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Public Health Policy to tackle obesity: An International Perspective
Article · January 2005
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Public Health Policy to tackle obesity:
An International Perspective
Iain K Crombie
Linda Irvine
Lawrence Elliott
Hilary Wallace
Commissioned and funded by NHS Health Scotland
March 2005
Iain K Crombie1
Professor and Head of Department
Linda Irvine1
Research Fellow
Lawrence Elliott2
Reader
Hilary Wallace1
Research Assistant
1Section of Public Health
Division of Community Health Sciences
University of Dundee
Mackenzie Building
Kirsty Semple Way
DUNDEE
DD2 4BF
2School of Nursing and Midwifery
University of Dundee
11 Airlie Place
DUNDEE
DD1 4HJ
Contact details:
Professor Iain K Crombie
Tel: + 44 (0)1382 420102
Email: [email protected]
This report is based on policy documents available up to July 2004.
ii

iii
Acknowledgements
We are grateful to NHS Health Scotland for providing the funding which gave us the
opportunity to carry out this work. We would like to thank Dr Laurence Gruer, Jackie
Willis, Jill Muirie and Erica Wimbush for their support during this work. We are very
grateful to those countries who kindly supplied us with paper copies of their policies.
The opinions expressed in this publication are of the researchers and not necessarily
those of the NHS Health Scotland.
iv
Caveat
This report is based on the extensive set of documents we were able to obtain from web
sites, individuals and government departments. To maximise coverage, the web was
searched in a variety of ways and individual web sites were visited several times.
However we cannot be certain that we obtained all relevant documents. Further, for
several countries it is likely that some documents may not have been translated into
English. Thus, some of our findings might well be modified had we had access to a
fuller set of documents.
v
Executive Summary
Introduction
Obesity is a major public health problem which is currently getting worse. The medical
and financial costs of obesity are widely recognised. We therefore conducted a review of
public health policy documents on obesity, nutrition and physical activity. These were
examined to identify the salient features of policy.
Methods
The review of policy covered fourteen developed countries: Australia, Canada, Denmark,
England, Finland, Ireland, Japan, New Zealand, Northern Ireland, Norway, Scotland,
Sweden, USA and Wales. Policy documents from every country were reviewed by two
independent observers. Short summaries were prepared of the key policy features on: the
assessment of the problem; the targets set; the interventions proposed; and the evaluations
that have been put in place.
Results
All countries express concern at the rapid increase in the prevalence of obesity.
Overweight and obesity are thought to result from the combination of the overconsumption of energy dense foodstuffs and inadequate levels of physical activity.
Despite the rapidly worsening situation only a few countries have specific strategies on
obesity. Instead obesity is often tackled indirectly through separate policies on nutrition
and physical activity.
The policies are often written in general terms and frequently identify sets of action
which could be pursued without making commitment to carrying them out. Interventions
in schools and the workplace are the most well-developed. Many countries have created
active transport strategies to increase both cycling and walking. Apart from these, there
are few specific proposals for tackling obesity. Those countries with obesity polices
highlight the need to tackle the problem among socially disadvantaged people.
vi
Fiscal and legislative interventions are almost completely absent from policy documents.
There is also little mention of funding for the range of proposed interventions. Further
research to develop effective interventions is recommended, as is the evaluation of the
impact of current policies. However specific proposals for these actions are seldom given.
Conclusions
Obesity is a major epidemic which needs urgent action. However, current policy is
largely concerned with exploring options on ways to develop policy, rather than
providing a comprehensive set of interventions to reduce obesity. The problem posed by
obesity completely overshadows the efforts being made to tackle it.
vii
Introduction
The association between obesity and chronic disease has been recognised for many
years1. In 1998, the World Health Organisation2 concluded there was an association
between obesity and seventeen diseases including type II diabetes, gallbladder disease,
coronary heart disease, osteoarthritis, sleep apnoea and cancer of the breast, endometrium
and colon. The extent of these disease associations are of concern because the prevalence
of obesity is now rapidly increasing: in England it tripled between 1980 and 19993.
Similar trends have been documented in Australia and the USA1. The prevalence of
obesity is also rising rapidly among children4. The scale of the obesity problem may be
underestimated. One recent report concluded that the deleterious effects of obesity on
health and health care costs substantially exceeds those of tobacco or alcohol5. Despite
this, obesity is given much less attention in public health policy.
Obesity is the natural consequence of energy intake exceeding energy expenditure. Thus
the cause of obesity is either overeating, sedentary behaviour or a combination of the
two6. Although genetic makeup is important, the prevalence of obesity has increased too
rapidly for genetic changes to account for it. Thus the focus of public health policy must
be on diet and physical activity.
There is a widespread view that modern society presents “an essentially unlimited supply
of convenient, relatively inexpensive, highly palatable energy dense foods”7. However
evidence for overeating is not persuasive. Dietary data in the UK shows a fall in per
capita energy intake since 19706, although concerns about the validity of these estimates
have expressed by the House of Commons Select Committee8. In the USA dietary
surveys show that energy intake appears to have remained stable during the last 40
years9.
Overall energy expenditure has reduced in recent years2 3. This is attributed to a
reduction in walking, occupational exercise and leisure time physical activity. This has
been paralleled by an increase in sedentary behaviour (television and computer games)
and an increase in energy saving devices in public places (lifts, escalators, automatic
1
doors and car useage). Physical activity is also being engineered out of people’s lives
through labour saving devices such as TV remote control devices, automatic car washes,
pizza delivery services and shopping on-line9.
Traditional approaches to preventing obesity focused on changing individual behaviour,
but these are now thought to be inadequate10 11. There is a growing consensus that
strategies for tackling obesity need to address the physical and social environment, the so
called obesogenic environment10 12 13. One proposal is to increase the availability and
palatability of foods that are low in fat and low in energy density7. This could be
accompanied by education to foster a preference for less energy-dense foods. Others
have suggested using fiscal policy by placing taxes on high fat foods and exempting
healthier foods 12 14 and restrictions on the advertising of junk foods10. Such proposals
are likely to meet considerable opposition from the food industry15. A complementary
approach is to make the environment more conducive to physical activity by providing
safe walking and cycling paths, parks and community recreation centres12. This could be
combined with campaigns to discourage sedentary activities such as watching television
and to promote regular exercise15.
The problems posed by the obesity epidemic are well understood, as are the directions:
reduced consumption and increased physical activity, which must be followed to tackle
them. The challenge for policy is to design and implement a programme of interventions
which will change the social and physical environment to allow the strategic objectives to
be achieved.
2
Aims
This study provides a review of obesity policy in fourteen developed countries and
investigates the interventions proposed in policy to address the problem. The aims of the
study were to:

Overview
This study was based on a review of public health policy documents from the following
countries: Australia, Canada, Denmark, England, Finland, Ireland, Japan, New Zealand,
Northern Ireland, Norway, Scotland, Sweden, USA and Wales.
3
Methods
Policy documents to address obesity were obtained from fourteen developed countries:
Australia, Canada, Denmark, England, Finland, Ireland, Japan, New Zealand, Northern
Ireland, Norway, Scotland, Sweden, USA and Wales. The majority of documents were
obtained from Ministry of Health websites. The initial search identified those countries
with stand alone policies on obesity. The overall public health policies from all countries
were then reviewed to establish which countries included obesity, nutrition or physical
activity as topics in their public health strategies. Websites were searched again for stand
alone policies on nutrition and physical activity. The majority of documents were
downloaded from the Ministry of Health websites. The public health policies from the
USA, Japan, Denmark and the Health Strategy and Health Promotion Strategy from
Ireland were obtained directly from the Health Departments of each country. We
identified some documents through links to other government department websites, such
as Departments of Education or Sport and Recreation. However, these websites were not
systematically searched.
Some countries have a limited amount of documents in the English language available on
the Ministry of Health websites. For example, Norway’s public health strategy is only
available as a summary document in English. In addition, we found little English
language documentation from Finland and Sweden. Thus, the amount of information
available varied substantially between countries. It is possible that the non-English
speaking countries have policies in their own language which we were unable to access.
Policy review
The policy documents were reviewed by two independent observers (LI and IKC). Data
on the format and content of the policies, with particular attention to potential
interventions to be implemented, were extracted from the documents. The organisation
of policy to address obesity varies across countries. Few countries have policies on
obesity, but strategies on nutrition and physical activity address the problem. This is
described in the section entitled Current Policy on obesity, nutrition and physical activity.
4
Summaries were prepared of the key policy features of policy: the assessment of the
problem, the targets set, the interventions proposed and the evaluations that have been put
in place. A comprehensive list of interventions proposed in policy was compiled.
Interventions were sub-divided into ten categories: fiscal; legislative; policy
development; transport; media; food and leisure industries; nutrition labelling; social and
physical environment; educational strategies; and settings for intervention. From the list
of all the interventions across all of the policies we have synthesised the range of
interventions which could be implemented within each of these categories. Because we
sought to provide as comprehensive a review as possible, we have included interventions
irrespective of the governments’ commitment to implementation. Some will no doubt be
implemented, but others may be mentioned in policy documents only for consideration.
5
The nature of the problem
All countries are concerned about the dramatic increase in overweight and obesity in
recent years. It is a growing problem among both genders, adults and children and in all
population groups16. England and the USA have recently reported that more than 60% of
the population are overweight or obese8 16. The prevalence of obesity, defined by a Body
Mass Index >30, varies between the countries studied. In England in 2002, 22.9% of
men and 25.4% of women were obese8. New Zealand reported that in 1999 15% of
males and 19% of females were obese17, while Denmark reported the prevalence in 1999
to be 8%18. It is estimated that there is a nine year reduction in life expectancy among
obese patients8. If current trends continue, obesity may soon be responsible for as much
preventable premature morbidity and mortality as smoking8 16 19. Overweight and obesity
in children gives particular cause for concern, due to the increased risk of many diseases
in adulthood. Thus it has been predicted that, for the first time in more than a century,
life expectancy for the current generation of children is likely to fall2.
Diseases caused by obesity
Individuals who are obese have an increased risk of premature mortality. Many health
risks are associated with obesity and as body weight increases, so does the prevalence of
health risks. New Zealand gives the relative risks of developing certain diseases20. These
are graded as: greatly increased for type II diabetes, gall bladder disease, dislipidaemia,
insulin resistance, breathlessness and sleep apnoea; moderately increased for coronary
heart disease, hypertension, osteoarthritis and hyperuricaemia; and slightly increased for
cancer of breast (post menopause), endometrium and colon, reproductive hormone
abnormalities, polycystic ovary, impaired fertility, increased anaesthetic risk, and fetal
defects. Denmark points out that from three years of age, obesity in children is
increasingly linked to obesity in adult life. In addition, children whose parents are obese
have a risk in developing obesity as adults whatever their weight in childhood18. The
Danish document also highlights the problem of prejudice in children, social problems
among adults and discrimination in the workplace. Australia points out that obesity can
destroy self-esteem, lead to social discrimination and contribute towards mental illness21.
