Highlights
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All EU countries are 'on track' to meet maternal, infant, and young child nutrition targets.
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Pre-packaged customer registration and the introduction of strict advertising restrictions with appropriate criteria are poor performance areas targeting childhood obesity.
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The current status of childhood obesity surveillance and monitoring of children under 5 years in Europe is discouraging.
Abbreviations: OW&OB, Overweight & Obesity; COSI, WHO European Childhood Obesity Surveillance Initiative; HFSS, High in saturated Fat, Sugar, and Salt; NCDs, Non-Communicable Diseases; SFP, School Food Policy/Policies; PA, Physical Activity
Keywords: Childhood obesity, Interventions, Public health, Nutrition policy, EU, WHO Europe
Abstract
Childhood obesity pandemic, a form of malnutrition including undernutrition, and other food-regime associated risks, has universally been on the rise during the chronic period of the past 4–5 decades and is now acknowledged as one of the most “toxic fuel” accounting for poor health in the majority of countries. In order to find remedies to heal this alarming issue, a corpus of European interventions have been brought to light in the recent years. Since the vague influence and effectiveness of these measures / policies is to be further identified, their evaluation screening is underlined as a pivotal necessity. Within this framework this paper aims to critically report on the development and evaluation of the implementation of the European Union, World Health Organization Regional Office for Europe, and European Union countries' national public health policy interventions and action plans in the fight against childhood obesity. Thus, this is a narrative review synthesizing the results -following a qualitative interpretation and analysis- of recent scientific epidemiological research and review studies evidence concerning European public health interventions tackling childhood obesity, through computer-assisted literature search -via PubMed, Scopus, and Google Scholar- scientific databases. According to the literature data, it is concluded that despite the unprecedented public health challenge of addressing childhood obesity, the extent to which related European policies and programs targeting healthy nutrition, increased physical activity, and healthy lifestyle ethos are truly efficacious is still under inquiry.
1. Introduction
1.1. Problem definition
Rising rates of childhood obesity is indisputably an extremely “hot” public health debate issue due to its acknowledged burden of short- and long-term health and socioeconomic costs of non-communicable diseases (NCDs) (Williams et al., 2020, Williams and Suchdev, 2017), or mental health illness expressed with depression symptoms (Quek et al., 2017). Numerous studies, conducted all over the world (Tran et al., 2019, Tran et al., 2019b), focus on the research landscapes in the intervention and treatment of children with overweight and obesity, such as pharmacotherapeutic, family-based, school-based, or community-based interventions.
Narrowing our spectrum in the European context, the last two decades have seen an exponential growth and a parallel intensification of European public health policy research and interventions aimed at the drain of lifestyle-related diseases (Kovacs et al., 2020, Kovacs et al., 2018). It is well documented that childhood overweight/obesity remains a key health problem unequally distributed across countries and populations in the European Union (Nittari et al., 2019), with over 398,000 children aged 6–9 years facing severe obesity in 2019 (Spinelli et al., 2021). According to recent (2017) WHO findings ((NCD-RisC, 2017) early life obesity occurrence inside the European framework is either swiftly growing or stabilizing at a very high level in almost all European countries, mostly affecting groups of low socioeconomic status, which relevantly cause huge economic and social costs for individuals and society in general (WHO, 2016).
Therefore, strategic documents addressing child nutrition, overweight, and obesity have been published over the last 20 years. Comprehensive monitoring of the nutrition environment and assessment of relevant targeted interventions issued publicly or privately are necessary to strengthen accountability systems for reducing NCDs. The European Commission (EC), together with the World Health Organization (WHO), has been committed to monitoring and assessing the chronic development of childhood obesity, understanding its determinants, and researching and implementing appropriate nutrition and lifestyle intervention policies, in a multisectoral and multidisciplinary (international, national and regional, community, work, school and home, individual) context (Fig. 1).
Fig. 1.
The multisectoral and multidisciplinary context of public health policies targeting childhood obesity.
