Obesity Policy in the EU - evaluating the options PorGrow project 2004-2006 Cross-national findings Erik Millstone University of Sussex e.p.millstone@sussex.ac.uk
The full title was: Policy options for responding to the growing challenge from obesity: a cross-national comparative study. Forecasting which policy options will be effective, requires understanding which options are judged likely to be effective and acceptable by stakeholder groups, and their reasons.
The project adopted a Multi- Criteria Mapping methodology. It enabled us to capture qualitative and quantitative aspects of those evaluations, criteria and reasons. The primary unit of analysis was public policy options.
The set of policy-options on which the project concentrated were those that are available to governments and collective European institutions such as the Council, the Commission, Parliament and WHO-Europe.
9 Partner countries
We selected: 7 core policy options and 13 discretionary options (additional options could also be added)
All were asked to evaluate 7 core options: Change planning and transport policies Improve communal sports facilities Set controls on food and drink advertising Control sales of foods in public institutions Mandatory nutritional information labelling Subsidize healthy foods Tax obesity-promoting foods
They could also to evaluate 13 discretionary options: Improve training for health professionals Reform Common Agricultural Policy Improve health education Introduce controls on food composition Set incentives to improve food composition More obesity research Require healthier catering menus
Include food and health in school curriculum Increased use of medication to control body weight Increased use of synthetic fats and artificial sweeteners Create new governmental body to co-ordinate policies relevant to obesity Control of marketing terms such as diet, light, lite Increase use of physical activity monitoring devices
Those options were clustered in 6 groups A. Exercise and physical activity-oriented B. Modifying the supply of and demand for foodstuffs C. Informational initiatives D. Educational and research initiatives E. Technological innovations F. Institutional reforms
The stakeholder groups are representatives of: Farming industry Food processing companies Large commercial catering chains Large food retailers Small health food retailers Public sector caterers (e.g. school meal providers) Consumer groups Senior government policy makers in health ministry Senior government policy makers in finance ministry Public health professionals
As well as Town and transport planners Life insurance industry Commercial sport or fitness providers School teachers Members of expert nutrition/obesity advisory committees Health journalists Advertising industry Pharmaceutical industry Public health non-governmental organisations Public interest sport and fitness NGOs Trades unions
> 14,000 option appraisal scores and ranks were collected, with detailed records of criteria of appraisal and conditionalities. Transcripts were analysed to identify the participants reasons for their selection of criteria and cores, weightings and ranks.
Aggregating across all participants, there was broad common ground that the costs of the various policy options were less important than the social and health benefits, efficacy, acceptability and practical feasibility of the options.
Average ranks for all participants combined core and discretionary options -- favoured order ranked by optimistic conditionality All participants -- core & discretionary options -- ordered by high rank 15. Food and health education in schools (D) 10. Improved health education for general population (D) 8. Improve training for health professionals (D) 13. More obesity research (D) 2. Improve communal sports facilities (C) 14. Provide healthier catering menus (D) (RULED OUT BY SOME #3) 11. Controls on food composition (D) (RULED OUT BY SOME #2) 5. Mandatory nutritional information labelling (C) 18. New government body (D) (RULED OUT BY SOME #1) 19. Control of marketing terms (D) (RULED OUT BY SOME #4) 3. Controls on food and drink advertising (C) (RULED OUT BY SOME #1) 4. Controlling sales of foods in public institutions (C) (RULED OUT BY SOME #2) 12. Incentives to improve food composition (D) 20. Physical activity monitoring devices (D) (RULED OUT BY SOME #1) 9. Common Agricultural Policy reform (D) 1. Change planning and transport policies (C) (RULED OUT BY SOME #1) 16. Medication for w eight control (D) 17. Substitutes for fat and sugar (D) (RULED OUT BY SOME #4) 6. Subsidies on healthy foods (C) (RULED OUT BY SOME #7) 7. Taxes on obesity-promoting foods (C) Option Key: Core Discretionary 0 10 20 30 40 50 60 70 80 90 100
Average ranks for all participants grouped into genders, showing ranks by favoured order under optimistic conditions (men) Male participants 15. Food and health education in schools (D) 10. Improved health education for general population (D) 8. Improve training for health professionals (D) 2. Improve communal sports facilities (C) 13. More obesity research (D) 14. Provide healthier catering menus (D) (RULED OUT BY SOME #2) 5. Mandatory nutritional information labelling (C) 18. New government body (D) (RULED OUT BY SOME #2) 11. Controls on food composition (D) (RULED OUT BY SOME #1) 19. Control of marketing terms (D) (RULED OUT BY SOME #1) 12. Incentives to improve food composition (D) (RULED OUT BY SOME #1) 9. Common Agricultural Policy reform (D) (RULED OUT BY SOME #1) 4. Controlling sales of foods in public institutions (C) (RULED OUT BY SOME #4) 3. Controls on food and drink advertising (C) 20. Physical activity monitoring devices (D) 16. Medication for w eight control (D) 1. Change planning and transport policies (C) 17. Substitutes for fat and sugar (D) Option Key: Core Discretionary (RULED OUT BY SOME #3) 6. Subsidies on healthy foods (C) (RULED OUT BY SOME #4) 7. Taxes on obesity-promoting foods (C) 0 10 20 30 40 50 60 70 80 90 100