6
Cost of obesity
The cost of managing obesity is high, due to the associated health problems and
subsequent mortality. This has substantial economic implications and places a major
burden on health care systems. The World Health Organisation, in 2000, estimated that
the cost for countries amounted to 2% to 7% of the annual health budget. The total cost
of obesity in England in 2002 was estimated to be £3.3 to £3.7 billion2. This includes the
direct costs of treating obesity and associated diseases and the indirect costs from
premature mortality and lost productivity. The total cost in the USA in 1995 was
estimated to be $99 billion1.
Causes of obesity
In simple terms, obesity occurs when energy intake exceeds energy expenditure. Genetic
susceptibility can play a role but the main reason for the sudden increase in obesity is due
to environmental factors5. Energy dense foods are becoming more available while in
today’s society energy expenditure is reduced. Australia in its strategic plan to reduce
obesity, Acting on Australia’s Weight22, acknowledges that the nutritional composition of
the diet has changed in recent decades, with fat typically providing a higher proportion of
energy intake. This is in part due to the increase in the use of convenience foods, many
of which are high in fat. It suggests that the reduction in physical activity during the
same period has also contributed. Australia’s Healthy Weight 2008, which addresses
overweight and obesity in children, puts the increased problem in children down to a
decrease in physical activity, an increase in unhealthy eating and an increase in television
viewing21. It states that changes to the social, cultural, physical and economic conditions
are driving these unhealthy behaviours.
New Zealand’s Healthy Eating – Healthy Action background document23 categorises the
influences as biological, behavioural and environmental. It states that the biological
influences of ethnicity, gender, age, hormonal and genetic factors explain the variance in
body fat in individuals, but do not explain the rapid increase in obesity at a population
level. It goes on to suggest important influences such as sedentary lifestyles at work and
leisure and spending less time on leisure and other physical activity. Less time for
7
cooking and loss of cooking skills are also seen as a problem as well as easier access to
food outlets, larger portion sizes, and easier access to pre-prepared foods which tend to be
high in fat, sugar and salt. Media influences, particularly on children, are also discussed.
The document reviews evidence that suggests that television viewing promotes weight
gain not only because it is a sedentary activity, but because the consumption of energy
dense foods increases with television viewing. Advertising may also affect dietary
patterns and children who watch television during meals have poorer diet23.
Sedentary behaviour as a cause of obesity
Several countries discuss the reduction in physical activity over recent decades. Australia
puts this down to a preference for sedentary lifestyles, lower participation in active
recreational pursuits, and the greater use of labour saving devices at home and in the
workplace22. The proportion of people in sedentary occupations has increased while
television viewing, particularly day time television viewing has become more popular,
mainly among women and children. Playing computer games, which leads to long
periods of inactivity, is also much more popular among children.
All countries recommend that adults accumulate 30 minutes or more of moderateintensity physical activity on most, preferably all days of the week. However, the
majority of the countries reviewed report that this is not achieved. Sweden estimates that
no more than 20% of the population may be sufficiently active to benefit their health24;
Scotland reports that 72% of women and 59% of men are not active enough to benefit
their health25, while Australia and New Zealand estimate that one third are not
sufficiently active to benefit health, although they acknowledge this figure may be
higher26 27.
High risk groups
Overweight and obesity are more common among the lower socio-economic and socially
disadvantaged groups, particularly among women. This is highlighted in the strategies
from Australia21, New Zealand20, Norway28, and Sweden29. People from minority ethnic
groups are also at higher risk. A recent report from the Health Committee appointed by
8
the House of Commons in England describes the differences between different groups8.
Men and women working in unskilled manual occupations are over four times more
likely to be classified as morbidly obese. In 2001, 28% of women and 19% of men in
unskilled manual occupations were obese compared to 14% of men and women in
professional groups. In England, children who are Asian are four times more likely to be
obese than white children. Among women there are also differences between ethnic
groups. In 1999 obesity was 50% higher in black Caribbean women than the national
average and 25% higher among Pakistani women.
Australia and Japan identify certain age groups who are most at risk. Australia suggests
men aged 25 – 40 years, and women aged 45 – 55 years are at greatest risk while Japan
has set targets for men aged 20 – 69 years and women aged 40 – 69 years. New Zealand
identifies older people as vulnerable and Australia, Japan and New Zealand all identify
children and adolescents as a high risk group.
9
Strategic approaches to tackling obesity and physical
inactivity
World Health Organisation Global Strategy on Diet, Physical Activity
and Health
The World Health Organisation’s Global strategy on diet, physical activity and health30
was endorsed by the 57th World Health Assembly in May 2004. The strategy was
developed in response to the recognition that a few largely preventable risk factors
account for substantial morbidity and mortality worldwide. This population-wide,
prevention-based strategy was developed through extensive consultation with member
states, organisations of the United Nations system, other intergovernmental bodies and
civil organisations.
Non-communicable diseases account for around 60% of all deaths and approximately
47% of the global burden of disease. Diet and physical activity were identified as two
main risk factors for these diseases. It is important to note that diet and physical activity
influence health together and independently. The effects of diet and physical activity
often interact, particularly in obesity, although their effects on health may be completely
independent. The major factors that contribute to the development of non-communicable
diseases include: diet that is high in energy dense, nutrition poor foodstuffs which are
high in fat, sugar and salt; and reduced levels of physical activity at home, school, work
and during recreation. Unhealthy diet, inadequate physical activity and energy
imbalances in children and adolescents give particular cause for concern.
Overall goal
The overall goal of the Global Strategy is to promote and protect health by guiding the
development of an enabling environment for sustainable actions at individual,
community, national and global levels. Taken together these should lead to reduced
disease and death rates related to unhealthy diet and physical inactivity.
10
Objectives
The Global Strategy has four objectives:
• To reduce the risk factors for non-communicable diseases that stem from unhealthy
diets and physical inactivity by means of essential public health action and healthpromoting disease-preventive measures
• To increase the overall awareness and understanding of all the influences of diet and
physical activity on health and of the positive impact of preventive interventions
• To encourage the development, strengthening and implementation of global,
regional, national and community policies and action plans to improve diets and
increase physical activity that are sustainable, comprehensive, and actively engage
all sectors, including civil society, the private sector and the media
• To monitor scientific data and key influences on diet and physical activity; to
support research in a broad spectrum of relevant areas, including evaluation of
interventions; and to strengthen the human resources needed in this domain to
enhance and sustain health
The Global Strategy is based on the evidence that a healthy lifestyle, which includes a
healthy diet and physical activity and avoidance of tobacco can lead to a long and healthy
life. The document acknowledges that more research is required, but that urgent public
health action is required to improve health. Recommendations for diet and for physical
activity are given to guide policy makers. For diet, the recommendations for populations
and individuals should include:
• achieve weight balance and a healthy weight
• limit energy intake from total fats and shift fat consumption away from saturated fats
and towards the elimination of trans-fatty acids
• increase consumption of fruit, vegetables, whole grains and nuts
• limit the intake of sugars
• limit salt consumption
For physical activity the recommendations state that individuals engage in adequate
levels throughout their lives. For adults at least thirty minutes of regular, moderate
11
intensity physical activity on most days is recommended to reduce the risk of
cardiovascular disease, diabetes, and colon and breast cancer. More activity may be
required for weight control.
Principles for action
The Global Strategy sets out the seven principles upon which it is based and recommends
their use in the development of national and regional strategies.
1. Strategies need to be based on the best available scientific research and evidence.
Strategies should be consistent with the Ottawa Charter and must recognise the
complex interactions between personal choice, social norms and economic and
environmental factors.
2. A life-course approach is seen to be essential. This includes good nutrition from
the antenatal period through all the stages of life and encourages physical activity
from youth to old age.
3. Strategies must include a comprehensive and coordinated approach to tackle noncommunicable disease. This must include all aspects of good nutrition, from
breast feeding, under-nutrition and over-nutrition, to food security and food
safety. For physical activity, all settings must be considered including the home,
schools and workplaces, as well as environmental factors such as city planning,
safety and access to facilities.
4. Priority should be given to activities that will benefit the most disadvantaged
groups and communities.
5. Evaluation, monitoring and surveillance are essential for all policies implemented.
6. Gender differences, cultural factors and the variation in need according to age
must be considered when developing policy.
7. Policies and plans must be culturally appropriate, bearing in mind that dietary
habits and patterns of physical activity are based on local and regional traditions.
National strategies should be able to respond to changes over time.
12
Responsibility for action
WHO recognises that bringing about the desired changes in dietary habits and patterns of
physical activity will need long-term action and will require the cooperation and
collaboration of many stakeholders. WHO itself will provide leadership and support to
member states in the development of, and implementation of national strategies.
Recommendations for action are also given for: member states, particularly for
government action; international partners; civil society and non-governmental
organisations; and the private sector.
Governments
Most emphasis is given to the role of governments:
1. Governments are encouraged to build on existing policies and action plans, but
the need for incorporating mechanisms to coordinate the implementation of a
comprehensive plan, is also emphasised.
2. Ministries of Health are identified as the department to coordinate and facilitate
the contribution of other departments.
3. The need to have broad support for strategies and plans is highlighted. To
achieve this, strategies should be supported by effective legislation, appropriate
infrastructure, implementation programmes, adequate funding, monitoring, and
follow-up. Governments are encouraged to develop national strategies and
guidelines on diet and physical activity.
4. Governments should also provide accurate and balanced information that will
enable people to make healthier choices. Care must be taken that the information
needs of all consumers are met. This can be achieved through:
a Education, communication and public awareness. Consistent, coherent, simple
messages should be conveyed by governments on the relationship between diet,
physical activity and health.
13
b Health literacy. Health literacy should be incorporated into adult education
programmes
c Marketing, advertising, sponsorship and promotion. Marketing of food and
beverages should not exploit children’s inexperience and credulity. Messages
that encourage unhealthy behaviour should be discouraged, and positive,
healthy messages should be encouraged.
d Labelling of foodstuffs. Accurate comprehensive information that will allow
customers to make healthy choices should be included on food labels.
e Information from food producers. Food producers should not provide messages
that can mislead the public about nutritional benefits or risks.
5. National food and agricultural policies should be consistent with the protection
and promotion of public health. Governments are asked to ensure that policies
facilitate the adoption of a healthy diet and that food and nutrition policies
incorporate food safety and food security. Four aspects are specifically
addressed:
a Promotion of food products should be consistent with a healthy diet.
Governments could consider additional measures to encourage the reduction of
the salt content of processed foods, the use of hydrogenated oils and the sugar
content of beverages and snacks.
b Fiscal policies through taxation, subsidies and pricing policy can be used to
encourage healthy eating.
c Food programmes for disadvantaged groups should ensure that the quality and
nutritional content of the food contributes to a healthy diet and that nutrition
education forms part of the programmes.
d Governments should consider healthy nutrition in their agricultural policies, as
agricultural policy and production can have an effect on national diet.
6. Multi-sectoral policies are encouraged as a way of increasing physical activity.
a National and local government policies should ensure that: walking, cycling and
other forms of physical activity are accessible and safe; transport policies include
14
non-motorised forms of transport; workplace policies encourage physical
activity; and sports and recreational facilities are suitable for all.
b Strategies should be geared to include community involvement to help change
social norms so that the integration of physical activity into everyday life is
accepted as normal. Environments that facilitate physical activity should be
promoted, and supportive infrastructures should be set up to increase access to
and use of facilities
c Ministries of Health should take the lead department in forming partnerships
with all stakeholders in developing strategies.
d Clear public messages should be given on the quantity and quality of physical
activity necessary to provide substantial health benefits.