According to the Joint Malnutrition Estimates (JME) report (2021) (UNICEF/WHO, 2015), deficient progress is made to meet the 2025 targets set by the World Health Assembly (WHA) to combat childhood obesity and the Sustainable Development Goals (SDGs) set for 2030. The latest analysis indicates that even less than a quarter of all countries are anticipated to encounter the 2030 goal set for 2030 of childhood obesity to reach the percentage of 3 % prevalence, with only 1 in 6 countries considered 'on track'. Since 2000, the number of overweight children under 5 worldwide has increased by nearly 6 million and now stands at 38.9 million. The pro- existing rising tide of childhood obesity has been further exacerbated by the COVID -19 pandemic. This is due to synergistic problem factors related to deteriorating home welfare, constraints in accessibility and affordability of nutritious diet, and limitations in physical activity (PA) way-out (Cuschieri and Grech, 2020).
Within this framework the critical question of whether there are indeed promising, coherent initiatives and practices in addressing childhood obesity management is arisen. This narrative review aims to shed light to this pivotal question by critically reporting on the advancement and assessment of policies, and national public health policies’ implementation in the WHO European region and the EU countries targeting childhood obesity.
2. Material and methods
2.1. Literature data sources and search
A comprehensive literature search was conducted in the MEDLINE, SCOPUS, and Google Scholar scientific databases, up to March 2022, using the following search terms: “childhood obesity”, “EU”, “WHO Europe”, “public health interventions”, “action plans”, “obesity programs”, “evaluation”, “effectiveness”. According to the eligibility criteria, the search has been restricted only to cross-sectional epidemiologic research studies, systematic reviews, and metanalyses, published in English, without time limit, investigating the development, evaluation and implementation of central EU and WHO Regional Office for Europe, as well as EU European countries public health policy intervention, monitoring and surveillance programs and tools in the fight against childhood obesity across Europe. Relevant literature was retrieved by the authors by looking through the references in original epidemiological articles and reviews. The reference bibliographies of studies from such searches were thereafter hand-searched to identify additional eligible studies.
As presented in Fig. 2, from the conducted comprehensive literature search in the aforementioned scientific databases, 345 articles were initially retrieved, while 29 additional studies were identified through manual search from reference lists. Of the initial 374 studies, 54 studies were excluded as duplicates. From the reaming 320 studies, titles and abstracts were screened, and 125 were further excluded as irrelevant to the research aim underpinning the current review paper; Following a second criteria-based screening, from the reaming 195 full-text reviewed studies, 117 were excluded from review, as the authors agreed that they did not provide accurate information concerning the under-search issue of the development, evaluation and implementation of central EU and WHO European Regional Office, as well as EU European countries public health policy interventions concerning childhood obesity. The remaining 78 studies included in this study comprise 19 representative papers and reports of the WHO European Region childhood obesity policies and action plans, 26 review papers mapping the health system response to childhood obesity in the WHO European Region and EU European countries, and 33 epidemiological studies reporting on the impact of WHO European Region, as well as EU countries nutritional policies, interventions and action plans for the prevention of childhood prevention.
Fig. 2.
The MOOSE flow diagram showing study selection process.
2.2. Data analysis
Each participating author independently evaluated the results of the literature search, extracted the most relevant knowledge, decided whether the search results were too diverse or too confusing to publish a comprehensive review of the area, and both authors checked the accuracy and completeness of the retrieved data, which were analyzed following a qualitative interpretation.
2.3. Ethical statement
The authors would like to clarify that the present study, being a narrative literature review, and not epidemiological research conducted in human population, it was based on publicly available anonymized databases, and thus exempt from ethical compliance.
Availability of materials used for this narrative review paper can be obtained upon request from C.M.
3. Discussion
3.1. Unveiling the problematic narrative of successful childhood obesity European public policy interventions: The goals, principles and framework for action.
