate or areplanning to launch products in the future?

5% 21% 22% 55%

Yes, but we arenot developingany more in the

near future

Yes, we aredeveloping more

for the near future

Considering it no

Figure 18; Companies producing or planning to produce low carbo-hydrate products, Obesity, Low-Carb Diets and theAtkins Revolution: Healthy profi ts from big issues in food and drinks, 2004.

76. Financieel dagblad. (08-09-2004). De dikmakers tegen volksvijand no. 1

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New research, media comment and other forms of information arepublished every day, is often contradictory. This makes for a complex situation in which it is diffi cult to fi nd a solution. Whilst much research and expert comment points to snack foods playing a signifi cant role in theincreasing 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 Obesitystated: “Our results suggest that although snack foods may have low nutritional value, they were not an important independent determinantof weight gain among children and adolescents.”

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

Research respondents stress the importance of education for young peopleon both the need to be physically active and sensible dietary patterns. It isbelieved that responsibility for this education lies with parents and schools.One respondent comments: “Maybe parents are not able to take thisresponsibility 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, forexample, free swimming was made available for foreigners new to theNetherlands. This was not a success, however, because women with certaincultural backgrounds would not attend if there were men also present.

In some cultures, being overweight is still a sign of good health. Oneresearch respondent comments: “Telling a Turkish mother that her baby isa 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.78 In Mauritania plump women8

are assumed to be both wealthy and more likely to bear healthy children.

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

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 withsmoking. 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 andphysical 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 some one 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 justifi ed to charge people higher premiumsfor their insurance.” Figure 19 represents a potential process.

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

Intake-outtake

Informing

Self-responsibility

Insurancepremiums

45

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 andpolitical 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 widerpolitical 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 toovercome in order to implement them.

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 safeenough 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 ofoverweight and obesity.

“The Dutch government has set a goal from the beginning to establish healthy consumer choice. In this it has distinguished for attention theconsumer, 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 consumershould be able to make a free choice from the assortment of foodproducts, the government sees a facilitating, informing and stimulatingrole for itself.

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

80. Ministerie van VWS (2003). Nota gezond leven, POG/OGZ/2.424.450. The Hague. p. 4.

46

Government wants to tempt the consumer to make a healthy choice andchooses more than ever to do so in cooperation with other stakeholders.The responsibility of the consumer to make that healthy choice is increas-ingly emphasised.”81

This view was confi rmed 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 thenecessity for a healthy lifestyle. In the end the consumer itself has to make that healthy choice.

PolicyThe government endorses a number of initiatives on the subject of diet andphysical activity which act as vital discussion and policy platforms for theissue of overweight and obesity. According to the Ministry of Public Healththis activity demonstrates its responsibility to provide direction to stake-holders.

- The Ministry of Public Health presides over the ROW (discussion platformon consumer goods). Specifi cally, part of this platform is the ROO (discussionplatform 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 ofactivity involving all participants. Eventually as many as twenty stakeholdersare expected to take part. The programme intends to outline the contributionevery interest group can make to the issue, with a central goal of stabilisingthe growing number of people affected by overweight and obesity.

- The government fi nances 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 specifi c aim of the institute is to create initiatives whichdiscourage the consumption of junk food and unhealthy snacks.82

- The government has initiated the BOS project (project to give education andsport in the local neighbourhood an impulse). Over the following six years(starting October 2004) !80 million will be invested in after-school sportactivities.83

- The government is making a concerted effort to support the promotion ofmore 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 instrumentthe government uses to combat overweight and obesity is the dissemi-nation of information.

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

82. Nederlands Dagblad (06-05-2004). De ziekte van Welvaart.

83. Ministerie van VWS (2004). Bos Impuls: stimulans voor samen-werking buurt, onderwijs en sport. The Hague.

47

This is achieved by way of public campaigns and institutions such as theNutrition Centre. Subsidy has also fi nanced preventive activities andresearch undertaken by third parties.84

With regard to the food industry, the government believes the fi rst courseof 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 200485 identifi es support from the Dutch population5

for government involvement when it comes to the promotion of a healthylifestyle choice: 64% of young people (aged 18-34) and 51% of elderlypeople (55+ years) agree.

Furthermore, of those individuals who applauded government inter-ference, the same research showed the following support for possiblegovernment 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 fi tness 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 Dutchgovernment; concentrated effort is spent on reducing the health riskswithin the lower income and education social groups.86 With this in mind, 6

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 specifi c subjects in large cities. Foreigners to the Netherlands and people with lowerlevel income and education are concentrated in the larger cities.

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

One barrier exemplifi ed by research respondents is the diffi culty inreaching young people and lower income groups by more traditionalmeans of health promotion. Reaching these groups specifi cally couldbe achieved more effi ciently through schools, recreation and workwithin the groups’ environments.88

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

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

86. Programmacommissie SEGV-II (2001). Sociaal-economische gezond-heidsverschillen verkleinen: Eindrapportage en beleidsaanbevel-ingen 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.