7. School policies and programmes should support the adoption of healthy diet and
physical activity. Schools should be encouraged to provide children with daily
physical activity and governments are encouraged to adopt policies that ensure
healthy eating in schools.
8. Member states are encouraged to establish mechanisms to promote participation
of non-governmental organisations, civil society, communities, the private sector
and the media in activities related to diet, physical activity and health.
Governments should consult with stakeholders on policy. Ministries of Health
are charged with establishing the mechanisms and strengthening intersectoral
working at all levels.
9. Health services and other services, particularly primary care, have an important
role in prevention. Routine contacts with health service staff should include
advice to patients on the benefits of healthy diet and increased physical activity.
Governments should consider incentives to encourage preventive services and
identify ways of financing a structure to enable health professionals to dedicate
more time to prevention.
15
a Health care providers, particularly those in primary care play an important role in
prevention by giving advice on diet and physical activity. Activities include the
measurement of the key biological risk factors eg blood pressure and cholesterol
level, and the identification and management of high risk individuals including
referral to specialist services. Training of personnel to deliver these
interventions is essential.
b Health professionals and consumer groups should be involved in raising
awareness of government policies in order to enhance their effectiveness.
10. Governments are also required to invest in surveillance, research and evaluation.
a Monitoring and surveillance are essential tools in the implementation of national
strategies.
b Research, especially in community demonstration projects and in evaluating
policies and interventions, should be promoted.
11. National institutions for public health, nutrition and physical activity, under the
Ministry of Health, are called upon to implement programmes.
12. Governments are asked to ensure that adequate funding, from various sources, in
addition to the national budget, is provided to assist in the implementation of the
strategy.
International partners
The role of international partners is of paramount importance in achieving the goals of
the Global Strategy. Organisations of the United Nations system, intergovernmental
bodies, non-governmental organisations, professional associations, research institutions
and the private sector can all contribute.
International standards
Suggestions are made for the introduction of international codes and standards in:
labelling of foodstuffs on the content and benefits of products; measures to minimise the
16
impact of marketing on unhealthy dietary patterns, more detailed information on healthy
eating patterns, including steps to increase the consumption of fruit and vegetables; and
the development of processing standards on the nutritional quality and safety of products.
Civil society and non-governmental organisations
Civil society and non-governmental organisations can play a role in influencing
individual behaviour and can help ensure that consumers ask government to provide
support for healthy lifestyles, and also ask the food industry to provide healthy products.
Private sector
The private sector can play a significant role in promoting healthy diet and physical
activity. The food industry, retailers, catering companies, sports-goods manufacturers,
advertising and recreation businesses, insurance and banking groups, pharmaceutical
companies and the media have been identified as having important roles as responsible
employers and as advocates for healthy lifestyles.
Follow up and future developments
WHO will take responsibility for reporting on progress made in implementing both the
Global Strategy and national strategies. Aspects that will be reported on include:
• patterns and trends of dietary habits and physical activity and related risk factors for
major non-communicable diseases
• evaluation of the effectiveness of policies and programmes to improve diet and
physical activity
• constraints or barriers encountered in implementation of the strategy and the
measures taken to overcome them
• legislative, executive, administrative, financial or other measures taken within the
context of the strategy
WHO will also work at global and regional levels to set up a monitoring system and to
design indicators for dietary habits and patterns of physical activity.
17
USA
The Surgeon General’s call to action to prevent and decrease
overweight and obesity 2001
The Surgeon General together with the Office of Disease Prevention and Health
Promotion and other agencies in the Department of Health and Human Services
developed The Surgeon General’s call to action to prevent and decrease overweight and
obesity 200116 in response to the escalating problem in the USA. Evaluation of progress
from 1990 to 2000 showed that the trends for overweight and obesity had steadily moved
in the wrong direction. Both overweight and obesity are therefore key health objectives
for the first decade of the 21st century.
The process of developing this Call to Action began in December 2000, when the
Surgeon General hosted a public Listening Session on Overweight and Obesity.
Discussion focussed on interventions and activities in five key settings: families and
communities; schools; health care; media and communications; and worksites. Key
actions were identified for each of the settings. The key actions were organised by
settings into a framework called CARE: Communication; Action; Research; and
Evaluation.
The CARE framework
The CARE framework has been designed to be implemented at many levels. A
multidimensional approach is essential in tackling the problem of overweight and obesity.
While individual behavioural change is necessary, efforts must focus on group
influences, institutional and community influences and public policy. It is recognised that
individual behaviour change can only occur in a supportive environment with accessible
and affordable healthy food choices and opportunities for regular physical activity.
The components of the framework are:
18
Communication: the provision of information and tools for decision makers at
governmental, organisational, community, family and individual levels who will create
change toward the prevention and decrease in overweight and obesity.
Action: interventions and activities that assist decision makers to help prevent and reduce
the problem of overweight and obesity.
Research and Evaluation: investigations to better understand the causes of overweight
and obesity, to assess the effectiveness of interventions, and to develop new
communication and action strategies.
For all of the five settings identified, the CARE framework is applied, and a list of
actions is identified under each section of the framework.
Setting 1: Families and communities
Families and communities are fundamental to tackling the problems of overweight and
obesity. Emphasis should be placed on family and community opportunities for
communication, education and peer support to ensure healthy eating and physical
activity. Communication strategies include raising awareness and education of
individuals, families and communities on the effects of overweight on health, on healthy
eating patterns and the benefits physical activity. Policy makers should be aware of the
need to develop social and environmental policy to help communities and families be
more physically active and consume a healthier diet.
Setting 2: Schools
Schools have been identified as a key setting for public health strategies to prevent and
decrease overweight and obesity. Schools provide opportunities for healthy eating and
participation in physical activity, as well as reinforcing messages about the benefits of a
healthy diet and physical activity. However, public health approaches in schools should
extend beyond health and physical education, to include school policy, the school social
and physical environment and links between schools and the wider community.
19
Setting 3: Health Care
The health care setting is also seen as key provider for reducing the prevalence of
overweight and obesity, as the majority of the population has a contact with a health care
professional in any one year period. Health care providers are seen as advocates for
effective public policy and may reinforce interventions in the community and media.
Most emphasis in this setting is on the education and training of health care staff.
Setting 4: Media and Communications
The media is an important tool for public education and for social marketing, by the
dissemination of health messages and by displaying healthy behaviours. The media can
also provide a powerful forum for community members who are addressing the social
and environmental influences on dietary behaviour and physical activity patterns.
Setting 5: Worksites
Worksites provide many opportunities to reinforce the adoption and maintenance of
healthy lifestyle behaviours. However, public health approaches in worksites should
extend beyond health education and awareness to include worksite policies, the physical
and social environments of the worksites, and their links with families and communities.
From all of the issues identified across the five settings, 15 activities were selected as
national priorities for immediate action. Individuals, families, communities, schools,
worksites, health care, the media, industry, organisations and government departments
are charged with determining their role and with taking action to prevent and decrease
overweight and obesity.
The Surgeon General’s Priorities for action
The priorities for action are arranged in three sections: communication; action; and
research and evaluation.
20
Communication
The Nation must take an informed, sensitive approach to communicate with and educate
the American people about health issues related to overweight and obesity. Everyone
must work together to:
• Change the perception of overweight and obesity at all ages. The primary concern
should be one of health and not appearance.
• Educate all expectant parents about the many benefits of breastfeeding.
-breastfed infants may be less likely to become overweight as they grow older.
-mothers who breastfeed may return to pre-pregnancy weight more quickly.
• Educate health care providers and health profession students in the prevention and
treatment of overweight and obesity across the lifespan.
• Provide culturally appropriate education in schools and communities about healthy
eating habits and regular physical activity, based on the Dietary Guidelines for
Americans31, for people of all ages. Emphasize the consumer’s role in making wise
food and physical activity choices.
Action
The Nation must take action to assist Americans in balancing healthful eating with
regular physical activity. Individuals and groups across all settings must work together to:
• Ensure daily, quality physical education in all school grades. Such education can
develop the knowledge, attitudes, skills, behaviours, and confidence needed to be
physically active for life.
• Reduce time spent watching television and in other similar sedentary behaviours.
• Build physical activity into regular routines and playtime for children and their
families. Ensure that adults get at least 30 minutes of moderate physical activity on
most days of the week. Children should aim for at least 60 minutes.
• Create more opportunities for physical activity at worksites. Encourage all
employers to make facilities and opportunities available for physical activity for all
employees.
• Make community facilities available and accessible for physical activity for all
people, including the elderly.
• Promote healthier food choices, including at least five servings of fruits and
vegetables each day, and reasonable portion sizes at home, in schools, at worksites,
and in communities.
• Ensure that schools provide healthful foods and beverages on school campuses and
at school events by:
21
-enforcing existing US Department of Agriculture regulations that prohibit
serving foods of minimal nutritional value during mealtimes in school food
service areas, including in vending machines.
-adopting policies specifying that all foods and beverages available at school
contribute toward eating patterns that are consistent with the Dietary Guidelines
for Americans.
-providing more food options that are low in fat, calories, and added sugars such
as fruits, vegetables, whole grains, and low-fat or nonfat dairy foods.
-reducing access to foods high in fat, calories, and added sugars and to excessive
portion sizes.
• Create mechanisms for appropriate reimbursement for the prevention and treatment
of overweight and obesity.
Research and Evaluation
The Nation must invest in research that improves our understanding of the causes,
prevention, and treatment of overweight and obesity. A concerted effort should be made
to:
• Increase research on behavioural and environmental causes of overweight and
obesity.
• Increase research and evaluation on prevention and treatment interventions for
overweight and obesity, and develop and disseminate best practice guidelines.
• Increase research on disparities in the prevalence of overweight and obesity among
racial and ethnic, gender, socioeconomic, and age groups, and use this research to
identify effective and culturally appropriate interventions.
22
Australia
Acting on Australia’s weight
Acting on Australia’s weight. A strategic plan for the prevention of overweight and
obesity22 is a ten year plan published by the National Health and Medical Research
Council Working Party on the prevention of overweight and obesity. The working party
was set up following a 1995 report by the Australasian Society for the Study of Obesity
(ASSO) entitled Healthy Weight Australia32, which stressed the need to increase the
proportion of Australians who maintain a healthy weight throughout life.
Acting on Australia’s weight22, reviews overweight and obesity in Australia and reviews
the effectiveness of initiatives aimed at the prevention of obesity. It then makes
recommendations on appropriate structural and educational strategies and advises on the
implementation of these strategies. The model that was adopted for the Plan proposes
that the three main influences on body fat equilibrium are biological, environmental and
behavioural. The importance of biological or inherited factors is acknowledged but the
document states that most overweight and obesity develops from lifestyle and
environmental factors. Opportunities for intervention therefore lie in changing
environmental factors and by influencing lifestyles.