Childhood obesity could be described as a ticking time bomb, against its “explosion” various European interventions have been adopted. Multisectoral actions have been prioritized by WHO Member States in the European Region and the European Commission (Pineda et al., 2018) over the past 20 years to monitor and combat the obesity disease by means of various curricula, strategies, digital tools, and creativities. These paradigms are thoroughly presented in the descriptive Table 1, Table 2, Table 3.
Table 1.
EU and WHO Europe Public Health Intervention Programmes tackling childhood obesity.
| Program | Country/ies involved | Aims & Areas of intervention | Year/s of implementation | Results |
|---|---|---|---|---|
| WHO: First Action Plan for Food and Nutrition Policy for the WHO European Region (Organization, 2001) | Austria, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Norway, Poland, Portugal, Romania, Slovenia, Spain, Sweden, The Netherlands | To promote healthy lifestyles in the European population by ensuring food security: improving dietary habits and PA, promoting healthy ageing, and preventing nutrition-related and food borne diseases, identify goals and actions at the European level to harmonize activities and bring synergy in the use of resources, advocate for and support a reassessment of national strategies and action plans or complete existing ones, so that detailed plans for implementation are included and plans are integrated within national public health policies, assist countries to foster the integration of nutrition, food safety and physical activity by different stakeholders in the health and other sectors. | 2000–2005 | All the participating countries had FNP strategies or action plans addressing the main areas of interest related to health and nutrition. However, in some cases these do not constitute a ‘real’ policy as they are not issued by a single body and actions are distributed throughout a variety of distinct documents. |
| WHO Second Action Plan for Food and Nutrition Policy for the WHO European Region (Organization, 2008) | Austria, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Norway, Poland, Portugal, Romania, Slovenia, Spain, Sweden, The Netherlands | Emphasizes the importance of developing FNPs that protect and promote health and reduce the burden of foodborne disease, contributing to socioeconomic development and a sustainable environment. It focuses on collaboration and interrelatedness of different sectors in the formulation and implementation of such policies (obesity and nutrition-related chronic diseases, micronutrient deficiencies, food insecurity and undernutrition). | 2007-2012 | All the participating countries had FNP strategies or action plans addressing the main areas of interest related to health and nutrition. However, in some cases these do not constitute a ‘real’ policy as they are not issued by a single body and actions are distributed throughout a variety of distinct documents. |
| EU CHOPIN | Germany and Spain | Examined the protein content in feeding formula and complementary foods and breast milk. The aim was to identify the differences in protein and fat contents and how this may influence the total energy expenditure of formula fed and breastfed infants at six months old. | 2002-2006 | https://cordis.europa.eu/project/id/QLK1-CT-2001-00389Total fat mass was lower for the breastfed than for the low protein formula fed infants. The research report made the inference that a six-month-old infant fed on low or high protein formula from birth had, on average, experienced a 14 to 21% increase in total fat mass compared to those infants which were breastfed at least for the first three months. |
| EU Childhood Obesity Program (CHOP) (Luque et al., 2018) | Germany, Italy, Greece, Poland, UK, Belgium, France | To test the primary hypothesis that a possible causal factor for the difference in long-term obesity risk between breast and formula fed infants is the much lower protein content of breast milk compared to infant formulae. To investigate the effects of these infant feeding regimes on body composition, energy expenditure, physical activity, protein metabolism, renal function, leptin and its binding protein and on insulin like growth factor1. | 2002-2006 | http://www.metabolic-programming.org/obesity/The first results of the EU Childhood Obesity program indicate that low protein content infant formulae bring metabolic and endocrine benefits, as well as body growth rates close to that of breastfed babies. The further follow-up of the children as part of the EU project EARNEST will indicate whether these changes are associated with lower risk indicators of childhood obesity at a later age. Low protein content in infant formulae did not show any untoward effects and is considered safe. |