48

Criticism from research respondentsThree main points of criticism have been identifi ed, shared by a number ofexperts, NGOs and research respondents alike.

1. The government does not provide the leadership, direction or facilitation thatis expected or required. There seems to be enormous differentiation ofunaligned initiatives from stakeholders within the fi eld. Whilst the Ministryof Health pointed at the new covenant as an expression of clarity and goodintent, 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 goodintent; anyone can express such a statement.”

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

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 ofEducation. 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 fl owing 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 beenestablished in just three months, exemplifying speed and effi ciency. 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 moredirectly in working towards a solution to the overweight and obesity issue.

4.2 Political parties

“Minister Hoogervorst from the Ministry of Public Health, do you share the opinion that it takes more to fi ght 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 forPublic Health is regularly asked to defend policy decisions. Is there politicalsupport for legislation from parties including the PVDA, CDA and VVD? Ifso, what form could legislation take in the Netherlands? After interviewing stakeholders from the PVDA, CDA and VVD, it appears that attention isconcentrated in the following areas.

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

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

49

Informing the publicThere is widespread belief across parties that raising public awareness byproviding 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 approachPolitical parties see the Ministry for Public Health as responsible fordirecting an integrated approach involving all stakeholders at a national level. There is a need for a setting of common goals and targets which canbe evaluated and adopted at a local level within a long-term planning frame work. Local government also plays a role in combating overweightand 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-regulationIn 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. Legislationconcerning the ban on some food products from schools and the restrictionof marketing directed at children, for example, receives general applause:

“No ban on advertising for confectionery: Parliament urges for a ban onadvertising directed at children. PVDA, Groenlinks and SP are in favour, and the CDA called the position ‘sympathetic’. Public Health MinisterHoogervorst, for now, opts for self-regulation.”91

Cutbacks on the national budgetDue to cutbacks in the national budget, restricted funds have been madeavailable for the promotion of physical exercise in the Netherlands. Political parties disagree as to whether budgets have been adequately allocated tothe development of physical education in schools, or the improvement of professional advice at sports clubs. Various political research respondentsnodded 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 agendaIt 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 tobe seen whether any one political party will truly claim the issue. Somestakeholders 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.

50

4.3 Non-governmental organisations

“The Consumer Association wants to help consumers in the supermarket byway of using the colours red, yellow and green on packages to distinguishthe ‘fat-makers’ from more healthy products.”92

There is a wide spectrum of non-governmental organisations in theNetherlands 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 NutritionCentre, 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 totake responsibility and act in the public’s best interests.

For this reason NGOs often take on the role of devil’s advocate. TheConsumer Association does this frequently on the subject of overweightand obesity and has proposed the traffi c 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 marketingbudgets for public information campaigns about a healthy dietary pattern.93

Labelling of food productsLabelling is a way of informing the public about the nutritional valueof that product. On the basis of this information, the consumer can thendecide whether the product fi ts in their dietary pattern and how much of it could be consumed. Packaging claims are a subject of marketing aswell 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 traffi c light system on product labelling, to guide consumers towards healthier eatingoptions. Success of such a scheme would be dependent on an effective public information campaign to support the labelling. Without it, consumers may fi nd it diffi cult to understand whether red signifi es ‘nevereat’ 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 useare open to interpretation and misunderstanding:

92. De Telegraaf (30-01-2004). Dikmakers krijgen rood van Consumer Association.

93. De Telegraaf (16-02-2004). Reclamegeld tegen overgewicht.

51

“Some consumer organisations in the European Union consider productsthat do not have a ‘desirable’ nutritional profi le, such as candies, high salt and high fat snacks or high fat and sugar biscuits and cakes, should not tobe allowed to bear claims. For example, a ‘low fat’ claim should only beallowed if the product does not contain high quantities of sugar or salt; ora ‘high calcium’ claim should not be used on a product with a high fatcontent.”94

Marketing practices of the food industryMost NGOs feel strongly about limiting the marketing practices of foodcompanies, especially towards children. According to research respondents, current intensive marketing practices undermine parental authority. Itcould also be claimed, however, that “Parents are the ones that ultimatelybuy ‘unhealthy’ products – the problem is not so much the number of commercials but the choices the parents make.”

Content of food productsThe content of food products also receives a great deal of attention from NGOs. General opinion states that whilst a few companies are making aneffort to address the issue, the majority of food companies make minimaleffort. 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 fi rst on a change in existing products, as an extendedproduct range could lead to yet more confusion. As with the introductionof smaller portion sizes, if new products are offered alongside currentproducts they may well be left on the shelf due to small perceived priceand 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, fi gures 20 and 21 are shown here below.