The Plan suggests that the macro-environment of food supply and opportunities for
physical activity determines the prevalence of obesity in a population and the microenvironment of knowledge, beliefs, social attitudes and behaviour determine the presence
of obesity in the individual. The model therefore proposes a supportive macroenvironment as the main public health strategy, but also highlights the need for programs
that aim to influence behaviour and the micro-environment of target groups.
The strategic plan focuses on changes to the macro-environment that will make it easier
for people to undertake physical activity and make healthier food choices. However,
improvements to the macro-environment need to be accompanied by complementary
activities focusing on shaping the micro-environment of knowledge, beliefs, social
23
attitudes and behaviour to influence the presence of overweight and obesity in
individuals.
All of the strategies for implementation of the Plan are organised in nine categories.
These categories give details on:
• the time frame for implementation
• the lead agency or agencies for implementation
• collaborating agencies
• the estimated cost
• the potential impact, as the estimated potential to prevent overweight and obesity:
high – great potential to prevent overweight and obesity; medium; or low – low
potential to prevent overweight and obesity
• achievability, which indicates the potential ease of implementation: high – minimal
difficulty to implement; medium; or low – difficult to implement
• sustainability, which indicates the longevity of the strategy implementation: high –
relatively easy to implement; medium; low – will require a large amount of effort or
funds to sustain
• performance indicators which have been developed to indicate how progress towards
meeting individual strategies may be measured
• target groups – priority groups for this plan are Aboriginal and Torres Strait Islander
people, men aged 25-40 years, post menopausal women, and children and
adolescents
Strategies for implementation
The Plan has eight strategies for implementation: infrastructure and education;
workplaces; schools; community environments; healthcare; research; monitoring and
evaluation ; and coordination of effort. All of the strategies have several strands and for
every strategy a rationale is given. These strategies focus on the macro-environment to
make it easier for people to undertake physical activity and make healthier food choices.
24
The Plan is accompanied by a detailed review of overweight and obesity in Australia.
The review looks at the causes and prevalence of overweight and obesity, the economic
issues in the prevention and treatment of overweight and obesity, the role of physical
activity and inactivity, the effects of cardiovascular risk factor interventions on weight
and weight loss beliefs and practices in Australia. All of these chapters contain a section
on the public health implications, suggesting ways in which overweight and obesity can
be addressed.
Healthy Weight 2008 – Australia’s Future
At a meeting of Australian Health Ministers in Sydney on 28 November 2003, the
Government’s Task Force on Obesity presented the National Action Agenda for Children
and Young People and Their Families – Healthy Weight 2008: Australia’s Future21,
which contains recommendations to the Government for tackling childhood obesity.
Following this, Australian Health Ministers asked the National Obesity Taskforce to lead
and coordinate the implementation of Healthy Weight 2008 and to provide advice on
strategies to address obesity in adults and older Australians.
Healthy Weight 200821 is a four year plan. The broad focus is on supportive
environments that will encourage healthier lifestyles. It places emphasis on the
prevention of overweight and obesity rather than on treatment, partly because overweight
and obesity are difficult conditions to treat. The document acknowledges that there is no
single cause of obesity. For some, it is due to a genetic disposition, but the decline in
physical activity in children and the increase in unhealthy eating over the past twenty
years has been the major problem. The changes in behaviour have been driven by social,
cultural, physical and economic conditions. For that reason an approach is needed which
creates living environments that support healthy eating and physical activity and
encourages families to adopt healthier lifestyles.
Healthy Weight 2008 presents a national strategic framework for action to address
overweight and obesity in children and young people (0-18 years). It is seen as the first
25
phase of a long term approach to tackling overweight and obesity. Addressing the needs
of adults and older people will be developed after the life of this plan.
A key requirement is to support young people and their families in the home and the
wider community. A cross-sectoral, multi-settings approach is needed to reach the young
people and to address the underlying environmental and lifestyle causes of overweight.
Healthy Weight 2008 gives a framework for action in various settings and also describes
national strategies to tackle overweight and obesity. For every setting desired outcomes
are listed. These are accompanied by actions which will commence in 2004.
Settings are:
• Child care (including child care centres, family day care and outside school hours
care)
• Schools – Primary and Secondary (including public and private schools, and use of
school facilities)
• Primary Care Services, (including general medical practice, community health
centres, and other community-based and private sector services)
• Family and Community Care Services (including social work, child protection,
juvenile justice, and outreach services to vulnerable and disadvantaged groups)
• Maternal and Infant Health (including hospitals, infant and child health clinics, and
community health services)
• Neighbourhoods and Community Organisations (including state/territory
government, local government, community groups, recreation and sporting bodies,
and private organisations)
• Workplaces (including government, private and non-government work settings both
formal and informal)
• Food supply (including, producers, manufacturers and retailers eg supermarkets,
markets, stores, and food service outlets eg restaurants, cafes and take-aways).
• Media and marketing (including television, cinema, videos, electronic games,
internet and commercial advertising, marketing and promotions)
26
National strategies
• Support for families and community-wide education (including public policy and
planned mass media communication and education)
• Whole community demonstration areas (integrated actions from all the settings
implemented in discrete population areas as potential models for wider long term
implementation in other communities and to enhance community ownership and
capacity for sustained action)
• Evidence and performance monitoring (including measurement, analysis, evaluation,
policy and action research to inform planning and management, and enhance
accountability)
• Coordination and capacity building (including strategic management, operational
coordination, infrastructure support, community and stakeholder strengthening and
professional development)
The Strategy lists forty outcomes that are sought across these areas and suggests actions
to be taken under the leadership of the health sector. Examples of the outcomes sought
include: ensuring that settings such as schools and care centres promote healthy eating
and physical activity; improving the knowledge of carers and teachers and the public;
improving facilities and opportunities for physical activity; providing improved access
and availability of the facilities in the community, schools and workplaces; referral of
individuals affected by overweight to specialist services; improved access to healthy
foods; and the protection of young people against the promotion of unhealthy foods. For
every setting, actions to be taken are also listed. Many of these proposed actions involve
establishing collaborative working across many areas and the development and/or
dissemination of guidelines on healthy eating and opportunities to increase physical
activity.
27
New Zealand
Healthy Eating – Healthy Action
Healthy Eating – Healthy Action23 33 is New Zealand’s strategy for reducing mortality and
morbidity from diseases that can be prevented by healthy eating and by being physically
active (particularly cardiovascular disease, diabetes, cancer and obesity). The Strategy
addresses nutrition, physical activity and obesity. The New Zealand Health Strategy17
identified thirteen priority areas for population health. Nutrition, overweight and obesity,
and physical activity are three of these health priorities. However, because these issues
are inherently inter-related, Healthy Eating – Healthy Action provides an integrated
approach by addressing the three areas simultaneously. The Strategy document23 has an
accompanying background paper33 which provides justification for the framework.
Healthy Eating – Healthy Action is a five year plan. It is directed at a range of
stakeholders. It identifies the key policy priorities for the Ministry of Health and aims to
guide District Health Boards in the funding of programmes and services. Research
priorities are identified and the need for intersectoral working is identified, particularly
between central and local government, non government organisations and industry.
Fundamental to Healthy Eating – Healthy Action is the recognition that environmental
modification is necessary, as well as behavioural change in order to improve nutrition,
increase physical activity and reduce obesity. Reducing inequalities in health is central to
the aims of the Strategy.
The Strategy is based on five key priorities for action
• low socio-economic groups
• children, young people and their families
• environments
• communication
• workforce
28
These priorities were selected, after consultation, as the most likely to result in progress
towards the overall goals of the strategy (to improve nutrition, increase physical activity,
and reduce obesity).
The framework for Healthy Eating – Healthy Action is based on the principles of the
Ottawa Charter. For every priority area, the rationale is given for its selection as a
priority. Each priority area has six objectives based on the components of the Ottawa
Charter:
1. build healthy public policy
2. create supportive environments
3. strengthen community action
4. develop personal skills
5. reorient services and programmes
6. monitor, research and evaluate.
Key actions to be taken are then listed for each objective. To illustrate this two examples
are given below:
Priority 1 is lower socioeconomic groups.
The document states that significant health gains can be achieved through improving
nutrition, increasing physical activity and maintaining a healthy body weight among
socioeconomic groups, who may have difficulty accessing good nutrition and being
physically active.
Objective 1.2 therefore is to create supportive environments for lower socio-economic
groups. Proposed key actions are:
• Work with the food industry, local government and non-government organisations to
encourage the increased availability of affordable, healthy food choices and physical
activity opportunities
• Create safe environments for physical activity, such as footpaths, access to public
transport, lighting, parks etc
29
• Create a range of environments that support healthy eating, which are accessible and
appropriate for lower socio-economic groups
Priority 3 is environments.
The document states that environments need to be developed and modified to support
good nutrition, physical activity and healthy weight across all key sectors and settings.
Objective 3.5 is to reorient services and programmes to modify environments. Proposed
key actions are:
• Encourage and support services and programmes with demonstrated effectiveness to
integrate nutrition, physical activity and healthy weight initiatives into each
programme (across, for example, transport, local government, education and health)
• Support the development of appropriate programmes and services for the treatment
of overweight, and obesity, including partnership with treatment and prevention
services.
The actions identified in the document are high level actions directed at the whole
population and/or specific groups. It does not give details on the implementation of the
recommended actions, but states that more specific actions will be developed as part of
the implementation plan.
New Zealand’s Toolkits
In addition to Healthy Eating – Healthy Action, New Zealand provides toolkits on
nutrition34, obesity20 and physical activity27. These toolkits are designed to give guidance
to District Health Boards in addressing the health priorities identified in the New Zealand
Health Strategy17. Both the obesity and physical activity toolkits are based on the
framework of the Ottawa Charter. Within the broad framework a setting-based approach
is used.
30
Obesity toolkit
Until recently, obesity prevention and obesity management were perceived as two distinct
processes. Overweight or obese patients were managed by clinicians and the aim of
treatment was weight loss. Preventive measures were undertaken by health promotion or
public health personnel. It is now realised that obesity management must cover longterm strategies ranging from prevention through weight maintenance, the management of
obesity co-morbidity and weight loss. These need to be coordinated in a variety of
settings.
The toolkit on obesity reports that the evidence for the effectiveness of many of the
suggested interventions is inconclusive due to a lack of well-evaluated interventions as
well as evaluation difficulties. However, it proposes a comprehensive approach which
addresses:
• Provision of supportive environments
• Health promotion of healthy eating and increasing physical activity
• Effective, sympathetic and accessible services for obese people
• Trained staff skilled in obesity prevention and weight management
• Credible publicity about healthy food intake and practical physical activity
• In cooperation with the food industry, reduction in the availability of high fat/high
sugar foods
• Development of awareness of the childhood risk of obesity and development of
strategies to manage and support families with obese children
• Regional data collection, information dissemination and research
• A framework for community action
• A well structured programme for monitoring and evaluation
The toolkit goes on to describe what District health Boards can do at a public health level
(settings) and in primary care. The suggested settings for delivery of interventions are:
• The media (influence purchasing and knowledge)
• Food consumption environments (schools, workplaces, homes)
• Food service industry (restaurants, takeaways)
31
• Food industry (influences consumption and marketing)
• Communities (influence cultural food consumption patterns)
Physical activity toolkit
Physical activity strategies from around the world were reviewed and several
common elements were identified and seen as essential for implementing a
physical activity strategy
• getting political endorsement and commitment from government at a national level
• recognising that promotion of physical activity is the responsibility of a wide range
of government and non-government agencies
• providing a framework for different sectors to collaborate
• recognising that moderate-intensity physical activity is the key public health
message, but that it must be backed up by strategies that make it easy for people to
become active
• recognising the need to influence the whole population but also targeting those
groups most at risk from being inactive
• continuing evaluation of the effectiveness of campaigns and programmes to learn
what works and what does not
• identifying factors that encourage long-term compliance or maintenance of physical
activity.