| EU EPODE (Borys et al., 2012) | France, Spain, Belgium, the Netherlands | EPODE is a coordinated, capacity-building approach aimed at reducing childhood obesity through a societal process in which local environments, childhood settings and family norms are directed and encouraged to facilitate the adoption of healthy lifestyles in children (i.e., the enjoyment of healthy eating, active play and recreation). Primary EPODE target groups are children aged 0–12 years and their families. Local stakeholders are also targeted. Through initiatives and a long-term program, stakeholders foster and promote healthy lifestyles in families in a sustainable manner. | 2004 | Community-based interventions are integral to childhood obesity prevention. EPODE provides a valuable model to address this challenge. |
| EPODE European Network (EEN) | The EPODE European Network (EEN) since 2008, has been working to enrich EPODE methodology and disseminate practical experience in the implementation of similar initiatives in other countries. | |||
| WHO: European Childhood Obesity Surveillance Initiative (COSI) (NCD-RisC NRFC, 2017, Breda et al., 2021, Wijnhoven et al., 2015) (NCS-RisC, 2017) | Albania, Bulgaria, Czechia, Cyprus, Greece, Hungary, Ireland, Italy, Latvia, Malta, Lithuania, Norway, Portugal, Republic of Moldova, Romania, San Marino Spain, Slovenia, Sweden, The former Yugoslav Republic of Macedonia, Turkey | Eating habits, physical activity patterns, school environments. | 1st round:2007-2008 2nd round: 2009-2010 3rd round:2012–2013 4th round:2015–2017 5th round:2018-2020 6th round:2021-2023 |
1st and 2nd round: The prevalence of childhood OW among boys varied from 19.3% and 18.0% of 6-year-olds in Belgium to 49.0% of 8-year-olds in Italy and 57.2% of 9-year-olds in Greece. In girls, the prevalence varied from 18.4% in Belgium to 42.6% of 8-year-olds in Italy and 50.0% of 9-year-olds in Greece. Τhe highest significant decrease in the prevalence of OW was found in countries with higher absolute BMI values in round 1 (i.e., Italy, Portugal and Slovenia), and the highest significant increase was found in countries with lower BMI values in round 1 (i.e., Latvia and Norway). 3rd round: The prevalence of OW ranged from 18% to 52% in boys and from 13% to 43% in girls and that of OB from 6% to 28% among boys and from 4% to 20% among girls. The data suggest the presence of an increasing north−south gradient, with the highest prevalence of overweight and obesity in southern European countries. In the countries in which data were collected on more than one age group, there was a tendency for an increase in the prevalence of OW/OB by age. According to WHO definitions, more boys than girls OW&OB in most age groups, particularly at older ages, and in most countries 4th round: There were large differences between countries in children’s dietary habits, with around 80% of children eating breakfast every day, 45% eating fruit daily, and 25% eating vegetables daily. Most children in all countries spent at least an hour playing outside. Around 40% of children spent at least 2 hours a day watching TV or using electronic devices. Healthy habits with respect to diet, PA and screen time were more likely to be exhibited by children from families of higher socioeconomic status. These results point to important opportunities to improve the health of primary school-aged children and future generations within the WHO European Region. 5th - 6th round: Data collection has been disrupted in several locations due to the COVID-19 pandemic, which has caused many disruptions across the Region, including closure of schools, economic hardship and stress on families, which are likely to have a negative effect on children’s health behaviors (such as diet, PA, screen time and sleep), widening inequalities. The possibility of ongoing restricted access to schools, combined with the necessity of in-person contact between the examiners and the children, present particular challenges for COSI implementation during the pandemic. |
| EU: Prevention of Obesity in Europe – Consortium for the prevention of obesity through effective nutrition and physical activity actions (EURO-PREVOB Project) (Harling et al., 2010) | Bosnia and Herzegovina, Czech Republic, Denmark, France, Italy, Latvia, Russian Federation, Slovenia, Switzerland, Turkey, United Kingdom | A European Coordination Action project financed by the 6th Framework Program of the EC. It aims to promote and support collaboration across networks to tackle the social and economic determinants of nutrition, physical activity and obesity in Europe and at the sub-regional level. | 2007-2010 | www.europrevob.eu EURO-PREVOB Community Questionnaire was found to be a reliable and practical observational tool for measuring differences in community-level data on environmental factors that can impact on dietary intake and physical activity. The Policy Analysis Tool was considered to be user-friendly, relevant and very useful as a research instrument to improve the policy response: Variation in public access to policy documents, A lack of monitoring and evaluation of policies was reported in all countries, Variation in the number of policy documents retrieved that explicitly discuss obesity and and/or inequalities |