ORGANISATION CAMPAIGN

SIRE Parents, say no more often! See fi gure 20

Nutrition Centre Don’t get fat!- 2000 cal for women / 2500 for men - New disc of fi ve (food pyramid in the form of a disc)

Heart Association Kids, kilo’s and overweight!

Consumer Association Association chooses health!

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.

Figure 20: SIRE campaign, Source

Adformatie, 23-12-2004.

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

52

Categorisation of food productsThe Confederation of Food and Drink Industries of the EU (CIAA) states: “The basic principle in nutrition is that there are no ‘good’ or ‘bad’ foodsbut rather ‘good’ or ‘bad’ diets. CIAA can therefore not agree with the concept of undesirable nutritional profi les and the consequent prohibition of any claim on those foodstuffs.”95 This is the proffered reasoning as to 5

why concepts such as ‘nutritional profi les’ 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 areevaluated. Under the traffi c light system where red is ‘halt/bad’ and green is ‘go/healthy’ one respondent questioned: “Is cheese red or amber? Oily fi sh is normally positioned as a healthy food – is it red or is it green?” Theprivate sector stakeholders were keen to point out that provision of publicinformation in support of such a scheme does not necessarily infl uencebehaviour. After all, after 40 years of debate and health education, thepublic 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 concerningthe overweight and obesity issue. But are news reports objective? Does themedia provide a balanced picture of the issue from the perspective of allstakeholders? Are the true motives for stakeholder action accurately portrayed?

Media analysisThere is a wealth of media coverage on the subject of overweight andobesity 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 thecountry 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:

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.

53

- The lower-educated sections of the population suffer the greatestproblems 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 stigmaattached to overweight and obesity (being overweight is sociallyunacceptable). On the other hand, medical conditions such as Type 2 diabetes and poor joints are more prevalent in those individuals sufferingfrom 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 foroverweight and obesity mainly with the food industry and the generalpublic. This is in contrast to other European countries, where thegovernment is predominantly held responsible; English and Americanmedia point towards the individual.

Objectivity within the mediaCertain research respondents from the food industry were wary of giving media interviews, citing a distrust of objective journalism in theNetherlands. Does this concern come from a journalist’s deliberate manipu-lation of the truth or a basic misunderstanding of the overweight and obesity issue? One research respondent from the food industry questionedwhether 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 fi nding is reported on, whether it is verifi able, respected, objective or otherwise. Such professional eagerness could besaid to contribute to public confusion. Some stakeholders go so far as toquestion the level of media interest in the issue, suggesting that publicinterest will decrease and momentum for change weaken if the populationtires of extensive media exposure.

96. Carma International commis-sioned by Edelman, the Netherlands (2004).

54

55

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 theoverweight and obesity issue, with its response to product labelling and marketing practices subject to public debate. NGOs and the mediaare the harshest critics.

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 reportto 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’sreport incorporated CIAA research fi ndings.99

The report of the VAI states that the food industry already took responsi-bility 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 asproactive compared to the response of the government.

In conversation with research respondents, there were a number of pointstaking 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 policiesof the food industry association are developed.

97. Financieele Dagblad (26-01-2004). Top-Unilever: voedingsin-dustrie moet actie tegen toename overgewicht.

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 consumerSimilar to other stakeholders, research respondents from the food industrybelieve that a workable solution to the overweight epidemic can only beachieved 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 insuffi cient dialoguebetween stakeholders to align different policies.

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

- The provision of a safe and varied food supply in suffi cient 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 exerciseAccording to research respondents, the food industry has initiated projects to stimulate physical activity, especially in schools. These range from fi nancial support to the distribution of pedometers and organisation of sports tournaments.

One stakeholder comments: “Being physically active should be made asmuch fun for children as playing computer games. Why does physicaleducation 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 expectsthe most success in combating overweight and obesity in the Netherlands. According to one research respondent: “People will simply have to learnthe value of physical activity and a balanced dietary pattern.”

3. Clear communicationTransparent 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, theprovision of specifi c information concerning the place a product has in aresponsible dietary pattern, and the establishment of an Advertising Code.