The toolkit gives a list of potential settings based interventions that district Health Boards
could work collaboratively to support and implement. Proposed settings and potential
actions include: schools; workplaces; communities/neighbourhoods; homes; local health
care and health promotion; health system; media; health insurance; fitness/leisure
industry; transport system and urban/rural development; and government and
regional/national organisations
32
Current policy on obesity, nutrition and physical activity
Strategies to address obesity may be spread across several public health policy documents
(Table 1, page 72). These inevitably include healthy eating and strategies to increase
physical activity. The majority of documents were identified from Ministry of Health
websites. A few documents from other departments were identified, eg two documents
from England, Game Plan: a strategy for delivering Government’s sport and physical
activity objectives35 from the Department of Media and Sport and Learning through PE
and Sport36, from the Department for Education and Skills. The websites of these
departments and other potentially relevant sites such as Departments of Education,
Transport or Social Welfare were not systematically searched.
We were unable to find policy documents from Finland. This is unfortunate as Finland
boasts major successes in healthy eating, including a trebling of vegetable consumption
in 20 years19 37. Finland also has a reputation for being a physically active nation2. A
recent review, Nutrition in Finland38, from the National Public Health Institute, gives
details of nutritional guidelines and recommendations dating from the late 1960s.
Similarly, few policy documents were found for Canada. However, Canada is currently
developing an Integrated Pan-Canadian Healthy Living Strategy39. This collaboration
between Federal/Provincial/Territorial Ministers of Health will initially focus on physical
activity, healthy eating and their relationship to healthy weight.
Obesity policies
Only four countries have specific strategies on overweight and obesity (Australia,
Denmark, New Zealand and the USA).
Nutrition policies
The majority of countries have a nutrition policy in place, and these may also address
obesity, particularly in making recommendations for fat consumption. Some countries
have had nutrition policies for many years. For example, in 1978, Finland officially
adopted general nutrition guidelines and created a nutritional policy40. By 1981 dietary
guidelines had been disseminated to the whole population. The widespread general
33
interest in nutrition is attributed to the North Karelia Project. However, since 1948 all
Finnish school children have been provided with free lunches and since the 1970s
recommendations have been issued for workplace lunches38. Australia’s public health
nutrition strategy which was adopted in 1979, has undergone several reviews. Despite
this history nutrition policies are still evolving. For example England has a Food and
Health Action Plan which was put out for consultation in July 200341.
Physical activity policies
In recent years all countries have introduced strategies to increase levels of physical
activity. Many of these strategies are also under development, such that initial
documents are superseded within a few years. In some countries, such as Scotland25,
obesity is directly mentioned within the policy document. However some policies have
other main aims; for example England’s Game Plan35 policy is concerned about
achieving international sporting success as well as increasing activity levels in the general
population.
34
Targets
The use of targets for obesity, nutrition and physical activity varies substantially between
the countries studied. While the majority of countries have targets for nutrition, few have
targets for obesity or physical activity.
Targets for obesity
Only four countries have set specific targets for obesity. The USA42 sets targets for
adults who are at a healthy weight as well as to reduce the proportion who are obese.
Japan43 sets separate targets for children and men and women from age groups that have
been shown to be at risk. Both countries have ambitious targets given the rate at which
obesity is currently increasing. Northern Ireland’s target is to halt the increase in the
prevalence of obesity in adults44. England’s only target, set in July 2004, is to halt the
year on year rise in obesity among children under 11 years by 201045.

35
Targets for nutrition
We identified nutritional targets for five countries; Japan; New Zealand; Northern
Ireland; Scotland; and the USA. Most common are targets for foodstuffs and the
proportion of calories from fats. The other targets cover dietary intake of grain, bread
and cereals, fruit and vegetables and sugar.

Japan is unusual in setting several targets for dietary knowledge and behaviour. These
are attractive because they identify some of the changes which will be required in order
to meet the nutritional targets.

36

The USA takes a different approach and specifies targets for nutrition and education at
specific settings: schools; worksites; and primary care. These targets will help monitor
specific mechanisms which could lead to changes in dietary behaviour.

Lastly, Japan identifies the environmental changes to achieve changes in diet. These
targets are new therefore no reference values were available at the time of publication.
Data from the Nutrition Survey in 2000 will provide baseline data, and targets for 2010
will be set.
37

Targets for physical activity
More of the countries included in the review have targets for physical activity. The most
common target is that a greater proportion of the population should undertake the
recommended levels of physical activity. This usually includes thirty minutes of
moderate activity on most days of the week for adults and an hour on most days for
children. England’s target is that 70% of the adult population achieves 30 minutes of
moderate activity on five days of the week by 202035. New Zealand aims for 75% of
adults to be moderately active for at least 30 minutes on most, if not all days of the week,
by 201027. Scotland’s target is that 50% of adults over 16 years will be physically active
for 30 minutes on most days and 80% of children should accumulate an hour of physical
activity on most days by 202225.
Japan and the USA have the most innovative targets for physical activity. Japan’s targets
are given for adults and older people are given separately. The targets for adults are to
increase awareness about the importance of physical activity; to increase walking and
also to encourage more vigorous exercise. Japan is the only country with physical
activity targets for older people. The aim for older people is to increase the number of
elderly who take a positive attitude towards going outside and to increase social activity
as well as increasing walking.
38

The USA’s targets are divided into four sections: physical activity in adults; muscular
strength/endurance and flexibility; physical activity in children and adolescents; and
access to physical activity. The USA, like Japan, has targets to increase both moderate
physical activity and vigorous activity. Targets for both moderate physical activity and
vigorous activity have been set for adults and adolescents. The USA also wants to
increase physical activity within schools, both during and outside school hours.
39
Importantly, they also set a target to ensure that at least 50% of time designated to
physical activity in class is spent being physically active. The USA is alone in setting a
target to reduce the time spent by adolescents watching television. The targets for
increasing access to physical activity include making school facilities available outside
school hours, increasing physical activity and fitness programs in the workplace and by
increasing the proportion of trips made by cycling and walking.

40

41
Policy interventions to reduce obesity
This section provides a compilation of the types of interventions proposed by the
countries to tackle obesity. Because policies on nutrition and on physical activity
propose interventions which will contribute to reducing obesity these have also been
included. Thus all interventions or actions which will lead to a reduction in consumption
of high fat or high sugar foods, or to an increase in the consumption of fruit, vegetables
or grains, have been included. Similarly all interventions from physical activity policies
which will lead to increased activity levels among groups in the general population are
described. Interventions to increase sporting success are excluded.
Several countries with obesity strategies emphasise the need for coordination between the
obesity, nutrition and physical activity strategies. New Zealand argues that the topics are
inherently inter-related and has therefore produced an integrated strategy for improving
health33. Thus its toolkit on obesity combines nutritional and physical activity
interventions within specific settings such as schools, workplaces, and health care20.
Denmark points out that nutrition and exercise are closely linked in both health care
professionals’ and the general public’s understanding of healthy lifestyles18. Norway,
although it does not address obesity directly, includes physical activity and nutrition in a
section on lifestyle choices28. Thus its package of proposed actions combines
interventions in both areas. Australia also adopts this combined approach and its
guidelines on nutrition and physical activity are grouped together to ensure they provide
the necessary complementary approach to tackling obesity22. The United States does not
explicitly link its policies on nutrition and physical activity, but it does identify instances
of overlap and shared interest42.
Organisation of strategies
Policy documents vary substantially in the descriptions of the proposed strategies. Many
of the proposed actions describe general areas where interventions may be put into place,
but the details of the interventions and mechanisms for implementation and evaluation
are not given. Strategies within policy can be categorised in many ways. We have
42
selected ten categories: fiscal; legislative; policy development; transport; media; food and
leisure industries; nutrition labelling; social and physical environment; educational
strategies; and settings for intervention.
Fiscal
No fiscal measures to address obesity were identified in policy documents. However
some governments, such as Northern Ireland47, recognise that cost is an important
motivator for healthier food choices.
Legislative
All countries have legislation on food safety and hygiene, food additives and
contaminants as well as packaging and labelling. No legislative measures to tackle
obesity are described in policy. However, New Zealand promises to investigate
regulatory and policy options to improve nutrition and increase physical activity. It also
calls for appropriate input into any legislation and regulations that impact on food and
nutrition, physical activity and healthy weight, both nationally and internationally33.
Policy development
Many policies propose actions in the area of Policy Development, reflecting
governments’ commitment to developing effective strategies. Nevertheless, some of the
proposed actions suggest that obesity policy is still under development. The US Surgeon
General’s Call to Action to Prevent and Decrease Overweight and Obesity16 wants to
raise policy makers’ awareness of the need to develop social and environmental policy
that would help communities and families be more physically active and consume a
healthier diet. New Zealand states that key leaders should be encouraged and educated to
understand the implications of environmental change on influencing obesity and health in
general33. There is also a call to develop policy at all levels (national, regional and local)
that will support healthy eating and physical activity by all people. New Zealand and the
USA seek the development of policies that will help to increase breast feeding16 33.
43
Wales has had a strategy to promote breast feeding since 200148. The USA wants
demonstration grants to address the lack of access to healthy and affordable foods in
inner cities and the lack of public access to safe and supervised physical activity. Work
needs to be done at policy level to ensure the inclusion of healthy options in restaurants,
worksites, cafeterias and schools.
Policy developments which increase physical activity are also proposed. The USA states
that public policy needs to be developed to ensure the provision of safe and accessible
sidewalks, walking and bicycle paths, and stairs16. New Zealand’s policy advocates that
the impacts on nutrition and physical activity should be considered in the development
and re-development of towns, suburbs and communities so that infrastructure becomes
more supportive of good nutrition and physical activity33. It also suggests that action
should be taken in the planning of buildings; for example buildings could be designed to
encourage stair use instead of lifts. Scotland’s physical activity strategy requests that the
Scottish Executive, through the proposed strategic planning framework, takes the lead in
developing policies and identifying resources to make sure that environments help people
to be active in everyday life25.
Intersectoral working
All countries recognise that intersectoral working is essential in tackling obesity,
improving nutrition and increasing physical activity and have established approaches to
encourage cross-sector collaboration. For example Australia22 identifies the lead
agencies and the collaborating agencies for all of the intervention areas in its obesity
policy. Wales also identifies the key stakeholders for each of the task force
recommendations in its Healthy and Active Lifestyles policy49. Scotland in its physical
activity policy25, identifies a wide range of potential collaborators and proposes that a
national coordination group be established to ensure the provision of leadership and
resources. Its new nutrition policy proposes the creation of a Food and Health Council
which will provide leadership and integrate the cross-cutting elements of the food and
health policy50.