| EU: The Health-promotion through Obesity Prevention across Europe (HOPE) project (Brug et al., 2010) | Northern Europe (Norway), Central and Eastern Europe (Germany, Poland and the Czech Republic), Southern Europe (Greece) and Western Europe (Belgium and The Netherlands) | Aims to provide a systematic inventory of existing scientific knowledge across Europe, looking especially at the obesity-causing environment to evaluate interventions, consider socio-economic and life-course aspects, and improve understanding of macro- and micro-level determinants. The project also aims to make a special effort to include data from Eastern Europe. Hope focuses on overweight and obesity as one of the main determinants of loss of healthy life years and of health disparities in Europe. In particular, it aims to expand understanding of key lifestyle factors such as nutrition and PA which are the primary determinants. It also aims to identify i) socio-economic and environmental determinants of these behaviors and ii) effective interventions for preventing obesity and reducing related social inequalities. | 2006-2009 | HOPE project provides further evidence on differences in obesity and overweight prevalence among different EU regions and countries, and contribute to the further exploration of risk factors that may or should be addressed in obesity prevention efforts for school-aged children and adolescents in EU countries. |
| EU European energy balance research to prevent excessive weight gain among youth (ENERGY Project) (van Stralen et al., 2011) | Norway, the Netherlands, Belgium, Spain, Greece, Hungary and Slovenia | Assessment of EBRBs (i.e., dietary behaviors, physical activity, sedentary, and dieting behavior). | 2009 | High levels and striking differences in overweight status and potential risk behaviors were found among schoolchildren (10-12 years) across Europe. |
| WHO: European Food and Nutrition Action Plan 2015–2020 (World Health Organization., 2015) | 53 countries in the Region | To significantly reduce the burden of preventable diet-related noncommunicable diseases, obesity and all other forms of malnutrition still prevalent in the WHO European Region. It calls for action through a whole-of-government, health-in-all-policies approach. Its priority actions will contribute to improving food system governance and the overall quality of the European population’s diet and nutritional status. | 2015–2020 | The overall findings of this study indicate that significant progress has been made in various areas of public health nutrition, including product reformulation, fiscal policies and monitoring the growth of children under 5 years of age. Other policy areas are underused and thus may require more attention and investment from Member States. These include the implementation of consumer-friendly front-of-package labelling and the introduction of comprehensive marketing restrictions of HFSS foods with appropriate and comprehensive criteria, particularly to children. |
| EU: Joint Action on Nutrition and Physical Activity (JANPA) (Chauliac et al., 2015) | Bulgaria, Estonia, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Luxembourg, Malta, Poland, Romania, Slovakia, Slovenia and Spain | Economic costs of childhood obesity, nutritional information and food reformulation, integrated actions in kindergartens and schools, early interventions for pregnant women and families with young children. | 2015-2017 | www.janpa.eu.As outcomes, JANPA promotes 1) advocacy based on an estimation and forecast of economic cost of childhood overweight and obesity (WP4); 2) increasing use of nutritional information on food and diet by public health authorities, stakeholders and families as well as for nutrition policy purposes and to promote food reformulation (WP5); 3) integrated actions in pre-school and school settings (WP6) and 4) improvement in implementation of interventions to promote nutrition and physical activity for pregnant women and for families with young children (WP7). WP6 is focusing on helping Member States to identify ways to create healthier environments in kindergartens and schools. It aims to provide guidance on policy options and initiatives at different levels for facilitating more effective measures in the countries. In this regard, WP6 collects and analyses existing good practices from WP6 partner member states based on a standardized protocol. |