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

57

In a 1992 nutrition policy document, the CIAA fi rmly 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 benefi ts. But in view of the averagelevel of the European consumer’s nutritional education, it is often diffi cultfor the consumer to understand absolute information concerning a givennutrient; he needs a reference to give meaning to the information. Such areference would be to use European-wide recommended dietary amounts for at least all relevant vitamins and minerals and maybe even forproteins.”102

The CIAA goes on to welcome an agreement by member states ona 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 profi lesis clear: “The concept of prohibiting the use of claims on certain foods on the basis of their ‘nutritional profi le’ is contrary to the basic principle in nutritionthat 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 foodscould be included in appropriate frequency and quantities. This argument, although scientifi cally valid, should be considered in the appropriatecontext.”103

The same report goes on to state: “Foods baring claims are presented bythe food operators as products whose consumption would provide abenefi t, which is as ‘good’ or ‘better’ products. In most cases, infl uenced 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 theirnutritional profi le 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 someproducts are less healthy than others. The Ministry for Public Health wentso far as to say that it could not agree 100% with the VAI’s statement thatthere 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 CodeAccording to Jan Droogh, Secretary to the VAI, an experiment withcommercial-free youth programming demonstrated that children areonly minimally less exposed to advertising than usual. Recommendationsfrom the report include a ban on celebrities to promote products and novolume-driven campaigns. NGOs believe that such a Code is not specifi cenough. 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 beenapproved by the Advertising Code Committee.

Instead, the VAI believes it is better to support initiatives such as ‘reclame-rakkers’,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 withinthe primary school curriculum.

Making children more resilient against marketing is “nonsense” accordingto some stakeholders. A political stakeholder said: “When we make kidsresilient against marketing, new ways of marketing are invented, then wehave to make kids resilient against those as well; this results in a neverending cycle.”

Whilst a food consumption overview (1997-1998) published by the NutritionCentre105 indicates that 90% of the time, parents determine the food 5

intake of their children, the ‘pester power’ phenomenon cannot be under-estimated.

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

6. Self-regulationOne of the most recent developments in the overweight and obesitydebate is the decision of the soda industry to stop selling drinks in Dutchprimary schools. This decision is in advance of agreements that thefood industry has made with the Minister for Public Health.106 The NRC 6

Handelsblad newspaper reports that the Public Health Minister willpropose a new policy, effective from July 2005, bringing changes inthe advertising industry, and banning soft drinks and confectionery inprimary schools. Limitations will also be set on the sale of these products in secondary education.107

104. Twentsche Courant (25-09-2004). Te dikke burger is ook zaak overheid.

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

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

107. NRC Handelsblad (5-01-2004). Playstation slechter dan Coca-cola.

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7. Product modification & researchThe report of the VAI mentions the following points108:

- Guarantee freedom of choice by offering a varied assortmentof food products;

- Optimal product composition on the basis of scientifi c research;- Research about the prevention of overweight and informing

the public about possibilities.

The industry association underlines the fact that most food organisations have introduced new or altered products containing less fat, sugar andsalt. Introducing light products increases the choices consumers have. Also, according to these respondents, the industry is working hard todecrease 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 withartifi cial sweeteners are consumed. When ‘light’ products containingthese artifi cial alternatives are consumed the body learns that no caloriesare associated with a sweet taste; when real sugar is consumed the body therefore still believes it is not receiving many calories. This stimulatesthe 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 theindustry brought about by a response to the overweight and obesity issue (see fi gure 22). Food industry research respondents have emphasised thedynamics of competition whereby marketing is intended not to drivepeople to over-consume, but to differentiate companies and their productsfrom one another: “When a customer wants to choose what product tobuy, we want him to buy ours.”

109. Vidyya Medical News (01-07-2004). Study: Artifi cial sweetener may disrupt body’s ability to count calories. Vidyya Medical News, vol. 6, Issue 182. www.vidyya.com/vol6

110. Diary reporter.com (27-09-2004). Food Industry manifesto targets obesity. http://dairyreporter.com/news

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

60

COMPANIES MOST AT RISK

IN THE OBESITY DEBATE

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 benefi t from the overweight and obesity issue see fi gure 23.

COMPANIES MOST LIKELY TO BENEFIT

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

9. Kellogg

10. Unilever

Figure 23: Companies most likely to benefi t from the obesity debate, JP Morgan, 2003.

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

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Initiatives of food companies to reduce overweight and obesity can beplaced in four categories:

1. Product modificationsChanges being embraced by some of the larger food companies includethe introduction of smaller portion sizes, new food product composition, ‘light’ variations on popular lines and functional foods. Some productlines face barriers to modifi cations, 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 informationSome companies have introduced caloric values for a portion size on foodlabels; 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 diverselabelling regulations.

Problems remain when a product is bought in a restaurant or from avending machine. One research respondent suggested a resourceful solution: “Maybe it would be a good idea to mention the caloric valuewhen 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 theproduct is bought.”

3. Responsible marketingPrimary schools allow no marketing on the premises other than non-branded sponsorship of events such as sports activities; this is usuallyreferred to as ‘soft’ branding. Food industry research respondentsquestioned whether NGOs would appreciate that without income from sponsorship opportunities, many sporting events would not take place.

4. Stimulating physical activityDuring the interviews, respondents accentuated diverse initiatives that food companies have taken to promote physical activity. In their viewphysical 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 fi nding a solution but physical activity has declined more than the caloric intake has increased.