44
New Zealand highlights the need to work together in order to increase access to
affordable exercise and recreation facilities33. Australia advocates that government
departments should work with local government to create local environments that can
increase physical activity, particularly incidental activity26. A recent initiative, “get a life,
get active”, is an example of cooperation between countries. The initiative was launched
jointly by the Ministers of Health from Ireland and Northern Ireland. Thus most policies
make a call to improve and initiate communication and collaboration at all levels,
including government, education, health care, local councils, and industry. Although
Departments of Health may be identified as the lead agencies in addressing overweight
and obesity, many other departments such as transport, education, planning, agriculture
and food are recognised as having crucial roles.
Transport
Several countries including New Zealand, Australia, Scotland, Northern Ireland and
Wales call for the provision of improved cycle lanes and pedestrian walkways,
particularly to encourage safe active transport to schools, but also to ensure safe access to
physical activity. Safe access includes features such as good lighting on roads and in
parks and traffic calming interventions. Australia specifically mentions the value of
working collaboratively with organisations to develop initiatives such a National Walking
Network and a National Bicycle Strategy26. Several countries including Northern
Ireland44 and Wales49 already have cycling strategies in place. These interventions are
mainly aimed at the local level. It is possible that national level strategies are given in
transport policies, but their review was beyond the scope of this study. For example, the
Northern Ireland Public Health Strategy reports that the regional transportation strategy
will contain a range of initiatives that will promote walking and cycling and provide an
increase in the walking and cycling infrastructure44.
Media
Considerable attention is given in several policies to the role of the media. Many of the
proposals are to raise awareness about the problems of overweight and obesity and to
45
provide education for media professionals on policy areas related to diet and physical
activity. The USA emphasises the need for media professionals to publicise that the
primary concern of overweight and obesity is one of health rather than appearance16. It
also suggests training nutrition and exercise scientists and specialists in media advocacy
skills that will empower them to disseminate their knowledge to a broad audience.
Further, the media is encouraged to employ actors of diverse sizes. Celebrities should be
encouraged to act as role models in promoting healthy living activities. Governments are
encouraged to develop campaigns with media groups that provide consistent health
messages about good nutrition and physical activity, including messages suitable for
youth television. The USA encourages community-based advertising campaigns to
balance messages that may encourage consumption of excess calories and inactivity
generated by fast food industries and by industries that promote sedentary behaviours16.
Australia calls for the monitoring of the effectiveness of the Children’s Television
Standards and regulatory framework for food and drinks advertising to children in
meeting health objectives21. As well as the national media, actions can be taken with
regional or local media groups. For example Wales proposes to secure the cooperation of
local media to ensure the correct messages are relayed to the public51.
Food and leisure industry
The food and leisure industry have an important role in promoting healthy eating and
physical activity. While most countries make recommendations on enlisting the support
of the food industry, few proposals appear in policy for actions to be taken by the fitness
and leisure industry. New Zealand calls for the fitness and leisure industries to promote
cycling and walking for sightseeing27. The food and leisure industries are encouraged to
provide truthful and reasonable consumer goals for weight loss programs and weight
management products42.
New Zealand encourages collaboration with food manufacturers, food technologists and
retailers to increase the production of low fat, low sugar foods20. Australia notes that the
food industry has already increased the number of low-fat and reduced-fat foods available
46
in the marketplace22. Food manufacturers and retailers are asked to provide more
nutrition information on foodstuffs in supermarkets as well as on meals eaten and
prepared away from home. Wales is proposing to work with the industry on food
advertising and promotion to put into place national schemes to assist improvements in
healthy eating51. It also proposes to discuss opportunities for same price healthier
product lines. Scotland is particularly concerned about marketing to children and hopes
to ensure that food promotion acts to promote a healthier lifestyle50. It also intends to
develop a stronger interface with the food industry with the aim of influencing food
composition.
The USA is concerned about the increase in food portion sizes in recent years and
highlights the need to encourage the food industry to provide reasonable food and
beverage portion sizes16. Australia also encourages the food service industry to limit
serving sizes and reduce the energy content of less healthy meals and snacks. Further, it
asks for the food service industry to support food manufacturers to develop less energy
dense foods. New Zealand suggests the introduction of courses on low fat cooking into
chef training programmes and is keen to train takeaway bar workers in best practice
methods to reduce fat uptake in foods20.
Nutritional labelling
Many countries recommend improvements to the labelling of the nutrition content of
foodstuffs. Scotland plans to develop stronger links with the industry so that it can
influence labelling50. Wales also plans to take action on food labelling to assist
individuals in choosing a healthy diet51. A major concern is that the information should
be presented in a form which is readily understood. For example the Australia Food
Authority has initiated action to create a more satisfactory labelling system that meets
consumer requirements and is achievable by the food industry22. Australia proposes to
take this further by developing a plan to educate both the public and health educators
about food labelling52. The Ministry of Food in Denmark plans to develop clear and
understandable labelling in an attempt to make it easier for customers to choose a healthy
47
diet and to prevent misrepresentation of the nutritional content of foodstuffs18. Japan has
a target to increase the proportion of people who read nutritional labels when eating out
and purchasing food43. This was chosen as a target because in a national survey,
respondents reported that reading nutrition labels was a means for achieving dietary
improvement43.
Educational strategies
Several countries recognise the need for coordinated strategies to ensure that educational
interventions reach all sectors of society. For example the 1994 Australian nutrition
policy53 proposes strategies to reach school children, health care professionals, adult
education authorities and the food processing industry. Scotland46 proposes a
multifaceted approach to influence consumers to move to healthier eating habits and
identifies many settings for action including community organisations, schools,
employers, the media and the voluntary sector. Northern Ireland highlights the
importance of accurate consistent and easily understood educational programmes47. It
notes that there was confusion about healthy eating guidelines and that some advice is
inconsistent, and proposes a review of nutrition education in schools, and for teachers and
health care professionals.
New Zealand cites scientific evidence which concludes that nutrition education works33.
It also reviews theories of health behaviour, including social cognition models and social
marketing, which provide the basis for the design of educational interventions.
Communication is seen as more than the giving of information. Communication
strategies can develop personal skills and reinforce the effects of supportive
environments. The United States policy also reviews scientific evidence on education42.
It points out that good parental knowledge encourages preschool children to make
healthful food choices. Incorporating nutrition into school curricula can help develop
behavioural skills for food selection and preparation. One concern about nutritional
education is that it might lead to an increase in eating disorders such as anorexia nervosa.
The USA42 and Australian22 policies have reviewed the research on this and conclude that
48
there is no evidence to support such a view. Nevertheless, Japan has set a target to
reduce the proportion of underweight young women because it has witnessed an increase
in the number of women with BMI less than 18.5 in the previous 20 years43. The Danish
National Board of Health, in 1998, launched a strategy to prevent and detect eating
disorders. The strategy was aimed at parents, teachers, sports instructors and health care
personnel18.
Settings
A range of settings have been proposed for the implementation of strategies to tackle
obesity. These include: population based strategies; community based strategies; the
home/family based strategies; the workplace; schools; and health care settings.
Population based strategies
Public awareness
Many population-based educational strategies are proposed in policy. The US Surgeon
General’s report highlights the need to raise awareness about the effects of overweight
and obesity on health and the need to recognise inappropriate weight change16. It also
stresses the importance of prevention of overweight through balancing food intake with
physical activity. Australia wants to raise people’s awareness and understanding of the
benefits of daily or regular participation in moderate-intensity physical activity26.
Further, people should be aware of the importance of social and environmental influences
on making appropriate diet and physical activity choices. New Zealand and the USA
point out that consumers should be aware of reasonable food and beverage portion sizes16
33. These strategies may be supported by multi-media campaigns. The Food Standards
Agency in the UK contributes by providing access to information and advice on a range
of food related issues, including the nutritional content of food54. Policies on obesity
stress the importance of implementing strategies that will not stigmatise people who are
overweight or obese, or foster an environment that is likely to lead to the development of
eating disorders33.
49
Guidelines
The majority of countries have nutritional guidelines for different population groups. For
example the publication of dietary goals for the United States in 1977 led to the issue of
dietary guidelines for Americans in 198131. Revised guidelines are published every five
years. Finland also issued national guidelines in 1981, and since then has issued catering
guidelines for schools, hospitals, military personnel and worksites as well as dietary
guidelines for children and athletes38. Denmark reported in 1999, that only 10% of the
population followed nutritional guidelines18. However, as part of its obesity strategy
Denmark proposed to establish guidelines for schools, other educational establishments,
health care professionals and social services. Australia highlights the need for specific
guidelines for different age groups and has produced separate guidelines for infants,
children and adults55. The development and dissemination of educational packages based
on these guidelines is encouraged. In the USA, to help individuals put nutritional
guidelines into action a Food Guide Pyramid, a graphical educational tool, was published
in 199242. Since then separate pyramids have been produced for children and for Spanish
speakers and resources have been produced for nutrition educators. Some countries also
have guidelines for physical activity. Where these are in place, policies recommend that
action should be taken to disseminate them effectively. Others recommend the
development and dissemination of new guidelines.
Inequalities in health
Healthy eating and access to physical activity are areas where socio-economic
inequalities are apparent. Reducing inequalities in health is the overarching aim of the
nutrition policy in Wales and opportunities to tackle them are identified throughout the
policy51. The recommendations include public education, skills training, supply of
foodstuffs, training of professionals and working with the food industry. The New
Zealand strategy Healthy Eating–Healthy Action33 also focuses on inequalities in health.
Government departments are asked to ensure that education and health promotion
programmes are appropriate and readily available for the most at-risk groups. Such
programmes should be appropriate for people for people in lower socioeconomic groups.
Australia recognises that economically disadvantaged people spend a higher proportion
50
of their income on food and is committed to increasing the affordability of food53. The
new nutrition policy52 therefore proposes a range of actions to ensure that the most
vulnerable people have access to adequate amounts of nutritious food. These include:
reviewing existing services to identify training needs and resources; disseminating
resources and models of effective initiatives for vulnerable people; and developing and
disseminating guidelines for agencies that supply meals to vulnerable groups. Australia’s
physical activity strategy insists that a component of the public education campaign
should focus on indigenous groups and other high risk groups26. Australia also
recognises that people with disabilities are at high risk of leading sedentary lives26. It
therefore proposes to implement an information system to enhance participation in
physical activity by people with disabilities. Northern Ireland acknowledges that low
income groups eat less fruit and more processed meats, chips and roast potatoes47. It also
identifies barriers to healthier eating including cost, lack of basic cooking equipment,
problems of access and a reluctance to try new foods. It calls for the elimination of food
poverty by targeting efforts and resources on the needs of those who are most
disadvantaged and by supporting community based programmes which improve access to
healthy eating choices44. Community based nutrition education initiatives and cooking
skills programmes for low-income families have also been introduced in Northern
Ireland.
Community based strategies
Several innovative community based interventions have been proposed in policy.