| WHO: CLICK monitoring framework (Wickramasinghek et al., 2021) | To evaluate the extent to which children are exposed to the marketing of unhealthy products online. | Comprehend the digital ecosystem, assess the Landscape of campaigns targeting children (need to integrate information such as children's time spent online, device, app and social media usage with outcomes such as child obesity), Investigate children’s exposure to them through social media, Capture real on-screen children’s exposure to advertising, and Knowledge sharing to raise awareness and public health policy interventions | 2016 | This monitoring framework inserts novel methodologies, providing insights on the current situation on the impact from influencer food marketing on children’s eating behavior, providing important insights on the digital content which children are being exposed to. More research is undoubtedly needed in this area. |
| Science and Technology in childhood Obesity Policy (STOP) (Rasella et al., 2021) | The project is supported by the European Union’s Horizon 2020 research and innovation program, and is led by Imperial College of Science Technology & Medicine, UK. The project engages international partners from different policy-contexts in the United Kingdom, Italy, Estonia, Romania, Portugal, France, Belgium, Slovenia, Sweden, Croatia, Spain, Finland, Switzerland | The STOP project brings together 24 international research and advocacy organizations to generate scientifically sound and policy-relevant evidence on the factors that have contributed to the spread of childhood obesity in European countries, and on the effects of alternative policy options, effective and sustainable policies to prevent and manage childhood obesity. The primary focus of STOP is on the cumulative impacts of multiple and synergistic exposures in vulnerable and socially disadvantage children and their families, which must be a priority target for the fight against childhood obesity in Europe to reach a tipping point and succeed. | 2018-2022 | https://cordis.europa.eu/project/id/774548 http://www.stopchildobesity.eu/On progress |
| EU I-FAMILY (Hebestreit et al., 2017) | Belgium Cyprus, Denmark, Estonia, Finland, Germany, Hungary, Italy, The Netherlands, Spain, Sweden, United Kingdom | EC funded research project followed up the large IDEFICS children’s cohort in the stage between childhood and their teenage years. I.Family has provided further insight into the most important influences on children group aged 2-10 years, their lifestyle behavior and their eating habits, studying the biological, behavioral, social and environmental factors that influence diet and health outcomes over time as the children transitioned into adolescence. | 2012-2017 | Girls are more likely to be overweight/obese. Children from disadvantaged families are more often overweight or obese than children from more advantaged groups. This social divide increases as children get older. The energy-density of European children’s diet is too high and increases with age. Unhealthy diets are far more common in children from poorer and less educated families. Outcomes also suggest that there is a link between shorter sleep duration and higher weight, particularly in primary school children. |
| EU HABEAT (Issanchou, 2017) | Exploiting existing data from 4 cohorts (Eden, France; ALSPAC, UK; Generation XXI, Portugal; EuroPrevall, Greece). | Based on a multidisciplinary approach (epidemiology, nutrition, behavioral science, psychology and sensory science), The HabEat project aims at Determining factors and critical periods in food habit formation and breaking in early childhood understanding better how food habits are formed and can be changed, in infants and children (< 5 years). | 2010-2013 | Habeat found evidence that breastfeeding may facilitate the consumption of vegetables and fruit and a greater variety of healthy foods in later childhood. Introduction of a variety of vegetables at the beginning of the complementary feeding period increases later acceptance of novel foods. Repeated exposure is a powerful mechanism to increase children's intake of a novel vegetable in infants and young children. Offering energy-dense snacks before or after meals should be avoided. Moreover, food should be offered to children in response to their feelings of hunger, and not used as reward for a good behavior or for any other reason. |