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who are involved: the retail industry; restaurants, cafes and otherbusinesses involved in the catering industry; health insurance companies; and the computer industry. The latter is thought of as a stakeholder due toits infl uence on decreasing physical activity.

6.1 The retail sector

“Supermarkets are also looking for measures to fi ght 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 ofoverweight’ 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 informationin consumer magazines, stimulating the consumption of vegetables andfruit, and offering a variety of product choice. A CBL 2003 policy document states: “Freedom of choice is the central point of departure for super-markets. The consumer has to decide for himself what to buy and make achoice in the store.”113

Freedom of choiceAccording to one research respondent, consumer choice drives productdevelopment: “The consumer has the strongest voice, the consumer comesfi rst. 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 hasa place on the shelves – this includes products across all categories.

LabellingLabelling receives more customer attention than ever before. One researchrespondent has introduced the caloric value of portion sizes on labels of itsown house brand; it is expected that others will follow. Retailers alsoconfi rmed 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

6 Other industries in the Netherlands

There are a number of private sector stakeholders besides the food industry

64

Shelf spaceSupermarkets try to position products in a way that shoppers fi nd mostlogical. Surveys show that ‘healthy’ aisles are not necessarily a logical storelayout for consumers. Rather, it seems that shoppers prefer to be able tocompare similar products. A ‘light’ product should therefore be offerednext to similar products within the same range. The same is true, inciden-tally, for vegetarian products.

The retail industry does however, have power to steer people’s choices by use of shelf space and position. The Nutrition Centre suggests theplacement of ‘healthy’ products at eye level.114 A number of research respondents were of the opinion that ‘unhealthy’ products are giventhe most prominent shelf space. Placement of confectionery at checkout counters has been stigmatised by certain stakeholders as a clear sign thatthe retail sector has not taken the issue seriously enough. At a 2004 debateon 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 shebegins to whine about one of those products. You cannot just walk away, people are looking and they feel uncomfortable. How many times dothose parents give in? Of course ultimately it is the responsibility of the parents, but these tactics make it very diffi cult for parents to stay strong.”

PricePrice is a major infl uence on consumer choice (see fi gure 24). Variousresearch respondents (non-retail industry) perceive that supermarket brochures predominantly advertise high fat, high sugar products andconcentrate on marketing initiatives from producers of ‘unhealthy’foods, such as towers of confectionery in the middle of supermarketaisles. Respondents from the retail industry disagree, citing regularoffers 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 inthe 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.

114. VARA-KASSA (12-07-2004). Supermarkten gaan verantwoordeli-jkheid nemen in strijd tegen overge-wicht. http://kassa.vara.nl

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

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HOW MANY TIMES DO YOU PAY ATTENTION TO THE FOLLOWING

WHEN BUYING FOOD IN THE SUPERMARKET?

Aspects Never Sometimes Always /

almost always

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 modifi ed substances 55% 26% 19%

Biological or not 40% 42% 18%

According to the KHN their fi rst responsibility is to support variety on themenu so people can determine for themselves whether to eat more or less healthy. Some members see this issue as an opportunity and believe thatmuch has already changed: “You can see a big difference when youcompare 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 combatingoverweight 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 lackof action - the Association represents such a vast number of small foodoutlets, that an industry-wide approach is unachievable. The Ministry ofHealth pointed out that the eating out industry will be a focal point in thenear 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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Not all companies in the catering business remain silent, however. Dutchnewspaper Algemeen Dagblad reported in 2004 on catering company Albron: “Fatima Moreira de Melo started a campaign this week fromcatering giant Albron to stimulate people to take up a healthier life and eating pattern.”116

Catering businesses hold essentially the same opinion as other stake-holders: they do not see themselves as primarily responsible; the issueis complex; it is a matter of caloric intake versus expenditure of physicalenergy; the consumer is ultimately responsible.According to one respondent from the catering industry, the issue isactually new to the sector. The KHN received its fi rst invitation to theRegional Discussion of Overweight (ROO) in 2004 - it attended the second.

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

6.3 Healthcare insurers

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

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

Health insurance companies are responsible for providing insurance foreveryone in the Netherlands. This is achieved by implementing a systemconsisting of public and private insurance. According to the industry organ-isation for healthcare insurers in the Netherlands (ZN) the Dutch system incorporates three parts:118

1. Long-term care and uninsurable risks: fi nanced 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;

116. Algemeen Dagblad (1-12-2004). Veel profi jt van ijdelheid.

117. Nederlandse Obesitas Vereniging (22-12-2004). Ziekte kosten-verzekeraars VGZ en CPG starten overgewicht offensief. www.dikke-mensen.nl

118. Zorgverzekeraars Nederland (22-12-2004). Dutch Healthcare system. www.zn.nl

67

3. Additional care: offered by the insurance company to the individual insupplementary policies. Cost control and monitoring of quality is in thehands 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 mustdo so without fi nancial support of the government. For this reason thecurative 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 thegovernment should provide the resources necessary to support theprevention 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 fi nancial contributionto 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 investmentCentral to the way insurance companies work are methods of risk selectionand damage control. The former refers to the marketing of health insurance products to the young, active and healthy; the latter refers tomethods of screening potential consumers for conditions such as diabetes, providing health information in marketing literature, and developinghealth 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 profi le 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 bybecoming actively fi nancially involved in this issue, it will send signals tothe government that health insurance companies should take responsibilityfor resourcing additional preventive health issues.