Communities are encouraged to use school physical education facilities outside school
hours, particularly in conjunction with physical activity clubs, in order to provide easily
accessible, local facilities16 25. The USA suggests the formation of community coalitions
to support healthier living. This includes the development of increased opportunities to
engage in leisure time physical activity and encouraging food outlets to increase
availability of low-calorie, nutritious food items16. Australia calls for the introduction of
“good practice” standards and interventions, including training for child care workers,
community care workers and teachers, and support for parents, grand parents and
carers21. Education of community leaders is encouraged so that they will support the
51
implementation of well-evaluated programmes that have a whole community and whole
family approach to improving nutrition and physical activity. The formation of
partnerships between the wider community and schools and other organisations to raise
awareness and provide resources and information is also encouraged. Denmark stresses
the importance of improving links between schools and community based activities so
that students are encouraged to continue physically active pursuits after leaving school18.
Scotland proposes that the social services promote physical activity with their client
groups, for example among older people and people with learning difficulties25.
Home/family
The USA makes several suggestions on ways that families can take action to reduce the
problems of overweight and obesity. It suggests that parents should be educated about
the need to serve as good role models by practicing healthy eating habits and engaging in
regular physical activity16. This could empower families to manage weight and health
through skill building in parenting, meal planning, and behavioural management.
Denmark and the USA recommend that families should be encouraged to spend less time
watching television and in similar sedentary activities16 18. Australia suggests that this
could be addressed by developing integrated programmes using multiple strategies with
young people, parents and teachers21. New Zealand suggests using interactive videos and
programmes to get children and adults to become active when watching television and
also suggests promoting physical activity around the home through activities such as
gardening, washing cars and cleaning windows27. Scotland identifies older people as a
priority group and states that older people living independently should have self-help
resources and support to ensure they can be physically active within their own homes25.
Scotland and Australia propose that people living in residential care should also be given
opportunities to be physically active25 26.
Workplaces
Workplaces provide opportunities for education and for implementing public health
initiatives that can influence large numbers of people. Wales51 encourages employers to
introduce policies that include healthy eating. Australia22 does this with the aim of
52
creating incentives for workers to achieve and maintain a healthy body weight. The US
Surgeon General’s report recommends that employers should be educated on the direct
and indirect costs of obesity. Thus they would be encouraged to take action to implement
initiatives to reduce the potential problems16. Other suggested actions include providing
protected time for lunch, and ensuring that healthy food options are available. The USA
supports the creation of work environments that promote and support breastfeeding16.
Many policies identify physical activity strategies for the workplace. Sweden intends to
ensure that the workplace provides a supportive environment for healthy physical activity
and exercise24. New Zealand’s physical activity toolkit identifies many opportunities to
increase physical activity during the working day, such as changing workflow patterns,
introducing flexible working hours, providing exercise and changing facilities, providing
incentives to join local fitness centres and encouraging the use of stairs instead of lifts27.
Scotland proposes that employers should be given incentives to promote physical
activity25. Australia intends to incorporate recommendations on regular moderate
physical activity in occupational health and safety policies22.
School based interventions
Schools provide many opportunities to influence overweight and obesity. The majority
of initiatives suggested in policy documents are not health promotion for the children, but
are more concerned with educating teachers and bringing about environmental changes to
foster healthier eating and increased physical activity.
Staff education and training
The Surgeon General’s report on preventing overweight and obesity makes many
recommendations for the training of teachers and staff16. It suggests that teachers, food
service staff, coaches, nurses, and other school staff should be informed about the
contribution of proper nutrition and physical activity to the maintenance of lifelong
healthy weight. Staff are also encouraged to develop sensitivity to the problems
encountered by the overweight child. Teachers, staff, students, and parents should be
advised on the importance of body size acceptance and the dangers of unhealthy weight
53
control practices. Teachers should be aware of their importance as role models for
children in adopting healthy eating practices and in being physically active. Denmark
plans to encourage schools, sports organisations and government departments to place
more emphasis on participation and enjoyment and less on competition18. Wales is
considering making school approaches to healthy eating part of the school inspection
framework51. It also plans to review the extent of training on diet and health within
teacher training courses, with a view to improving this if necessary.
School personnel influence children’s eating habits. Scotland’s nutrition policy
highlights the role of School Boards in promoting healthy eating46. Northern Ireland
proposes a review of nutrition training for teachers at undergraduate and postgraduate
level and suggests that School Nutrition Action Groups should be established47. The new
Australian nutrition strategy has as one of its priorities for action in schools, the need to
identify best practice programmes and materials across a range of settings, issues and age
groups, and to disseminate these programmes52.
To increase physical activity, the UK countries provide training for schools sports
coordinators to identify and integrate physical activity initiatives36 49. England has a
detailed strategy to increase physical education in schools36 49. The aim is to increase the
uptake of sporting opportunities by 5–16 year olds. The percentage of school children
who spend a minimum of two hours each week on high quality physical education and
school sport within and beyond the curriculum should increase from 25% in 2002 to 75%
in 2006 and to all children by 2007. This will be delivered by through a range of
programmes in addition to the role of the school sport coordinators. Sweden’s physical
activity strategy highlights the role of staff and proposes that all staff at pre-schools and
schools are made aware of the educational possibility of the outdoor environment, and
children’s need for physical activity for health, development and learning24.
Knowledge/guidelines
Schools should provide a range health education measures that help students to develop
the knowledge, attitudes, skills, and behaviours so that they will adopt healthy eating
54
habits and a physically active lifestyle. Australia, who already has nutritional guidelines
for school children, suggests the development and implementation of physical activity
guidelines for children and adolescents21.
Curriculum
The majority of countries propose that more physical activity should be incorporated into
the curriculum. For example, Wales and Scotland suggests that two hours of physical
education and sport should be achieved by all pupils every week25 49. The USA has set a
target to ensure that children spend at least 50% of the time designated for physical
education being physically active42. The Surgeon General’s Report advocates that all
children from kindergarten upwards should have daily physical education16. The
Australian strategy for the prevention of overweight and obesity also calls for daily
physical education in schools22. Most countries propose that pre-school children should
have daily sessions of supervised physical activity or active play times. Australia and
Wales suggest that opportunities for physical activity in tertiary and further education
campuses should be investigated26 49. Denmark calls for an improvement in school
physical education programmes for adolescent girls, a group that is typically resistant to
taking part in physical activity18. It also stresses the importance of improving links
between schools and community based groups so that students continue to take part in
physically active pursuits after leaving school20. In addition to incentives to increase
physical activity New Zealand suggests that cooking classes should be re-introduced in
schools, while Australia wants to strengthen nutrition education in the curriculum.
Northern Ireland also proposes a review of the home economics syllabus47. Scotland
intends to ensure a whole-school approach to food related education in schools and preschools, and began implementing a scheme called Hungry for Success in 200356.
School environment
Perhaps the greatest opportunities lie in changing the school environment. Australia
recommends that schools focus on the development of good eating habits rather than on
weight control22. It also suggests that schools should be encouraged to introduce school
policies and standards for school canteens, vending machines, fund raising, and
55
sponsorship. Meals offered to children should meet nutrition standards and should
include options that are low in fat and sugars, such as fruits, vegetables, and whole
grains22. Northern Ireland has also proposed the introduction of compulsory nutritional
standards for schools44. Finland is unusual in providing free school lunches at
comprehensive schools, upper secondary schools and vocational institutes38.
Vending machines and tuck shops in schools are often a source of unhealthy foods and
snacks. Several policies suggest that schools should be required to ensure that healthy
snacks and foods are provided in vending machines, school stores, and other venues
within the school’s control. The provision of free fruit in schools has been introduced in
all UK countries57 58. Wales has a system of school fruit tuck shops which run on a cost
recovery basis51 59. The USA suggests that students be prohibited access to vending
machines, school stores, and other venues that compete with healthy school meals16. It
also advocates that students should be given an adequate amount of time to eat school
meals. Wales is concerned that queuing for school meals is a disincentive for eating
healthy meals in schools. It therefore proposes to investigate both uptake and
effectiveness of a healthy take away meal as one initiative to tackle queuing51. It is also
planning to encourage the introduction of fresh water dispensers in all schools and to
increase the uptake of school milk and free school milk.
Several countries want to increase physical activity by the promotion of walking and
cycling to school25-27. New Zealand also encourages the promotion and provision of
extracurricular physical activity20. Wales suggests that primary schools should paint
playgrounds to encourage physical activity49.
Nutrition Programs in the USA
The USA has a range of federally assisted school based nutrition programmes, many of
which are administered through the Department of Agriculture. These were initiated in
1946 with the launch of the National School Lunch Act60 61. The National School Lunch
Program was the first and was established to tackle food insecurity among disadvantaged
children. In the fiscal year 2003, the Program covered over 28.4 million children in
56
100,000 institutions, at a cost $7.1 billion62. Although the main purpose is to prevent
hunger among disadvantaged children, the emphasis is on the provision of nutritionally
balanced free or low cost meals to children. The meals provided therefore must meet a
very detailed set of dietary guidelines63. In addition to the School Lunch Program, the
state provides: School Breakfast Programs; Afterschool Care Snacks Programs; Summer
Food Service Programs; Special Milk Programs; Food Stamp Programs; and a Special
Supplemental Nutrition Program for Women, Infants and Children61 64 65. More recently
the 2002 Farm Act provided $6 million from the US Department of Agriculture, to
establish a Fruit and Vegetable Pilot Program to provide free fruit and vegetables to 107
elementary and secondary schools66.
Health care sector
The health care setting also provides opportunities to tackle obesity. Current policy
suggests action in three areas:
Training for health professionals
Training for health professionals includes both prevention and management of obesity.
The US Surgeon General’s report recommends that health care providers and
administrators be made aware of the extent of the burden of overweight and obesity on
the health care system in terms of mortality, morbidity, and cost16. It goes on to state that
they should be aware of the barriers for patients including lack of access to effective
nutrition and physical activity interventions and that training should be available in
effective prevention and treatment techniques. New Zealand proposes to investigate the
potential of including physical activity and nutrition as areas of learning for health
professionals33. It also supports increased training in obesity for GPs, nurses and other
health professionals to be undertaken by nutritionists and dietitians20. Australia and the
USA want to promote the use of dietary guidelines on the prevention, treatment and
management of obesity to all health care professionals16 22. New Zealand recommends
that health professionals, including GPs, practice nurses and rest home staff should be
trained in prescribing physical activity, the so called green prescriptions33. England has
introduced guidance for health professionals on exercise referral. The National Quality
Assurance Framework (QAF) for GP exercise referral67 provides guidelines for exercise
57
referral systems, with the aim of improving standards among existing exercise referral
schemes, and helping the development of new ones. The Framework focuses primarily on the
most common model of exercise referral system, where the GP or practice nurse refers
patients to facilities such as leisure centres or gyms for supervised exercise programmes.
Wales proposes to review the QAF for exercise referral to decide on its appropriateness for
Wales68.
Actions in health care sector
There is a need to increase collaboration of those working in prevention and treatment
within health care settings. The USA encourages partnerships between health care
providers, schools, and other community organisations in prevention efforts targeted at
social and environmental causes of overweight and obesity. New Zealand suggests that
appropriate health professionals should be involved in the delivery of the Health and
Physical Education Curriculum in schools33. It also wants to integrate physical activity
advice and programmes into clinical services related to at-risk groups, particularly those
with cardiovascular disease, diabetes, and for those who are overweight or obese20.
