A "Whole of Government" approach to promoting short and

long term well-being in the European Region

Philip James MD, DSc, FRCPLondon School of Hygiene and Tropical Medicine, International Association for the Study of Obesity

Health's contribution to improved prosperity in the past 50 years: a missed opportunity in

Central Europe and Central Asia Health's contribution to full income growth

% 50

40

30

20

10

Europe+C. Asia

SEARO WPRO

EMROAFRO

Lat Am+Caribb.

Smith et al World Bank June 2013.

EU 15Europe+

Central Asia

South Asia

Latin America+ Caribbean

Middle East + North Africa

Central Europe and Central Asia (WHO EURO) is the region with the slowest improvement in life expectancy

since 1960 of all the WHO regions in the world.

Smith et al. Improving health service outcomes in Europe and Central Asia. World Bank June 2013.

80

70

60

50

40

1960 1970 1980 1990 2000 2010

-2 0 2 4 6 8 10

Smoking

High blood pressure

Overweight & obesity

High cholesterol

Alcohol use

Physical inactivity

Low fruit & veg. intake

Illicit drug use

Unsafe sex

Iron deficiency anemia

Attributable disease burden (% regional DALYs; total 149 million)

The top risk factors underlying the disease burdenof high income countries (all preventable)

WHO / World Bank. Global Burden of Disease. Lopez et al., 2006.

Primary dietary cause

Classic problems of nutritional deficiency persist: Lancet July 2013

• Anaemia - a neglected issue affectingChildren 11% affluent; 26% Central/Eastern Europe

Women 16% affluent; 22% Central/Eastern Europe

• Exclusive breast feeding limited and needs ignored: major public health issue in Western & Central Europe: need to replicate Scandinavia and transform societal approach

• Childhood stunting still affects 20-30% in some rural areas of EURO

• Pregnancy - the forgotten public health issue: 15% small for dates babies in Caucasus/Central Asia+ Asian

immigrants: babies programmed for abdominal obesity + diabetes Overweight girls/women: gestational diabetes+ big babies:

programmed obesity and diabetes. Optimum birth weight range!

Crucial nutritional effects do not just affect the first 1,000 days of life: sensitive organs mature

at different rates

Muscle, bone & gut

Reproductive organs

Lymphatic immune system

Liver, kidney, heart, lung.

Brain: follows internal organ changes in size but major structural and functional changes before full maturation at age 20+.Adolescent brain highly susceptible to emotional cues

Prentice et al. Critical windows for nutritional interventions against stunting Am J Clin. Nut. 2013;97: 911-918

For brain changes see:: Dosenbach et al . Prediction of individual brain maturity using fMRI. Science 2010;329: 1358-1361

Marked changes in societal practices needed : eliminate smoking, limit markedly alcohol intake &

transform dietary and inactivity patterns

FIBRE-RICH Vegetables &

Fruit

Increase fatty acids from fish &n-3 vegetable

sources

Exclusive Breast Feeding for 6 months

Modest animal protein intake

Saturated Fats

TOTAL FAT

Trans fat

Sugars & Refined starches

Salt Iodine+

Why do we not eat optimally - is it a matter of education? The current obesity dilemma

Obesity is a normal "passive" biological response to our changed physical and food environment

Some children/adults are more susceptible for genetic, social and economic reasons

Overwhelming environmental impact reflects outcome of normal industrial development

"Obesity reflects failure of the free market"

UK Government report Oct. 2007 Provided on a non - political basis by the Chief Scientist

25 years

65 years

General Pop.

Decrease in obesity rates in 25 and 65 year olds + general population induced by different government policies. OECD 2010. Note insignificance

of approaches using media on its own

Media

Work-site

Schools Drs + Dietetic

Fiscal

FoodLabelling

Food Advertising

Regulated

Voluntary

The cost-effectiveness of policies: individual education for behavioural change for a whole population is very expensive and

often ineffective. Legislative/regulatory measures usually much more effective and less costly.

The keys to success in the food business and in obesity and chronic disease (NCDs) prevention

• Price

• Availability

• Marketing

Margaret Chan, DG WHO. WHO 8th Global Health Promotion Conference

June 10th 2013

• "..it is not just Big Tobacco anymore. Public health must also contend with Big Food, Big Soda and Big Alcohol. All of these industries fear regulation, and protect themselves by using the same tactics.