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Use of available dataResearch respondents share a belief that the general public does notwant 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 healthdetails in ‘preventive measure’ marketing campaigns. For example, usingavailable data it is possible to construct a list of people who use insulin. With this list healthcare insurance companies could send specifi c infor-mation to those clients with diabetes. Instead, when companies want toprovide clients with information regarding diabetes they are required tocontact all clients, asking whether they have diabetes and whether they would like to receive additional information.

Taking initiativeWhilst the health insurance system does not perhaps stimulate the publicto become more concerned about their health, some healthcare insurers do take the initiative. Insurer VGZ began an offensive in January 2005 against obesity specifi cally, 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 relationto 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 lifestyleand achieve results.

The industry association of healthcare insurers intends to sign anagreement with the Ministry of Health. The next steps would be theinstalment of a study group on the issue of overweight and obesity. Research respondents highlighted two practical solutions coming fromthis: it would stimulate the development of guidelines for general practitioners and the allocation of 3% of healthcare insurance mutualfunds 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.

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

69

Signifi cantly, respondents pointed out that people are responsible forbuying 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 signifi cant contribution to the decreasein physical activity.

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

The computer industry, however, sees itself as having no responsibility foroverweight and obesity. Indeed, there has been no direct scientifi c link made between the computer industry and overweight. There has alsobeen no real pressure from the media, politics, NGOs or other stakeholderstowards the computer industry. The general notion among respondentsfrom various stakeholder sectors was that the computer industry would only enter the debate if the issue was seen as an opportunity. Exposure atthis stage would mean linking a company to a negative issue.

COMPUTER USE COMPUTER

USE 2000

1985 1990 1995 20 0 0 Inter -

net

Other

use

Population ! 12 years 0.1 0.5 0.9 1.8 0.5 1.3

Sex

male female

0.30.0

0.80.1

1.50.4

2.51.0

0.70.3

1.80.7

Age

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

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

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

70

71

The importance of physical activity in combating overweight and obesity has been noted throughout the report. A few physical education initiativessuch as the BOS impulse (increase education and sport in the localneighbourhood) 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 theNetherlands: 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 isdesigned 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 alsochanged (see fi gure 26).

1975 1980 1985 1990 1995 2000

Total travel 6.6 6.8 7.2 7.9 8.5 8.4

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

Transport mode

car 2.9 3.3 3.5 3.8 4.2 4.7

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

7 Physical activity in the Netherlands

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

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

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

72

According to the Dutch Health Enhancing Physical Activity Guideline (NNGB) people should spend at least half an hour a day (one hour a day foryoung people) performing moderately intensive physical exercise to reap real health benefi ts. Physical exercise refers to sports and other daily activ-ities such as walking and cycling123 (see fi gure 27). It appears that sportingactivity 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 byan increase in the general number of people participating in sport. The amount of time spent on sport individually did not rise substantially.124

1975 1980 1985 1990 1995 2000 INDEX

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

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



73

Figure 28 outlines that people who are studying exercise more than thosein employment. Whilst average total exercise time is 4.4 hours per week, this fi gure increases to 8.3 hours for 12 -19 year olds. This could beexplained by additional time spent cycling due to lack of other transportpossibilities 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.

1975 1980 1985 1990 1995 2000 INDEX

Population ! 12 years 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

Age

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

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

Family position

living with parents 6.1 6.8 7.4 6.9 7.2 7.5 105

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

Level of education

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

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 andorganisation of time in theNetherlands 1975-2000’ September 2004.

74

7.2 Barriers to an increase in physical activity

In addition to infl uences already discussed, research respondents across allsectors point to the following when considering barriers to physical activityin the Netherlands:

- Government subsidy: the government makes less provision of subsidyfor sport, suggesting an increase in fi nancial 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 andobesity.

- Sports associations: with a change in people’s choice of sporting activity(towards fi tness or skating, for example) sports associations are seeing fewermembers and reduced subsidies. In this environment sports associationsneed to change and professionalise. A respondent pointed out the larger roleplayed by the private sector (including food companies.) Sport associationsneed fi nancial support from this sector, given, for example, in the form ofs ponsorships.

- Geographical location: sports clubs have been increasingly developed inthe 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 backin city centres.