Average ranks for all participants grouped into genders, showing ranks by favoured order under optimistic conditions (women) Female participants 15. Food and health education in schools (D) 10. Improved health education for general population (D) 8. Improve training for health professionals (D) (RULED OUT BY SOME #1) 11. Controls on food composition (D) 14. Provide healthier catering menus (D) 13. More obesity research (D) 2. Improve communal sports facilities (C) 18. New government body (D) 3. Controls on food and drink advertising (C) 20. Physical activity monitoring devices (D) 19. Control of marketing terms (D) 5. Mandatory nutritional information labelling (C) 4. Controlling sales of foods in public institutions (C) (RULED OUT BY SOME #1) 12. Incentives to improve food composition (D) 9. Common Agricultural Policy reform (D) (RULED OUT BY SOME #1) 6. Subsidies on healthy foods (C) 1. Change planning and transport policies (C) (RULED OUT BY SOME #1) 16. Medication for w eight control (D) 17. Substitutes for fat and sugar (D) (RULED OUT BY SOME #3) 7. Taxes on obesity-promoting foods (C) Option Key: Core Discretionary 0 10 20 30 40 50 60 70 80 90 100
Average ranks for all participants showing ranks by favoured order under optimistic conditions - Mediterranean region (Cyprus, Greece, Italy and Spain) Cyprus, Greece, Italy and Spain 15. Food and health education in schools (D) 10. Improved health education for general population (D) 8. Improve training for health professionals (D) 18. New government body (D) (RULED OUT BY SOME #1) 16. Medication for w eight control (D) 13. More obesity research (D) 11. Controls on food composition (D) 14. Provide healthier catering menus (D) 5. Mandatory nutritional information labelling (C) 2. Improve communal sports facilities (C) (RULED OUT BY SOME #1) 3. Controls on food and drink advertising (C) (RULED OUT BY SOME #1) 4. Controlling sales of foods in public institutions (C) 19. Control of marketing terms (D) 12. Incentives to improve food composition (D) 20. Physical activity monitoring devices (D) (RULED OUT BY SOME #1) 9. Common Agricultural Policy reform (D) 17. Substitutes for fat and sugar (D) 1. Change planning and transport policies (C) (RULED OUT BY SOME #1) 6. Subsidies on healthy foods (C) (RULED OUT BY SOME #2) 7. Taxes on obesity-promoting foods (C) Option Key: Core Discretionary 0 10 20 30 40 50 60 70 80 90 100
Average ranks for all participants showing ranks by favoured order under optimistic conditions - Eastern region (Finland, Hungary and Poland) Finland, Poland and Hungary 15. Food and health education in schools (D) 2. Improve communal sports facilities (C) 10. Improved health education for general population (D) 8. Improve training for health professionals (D) 20. Physical activity monitoring devices (D) 14. Provide healthier catering menus (D) 13. More obesity research (D) (RULED OUT BY SOME #2) 5. Mandatory nutritional information labelling (C) (RULED OUT BY SOME #1) 19. Control of marketing terms (D) (RULED OUT BY SOME #2) 11. Controls on food composition (D) 18. New government body (D) 16. Medication for w eight control (D) (RULED OUT BY SOME #1) 12. Incentives to improve food composition (D) (RULED OUT BY SOME #3) 3. Controls on food and drink advertising (C) 4. Controlling sales of foods in public institutions (C) 1. Change planning and transport policies (C) (RULED OUT BY SOME #2) 6. Subsidies on healthy foods (C) 9. Common Agricultural Policy reform (D) 17. Substitutes for fat and sugar (D) (RULED OUT BY SOME #3) 7. Taxes on obesity-promoting foods (C) Option Key: Core Discretionary 0 10 20 30 40 50 60 70 80 90 100
Average ranks for all participants showing ranks by favoured order under optimistic conditions - Western region (France and UK) France and UK 15. Food and health education in schools (D) 10. Improved health education for general population (D) 8. Improve training for health professionals (D) 13. More obesity research (D) 1. Change planning and transport policies (C) 14. Provide healthier catering menus (D) 2. Improve communal sports facilities (C) (RULED OUT BY SOME #1) 11. Controls on food composition (D) 3. Controls on food and drink advertising (C) 4. Controlling sales of foods in public institutions (C) (RULED OUT BY SOME #1) 12. Incentives to improve food composition (D) 19. Control of marketing terms (D) 5. Mandatory nutritional information labelling (C) 18. New government body (D) 9. Common Agricultural Policy reform (D) 20. Physical activity monitoring devices (D) (RULED OUT BY SOME #1) 6. Subsidies on healthy foods (C) 16. Medication for w eight control (D) 17. Substitutes for fat and sugar (D) (RULED OUT BY SOME #2) 7. Taxes on obesity-promoting foods (C) Option Key: Core Discretionary 0 10 20 30 40 50 60 70 80 90 100
Interpreting the evidence Broad agreement on educational initiatives, uneven acceptance of regulatory controls (eg on marketing); broad opposition to financial instruments and technological fixes. Nuances: scores were highly conditional (eg what sort of nutritional labelling, transport policy). Inter-dependence: performance of one policy (eg education) depends on other policies (labelling and availability). Scoring bias? Discounting possible stakeholders evident selfinterest, on average, changed scores by +/- 4%.
Policy implications Policy-makers should implement some policies in each of the four main categories: 1) education, 2) physical activity 3) information and 4) change patterns of supply and demand for food and drink. Need to improve and sustain monitoring of diets, physical activity, and BMI levels, especially amongst particularly vulnerable groups to monitor impact of measures. Measures will be acceptable if they are seen to provide wider health and social benefits.