Australia and the USA advocate increased promotion and dissemination of dietary
guidelines by health professionals16 21. Australia suggests that dietary and physical
activity guidelines should be available to primary care staff for use in prevention and
treatment of people who are overweight or obese. Good practice programmes for healthy
eating (including breastfeeding) should be included in antenatal care, post natal care and
at different stages of children’s development21. Finally, the USA wishes to establish a
dialogue to consider classifying obesity as a disease category for reimbursement coding16.
Management of obesity
The New Zealand Toolkit on obesity provides a list of actions that may be taken in
primary care to tackle obesity20. These include:
• Advice on weight control, diet and physical activity
• Advice on how to modify diet and lifestyle in order to build in physical activity
• Provision of specialised diets and diet plans
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• Referral to exercise programmes (green prescription)
• Ongoing support
• Promoting healthy eating and physical activity through general information
Australia suggests that the number of health sector led community based support
programmes for the management of overweight and obesity, that are culturally
appropriate should be increased. It also advocates that Lifestyle Scripts for young people
and parents should be developed and implemented21.
The interventions described above are not necessarily being implemented through current
policy. Many are suggestions that could be introduced. Unfortunately the mechanisms
through which these can be implemented are not described in the documents, nor are
plans for evaluation.
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Evaluation
Evaluation of trends in obesity
All countries report an increasing prevalence in overweight and obesity in recent years.
The USA has a sophisticated system for monitoring progress towards its obesity,
nutrition and physical activity targets. From the late 1970s to 1999 the prevalence of
obesity among adults in the USA increased from 15% to 27%16. Over the same period
among adolescents it increased from 5% to 14%. However, the Healthy People 2000
Final Review69 reported modest reductions in the amount of saturated fat consumed and
an increased consumption of fruit and vegetables. Further, increases were reported in the
frequency of light to moderate physical activity and vigorous physical activity as well as
stretching exercises. Only the levels of daily physical education in schools had fallen. It
is surprising that the nutritional and activity indicators are moving in the desired direction
at the same time that the prevalence of obesity is increasing.
Japan reports that the proportion of the population with a BMI greater than 25 (Japan’s
measure of obesity), increased from 16% to 24% among men over the 20 year period to
199743. New Zealand reports that from 1989 to 1997 the prevalence of obesity increased
by 55% and that currently 15% of men and 19% of women are obese23. In Denmark the
prevalence of obesity increased from 6% in 1987 to 8.5% in 199418. England, in 1992,
set a target in Health of the Nation70 to reduce the prevalence of obesity among men from
8% to 6% by 2005 and among women from 12% to 8%. However, a House of Commons
Select Committee report found that by 2002, 22% of men and 23% of women were
obese8.
Proposals for evaluation in current policy
The USA and Japan have mechanisms in place to monitor progress towards all of their
targets. Both countries have many targets for monitoring changes in obesity and
overweight, nutrition and physical activity. Many countries give a commitment to
evaluation of the impact of their policies but do not give details. For example, Sweden
60
proposes to monitor progress to increase physical activity and good eating habits every
fourth year29, whereas Denmark proposes monitoring at intervals of one to three years18.
Ireland is also committed to systematic evaluation but recognises the difficulties of doing
so
71. The Scottish nutrition strategy46 reports that progress on targets will be consistently
monitored through the Scottish Health Survey which is conducted at three yearly
intervals. Australia’s nutrition strategy52 also proposes triennial reviews culminating in a
major evaluation in 2010.
Northern Ireland, in its food and nutrition strategy47, recommends that a group
representing the main interest groups, for example, the Health Promotion Agency, food
producers and retailers, as well as government departments, should be established. Part
of the remit of this group would be to evaluate as well as to monitor and coordinate
activities. Scotland in its physical activity strategy, makes research and evaluation one of
its four strategic objectives, recognising that a monitoring system should cover all of the
agencies involved25. It also proposes to provide evaluation guides and templates for use
by local groups and communities.
Some countries recognise that evaluation should involve more than just progress towards
the achievement of specific targets. For example Denmark points out that their strategy
for evaluation is partly to assess the outcome of the programme and partly to improve the
initiatives being implemented if necessary18. It also recognises that special research
studies will be required to measure the extent to which any changes can be attributed to
policy interventions rather than other secular changes. The Australian physical activity
strategy reports that the educational strategy to promote moderate-intensity exercise will
be subject to rigorous evaluation and careful review at each phase of implemention26.
Scotland recognises that many initiatives fail because the do not adequately monitor
progress towards the achievement of goals and proposes to remedy this25. In its physical
activity strategy Sweden proposes to use process measures initially to determine
interventions are being successfully implemented and maintained24. The outcomes of
these interventions would be measured in the longer term.
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Australia provides the most detailed description of how the evaluation of strategies to
prevent and reduce obesity may be achieved in Acting on Australia’s Weight22.
Monitoring strategies for overweight and obesity, physical activity and dietary intake will
be used. The three strategies are:
• monitor changes in weight and waist measurements of the Australian population
using standardised methods
• monitor physical activity patterns by using ongoing surveys and using standardised
methods of measuring activity
• monitor dietary intake (with a particular focus on fat-energy intake) and diet related
community weight control practices
Some of the required data will be available from routine data collection sources.
However, some new measures are also required. These will be developed through
research. Part of the remit for research therefore is to develop standard methods for
measuring overweight and obesity and to develop standards for measuring and defining
activity. Proposals are in place to collect height, weight and waist measurements and
self-reported physical activity data in five-yearly population surveys. This will be
supplemented by self-reported data in more frequent population surveys. Prior to the
publication of the strategy, Australia did not routinely collect data to monitor food intake.
It therefore planned to implement a program of standardised data collection of food
intake with periodic over-sampling of priority groups, in order to obtain the necessary
data on food consumption. The strategy recommends that anthropometric measurements,
data on physical activity and dietary intake be collected on the same individuals, so that
the associations between the three factors can be taken into account, thereby increasing
the value of the data for monitoring purposes. These measures will ensure that trends in
obesity can be monitored.
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Summary
All countries are concerned at the rapid increase in the prevalence of obesity. They also
recognise the many serious diseases associated with obesity and the costs that result to
health care systems and through lost productivity. A recent estimate from England put
the annual cost to the country at over £3 billion8. A 1995 estimate from the USA was
$99 billion42. Obesity reduces life expectancy by approximately nine years. The health
threat from obesity could reverse recent reductions in mortality from coronary heart
disease8.
Overweight and obesity is thought to result from the combination of the overconsumption of foodstuffs and inadequate levels of physical activity. Dietary change is
attributed to the increased availability of convenient and palatable energy dense foods,
combined with a reduction in the time spent on cooking and a loss of cooking skills.
Increased sedentary behaviour is thought to have resulted from the changing nature of
employment with an increase in the number of sedentary jobs, the development of a
transport system that militates against activity and an increase in the number of sedentary
leisure activities.
Despite the high levels of concern few countries have obesity strategies. However all
countries have policies on physical activity and most have separate nutrition policies.
Although both physical inactivity and poor nutrition contribute to obesity, each is
independently involved in the causation of other diseases. Thus the health benefits of
increased activity and better nutrition are much wider than reducing obesity. The
challenge is to coordinate these policies to ensure that all at risk groups within society
benefit from interventions on both topics.
Only four countries (USA, Japan, Northern Ireland and England) have set targets for the
reduction of the prevalence of obesity. However most countries specify desired
reductions in fat consumption, and desired increases in the consumption of fruit and
vegetables. All countries specify the amount of regular exercise which adults should
perform and most indicate the amounts for children. Only Japan sets targets for physical
63
activity among older people, although most countries identify the elderly as a special
interest group.
There is widespread recognition that changes in the physical and social environment will
be required to change nutritional patterns and increase physical activity levels. Although
interventions aimed at individuals will be necessary these are of secondary importance
compared to environmental change. Many specific settings for interventions are
identified including schools, the workplace, communities and health care settings. Most
countries identify high risk groups particularly children and socially disadvantaged
groups.
All countries stress the importance of intersectoral working, and a range of government
departments, local authorities, private and voluntary sector groups are identified. The
processes by which intersectoral working will be achieved is not well documented.
Action at government level action is widely seen as essential and all countries specify
similar broad areas in which action should be taken. Policy on obesity and physical
activity is acknowledged to be at an early stage of development. Policy documents are
concerned with the education of policy makers and with the need to develop strategies to
tackle current problems. Often a list of possible activities is identified, but there is no
indication of whether these will be undertaken. Current policy is thus concerned with
exploring options, rather than providing a comprehensive set of interventions to improve
health.
The most common specific proposal is to increase opportunities for increased cycling and
walking, by providing safe and attractive cycle routes and walkways. Interventions in
schools are also prominent. These include the introduction of school policies and
standards for school meals, vending machines and take-away foods. The amount of time
within the school curriculum for physical activity is to be increased. This can be
supported by providing protected time for teachers to become school sports coordinators.
64
The worksite is the other setting in which a coordinated programme of nutritional and
physical activities can be implemented. One strategy is to increase employers’ awareness
of the benefits of a healthy workforce. In addition to increasing opportunities for active
recreation employers can ensure that workplace canteens supply low-calorie, nutritious
food items.
Many interventions at a community level are proposed. One specific intervention is to
make school physical activity facilities available out of hours. Other interventions
include mass education campaigns, the education of community leaders and the creation
of partnerships within communities. It is not clear how this will be achieved, nor is it
evident how such actions will lead to the desired changes in the physical and social
environment.
The role of the food industry is acknowledged to be vital. Most countries propose to ask
the food manufacturers to cooperate by producing healthier foods, for example by
reducing the fat content of prepared meals. Food service outlets such as restaurants and
takeaways will also be asked to contribute for example by providing an increased of
choice low energy foods and by keeping portion sizes moderate. Improved nutrition
labelling is also proposed, particularly in a form which is easily understood. The
mechanisms by which these changes will take place are not described, and there is no
mention of devices such as voluntary codes of conduct.
Fiscal and legislative interventions, which are recommended by the World Health
Organisation30 and in scientific articles, are almost completely absent from policy
documents. The introduction of fiscal measures is strongly recommended in scientific
papers12-14 and Sweden notes that the European Common Agricultural Policy subsidises
unhealthy foods, such as full fat milk, while disadvantaging fruit and vegetables72. There
is also little mention of funding for the range of proposed interventions. Further research
to develop effective interventions is recommended, as is the evaluation of the impact of
current policies. However specific proposals for these actions are seldom given in policy
documens.
65
Conclusion
Obesity is a major public health problem which is currently getting worse. The medical
and financial costs of obesity are widely recognised. The policies also recognise that
tackling obesity will require fundamental changes in the physical and social environment.
Interventions in schools and the workplace are the most well-developed. Many countries
also have active transport strategies to increase cycling and walking. Those countries
with obesity polices highlight the need to tackle the problem among socially
disadvantaged people. However policies are often written in general terms with few
specific proposals for tackling obesity. Much of policy makes recommendations for
further policy development. Frequently policy documents identify sets of action which
could be pursued without making commitment to carrying them out. The problem posed
by obesity completely overshadows the efforts being made to tackle it.
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