- Playing outside: respondents remark that little thought has been givento 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 publichealth (GGDs) display little awareness of how to promote physical activity inan increasingly culturally diverse population. The NOC*NSF, however, believesthat time and fi nancial resourcing regarding research, development andimplementation should be split in a ratio of 1:3:9; in the Netherlands thisratio is more realistically 1:3:3.

75

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 oflegislation and litigation?

8.1 The issues of smoking, alcohol and obesity compared

“Tobacco and obesity epidemics: not so different after all?”125

At a fi rst 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 fi ght smoking becausethey have a right to clean air. These differences make it diffi cult 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 tosociety. Industry reaction is essentially the same: the individual is primarily responsible themselves; they are intelligent enough to make their ownchoices; 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 certaindiseases, arguing that they were not based on sound scientifi c research127, while the food industry proclaims, as previously discussed, that there areno ‘bad foods’.128 Some accuse the three industries of having pointed to 8

confl icting scientifi c data – is this to encourage a ‘smoke-screen’ effect? For example, reports have said that sugars can help children to concentratemore, or that alcohol is good for widening the blood vessels, resulting inlower 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 substancesdue 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.78128. 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

76

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

In February 2004 the Dutch Minister for Public Health spoke of expecta-tions of a fi rm approach from the food industry, referring to the tobacco industry’s refusal to make fi rm 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 theverdict 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 advertisingand promotion was banned in Britain, weeks later New York outlawed smoking in public places and Dublin soon followed. Could the samebludgeon of litigation be directed at food companies? The threat is soreal that public-liability insurance for fast-food and other restaurants rose by 35% last year, with further hikes expected.”

It is diffi cult to implement effective legislation for something that people already know is ‘bad’ for them. What does seem better possible is legis-lation regarding information. People have a right to know when food is‘bad’ for them, recommended amounts for consumption and what exactlyis 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 thisissue should be directed only at foods deemed ‘unhealthy’ from a physi-ological point of view. Essentially, smoking, alcohol and ‘unhealthy’ foodsare all stimulants. From this perspective it would appear that the samepolicies could be implemented.

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

130. Adformatie (17-02-2004). Minister wil snoep en snackreclame beperken. 131. Management today (01-06-2004). Big food and drink bites back.

132. Zie bijvoorbeeld de Keuringsdienst van Waarde. www.rvu.nl/kvw/index133. New York Times (14-05-2003). A Suit Seeks to Bar Oreos as a Health Risk.

77

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 begenerally distinguished by fi ve key stages: birth; growth; development;maturity; and post-maturity (see fi gure 29).

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 stakeholderexpectations change, an issue is born. When an issue grows and develops itbecomes 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 orregulations to solve the issue, and when legislative proposals or draftregulations emerge.

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

Figure 29: Issue Lifecycle,Burson-Marsteller 2004.

Pro-active(opportunities)

Reactive(damage control)

Birth

Identification

Growth

Increasing attention NGOs

Develop-mentAttention Media & Public

NetherlandsrEurope United States

Maturity

Political attention

Post-maturityLegislation

New balance

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

78

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

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-fi ghting legislation.135

In the Netherlands the issue hit the political arena in 2001 whenthe Minister of Health stated a belief that obesity was becoming anepidemic. 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 intensifi ed after the subject of ‘fat-tax’ came up in the report of the Council of PublicHealth, November 2002. From this moment on, politicians have beentalking about regulation. In the political debate that followed the diplo-matic paper Longer Healthy Living (October 2003)136, numerous questionsregarding the possibility of regulation were posed to the Health Minister. Many were disappointed by ‘just self-regulation’ and referred to theBelgian Minister of Health who was considering a ban on advertising forcandy and junk food.

An issue usually advances to the growth phase when attention is drawnby certain events – the issue becomes part of public debate. In theNetherlands, this could be the media attention for Morgan Spurlock’s documentary ‘Super Size Me’ and the reaction from Dutch journalistWim 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 countriessuch as France and the UK, debate on possible legislative measures and policies is more advanced. In contrast, research respondents point to alack of signifi cant political interest in the Netherlands.

135. American Heart Association (07-01-2004). American Senate intro-duces obesity-fi ghting legislation. http://www.americanheart.org.