• Research has documented these tactics well. They include front groups, lobbies, promises of self-regulation, lawsuits, and industry funded research that confuses the evidence and keeps the public in doubt.

Margaret Chan, DG WHO. WHO 8th Global Health Promotion Conference

June 10th 2013

• Tactics also include gifts, grants and contributions to worthy causes that cast these industries as respectable corporate citizens in the eyes of politicians and the public. They include arguments that place the responsibility for harm to health on individuals, and portray government actions as interference in personal liberties and free choice.

PACO III Latin American & Caribbean Ministerial Conference on childhood obesity 6th

- 8th June 2013Ministers of Health's primary role is to act as leaders and ambassadors for change in other government departments e.g.

a) Education - changing curriculum and total food + drink sources in all educational facilities

b) Transport: structural changes promoting walking/cycling + public transport & minimizing car use

c) Finance: Taxation of unsuitable foods/drinks; financial incentives for behavioural change allowing for regressive effects on disadvantaged; Planning for progressive help to local farming/food provision + activity industries

d) Business : promote good food and activity: import /export health criteria + supermarket changes

e) Agriculture & Food: Link local industries to government supported catering.

Food tax developments

Trans fats: Denmark bans in 2003 . Now also Austria & Switzerland. New 2013 analyses: legislation is the most cost effective intervention not voluntary measures.

Sugar : Finland introduced taxes on sugared products such as soft drinks , ice cream and confectionary by EUR 0.75 per kilo product. Also Denmark.France introduces a 7 cent/litre tax on all soft drinks

HFSS: Sept. 1, 2011. Hungary: a 10 forint (€ 0.37) tax on foods with high fat, sugar and salt content; also increased taxes on soft drinks and alcohol

Saturated fat. Denmark introduces small selective tax for 15 months: clear reduction in intake - see separate presentation

Early success of major French Parliamentary initiatives in changing school foods, limiting marketing of foods high in fats, sugar and salt and new taxes on soft drinks; now a new National

Nutrition and Health Programme 2011 - 2015

20051. Vending machines banned in schools;

quality of all foods served improved2. All national advertising of foods and

drinks must carry a health message, with the penalty of being subject to an earmarked tax

December 20113. Tax of 7 cents/ litre on all soft drinks

4. Food quality in schools controlled by law

Repeated national surveys:

Overweight &obesity rates in 7-9 year old children

(IOTF criteria)Fall of ≈ 15% from 1998-2007

Government initiatives Results

1 Actual price increase =7cents/l2. Sales fall by 4%3. Population accepts especially if some tax transferred for health care 4.Tax income 280 M€ in 2012

Profitable government opportunities for adults and children based on evidence from Chile, Denmark, France, Finland, Netherlands & Sweden

relating to cardiovascular disease, diabetes and obesity prevention.

1. Control foods+ drinks available in schools, hospitals, all government supported institutions - this induces major driver in the free market food chain

2. Develop local farming consortia to provide school meals etc. as educational + financially rewarding strategy (a major opportunity for Europe)

3. Promote inclusion of vegetables/salad bar in main meal at no extra cost

4. Ban trans fat production in country

5. Define progressively lower food salt content ; no salt on tables as a default measure

6. Regulate lower cost for half and skimmed milk, butter and margarine sales

7. Tax price sensitive items: sugar, - fat (especially saturated fats) on a commodity not a retail basis

8. Ban all marketing of food and drink to all children including adolescents

9. Control fast food outlet density as well as alcohol and tobacco sales in city centres

Conclusions

• The burden of diseases from inappropriate diets and physical inactivity in the WHO EURO region is exceptionally high

• Slow progress in reducing the premature mortality and disease burden in many countries in the region.

• Anaemia and poor pre-pregnancy and maternal nutrition are neglected issues; low birth weight and stunting persists: EURO is also the region with the lowest natural dietary iodine supply.

• High priorities in nutrition: Reduce substantially intakes of total fat, trans fat, saturated fat, sugar, salt. Iodize salt and ensure folate + iron for anaemia. All are explicit, newly reinforced, WHO recommendations.

• Legislation, regulatory, fiscal policies are far more effective than media campaigns; establishing a healthy foods exclusive policy in all government supported institutions transforms the food chain and health.