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

79

Appendix I

List of interviewed stakeholders

Public domain1. Drs. S. Buijs, Member of Parliament CDA2. Ms. M. van Dijken, Member of Parliament PVDA3. J. Rijpstra, Member of Parliament VVD4. Ms. Dr. C.E.J. Cuijpers, Policy Offi cer, Ministry of Health5. Drs. J.A.J. Krosse, Director NIGZ6. Drs. R. Kramer, Senior Consultant NIGZrr7. W. Meij, Chief Editorial Offi ce ‘Diagnosis’ Algemeen Dagblad

Private domain8. G. van Alphen, Corporate Relations Manager Coca-Cola9. Dr. Ir. G. de Bekker, Nutrition Manager Danone-LUrr10. L. Blommaert, General Manager Kraft Foods11. J.M. van Boxtel, Franchise-Manager FEBO12. F. de Jonge, Issue PR Media Manager Unilever Bestfoods13. H. Scholten, Sr. Marketing Manager Smiths Food Group B.V.14. M. Simonis, Communication Coordinator McDonalds15. Ms. Dr. S. A. Hertzberger, Head of Quality Albert-Heijnrr16. K. van den Hoven, Head of Communication and Promotion Schuitema N.V.17. F. Rittinghaus, Marketing Manager Nintendo Benelux B.V.

Industry associations18. Drs. J.A.M. Droogh, Secretary of the VAI (FNLI)19. M. Klok, Policy Offi cer Royal Dutch Catering (KHN)20. A.L.J.E. Martens, Policy Offi cer sector organisation of healthcare insurers (ZN)21. J.W. Schouten, Policy Offi cer sector organisation of healthcare insurers (ZN)

NGOs22. Ms. K. Bemelmans, Policy Offi cer Project Overweight Nutrition Centre23. Ms. I. van Dis, Heart Foundation24. Ms. A.M. van der Laan, Policy Offi cer Consumer Association25. Ms. M. van Spanje, President Dutch Obesity Association (NOV)

Science / knowledge institutions26. 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)

Sport28. Ms. H. Mulder, Senior Project Manager NOC*NSFrr

80

81

Appendix II

List of abbreviations

AWBZ General Law Special Health Costs

BMI Body Mass IndexBOS Impulse Neighbourhood, Education and Sport

CBL Industry Association of SupermarketsCDA Christian Democrat PartyCIAA Confederation of the Food and Drink Industries of the EUCPG Collective Preventive HealthCSPI Centre for Science in the Public Interest

EU European Union

FNLI New name for the VAI and SMA after mergingFLASH Government campaign stimulating physical activity by way of

Biking, Walking, Active playing, Sports and HousekeepingFSA Food Standards Agency

GGD Institutions for Public Health on a local level

Kcal KilocaloriesKHN Royal Dutch Catering Association

NGO Non-Governmental OrganisationNHS National Health ServiceNIGZ Netherlands Institute for Health Promotion and

Disease PreventionNISB Dutch Institute for Sports and Physical activityNNGB Dutch Health Enhancing Physical Activity GuidelinesNOC*NSF National Olympic Comity and Sport Federation

OC&W Ministry of Education, Culture and ScienceOECD Organisation for Economic Co-operation and Development

PVDA Labour Party

RIVM National Institute of Public Health and EnvironmentROO Discussion platform on the topic of overweightROW Discussion platform on consumer-goods

82

SIRE Foundation of Ideological AdvertisingSMA Association for the interests of producers

and importers of fast consumer goodsSP Socialist Party

TNS NIPO Dutch Research Institute of Public Opinion

UK United KingdomUS United States

VAI Dutch Food Industry AssociationVROM Ministry of Spatial PlanningVU Free University AmsterdamVVD Liberal PartyVWS Ministry of Health

WHO World Health OrganisationWTZ Law for the access to healthcare InsurancesWUR 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 over gewicht: 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.

- Clémence 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 Directorate-General (2004). Summary Report; Roundtable on Obesity. Luxembourg.

- European Commission; Health & Consumer Protection Directorate-General (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.

84

- 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 manage-mentvraagstuk. 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.

85

- Reuters Business Insights (2004). Obesity, Low-Carb Diets and the Atkins™ Revolution: Healthy profi ts 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 Stafl eu 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 volksge-zondheid: 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.

86

- 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.

87

Appendix IV

Media analysis

Local newspapers

1. Dagblad van het Noorden, November 11, 2004, Centre for heavy weightsin hospital; Emmer surgeon Reijnen offers help for overweight people.

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

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

4. Dagblad Tubantia / Twentsche Courant, November 19, 2004, Sugar andfat 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 startscampaigns for children.

8. Goudsche Courant, November 24, 2004, low-educated have moreproblems. ... 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 withoverweight children.

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

12. Rotterdams Dagblad, November 27, 2004, Sponge Bob doesn’t make anapple 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!

88

National newspapers

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

16. Algemeen Dagblad, November 17, The scale of fi ve (food pyramidshaped as a disc) is back.

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

18. Trouw, November 27, 2004, Hamburger-giant against overweight; noteverybody happy with money McDonalds.

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

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

89

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Appendix V

Obesity treatment fl owchart

90

91

Notes

92

Notes

93

Notes

94

Notes

95

Notes

96

Documents

Obesity on the move – Changing perceptions about a weighty issue