| EU: ToyBox INTERVENTION (Lambrinou et al., 2019) | Belgium, Bulgaria, Germany, Greece, Poland, Spain. | ToyBox project aims to prevent early childhood obesity using a holistic, evidence-based approach that focuses on behavioral models to understand and promote fun, healthy food, play and policy. A kindergarten-based, family-involved intervention targeting multiple lifestyle behaviors in preschool children, their teachers and their families. |
2010-2013 | The ToyBox-intervention significantly improved parental rule setting on children’s unhealthy snack consumption (i.e., restriction of snacking while watching television and permission only at certain occasions) and parental consumption of unhealthy snacks, while it increased parental knowledge on snacking recommendations. Regarding healthy snacking, the ToyBox-intervention improved children’s attitude towards fruit and vegetables (F&V). |
| EU MyNewGut Project (Wolters et al., 2019) | Italy, Ireland, Denmark, France, Belgium, Germany, Netherlands, Germany, United Kingdom, Austria, Spain, Serbia | the gut microbiome contributes to our ability to extract energy from the diet and influences development and function of the immune, endocrine and nervous systems, which regulate energy balance and behavior. Developing microbiome-based dietary interventions can be cost-effective measures to prevent diet-related and behavioral disorders obesity disease risk. | 2013-2018 | https://cordis.europa.eu/project/id/613979/reporting Through a longitudinal study conducted in children, the consortium considered the impact of an unhealthy diet, including a high intake of simple sugar and fat. This is associated with a low-diverse microbiota and heightened inflammation in normal weight children who later develop obesity, compared to children who remained normal weight. |
| EU ‘EarlyNutrition Project’ (Koletzko et al., 2011) | 12 European Countries | provide understanding at the cellular and molecular level, and refined strategies for intervention in pregnancy and early post-natal life to prevent obesity. | 2011-2017 | www.project-earlynutrition.eu The project ‘EarlyNutrition’ has collated convincing evidence demonstrating that early nutrition and lifestyle before and during pregnancy, during the breastfeeding period, and during infancy and early childhood have important long-term effects on later health and the risk of common non-communicable diseases. |
| the Feel4Diabetes Programme (Manios et al., 2018) | Finland, Belgium, Spain, Hungary, Bulgaria, and Greece | The overall aim of the Feel4Diabetes program was “developing and implementing a community-based intervention to promote behavioral changes and creating a more supportive social and physical environment to prevent diabetes in vulnerable families across Europe”. | 2016-2018 | feel4diabetes-study.eu The Feel4Diabetes-intervention is expected to provide evidence-based results and key learnings that could guide the design and scaling-up of affordable and potentially cost-effective population-based interventions for the prevention of type 2 diabetes. |
| The EU Horizon 2020 project “Confronting obesity: Co-creating policy with youth” (CO-CREATE) (Neveux et al., 2019) | Norway, Netherlands, United Kingdom, Portugal, Belgium, Poland | CO-CREATE aims to curb the childhood obesity epidemic reduce the prevalence of obesity in Europe through policy actions to promote a healthier food and physical activity environment. | 2018-2023 | https://co-create.eu |
| EU: Big Data Against Childhood Obesity (BigO) (Tragomalou et al., 2020) | Greece, Sweden, Ireland, Spain and the Netherlands. | An EU-funded project that collects objective evidence on the causes of obesity in local communities and enables public health authorities to design effective interventions to prevent or combat obesity in children and adolescents aged 9-18 years. BigO aims to redefine the way those strategies are designed and deployed, to extract relationships between environment, personal behavior, obesity risk factors and obesity prevalence, and determine which particular local conditions are associated with the development of obesity in children of a specific region. Data driven analytics will then be employed to extract relationships between environment, personal behavior, obesity risk factors and obesity prevalence, and determine which particular local conditions are associated with the development of obesity in children of a specific region. School aged children become citizen scientists by collecting data about their behavioral patterns and local environment, using the myBigOapp. | 2016-2021 | https://bigoprogram.eu/big-data-against-childhood-obesity/ Comprehensive models of the obesity prevalence dependence matrix will be created, allowing, for the first time the data-driven effectiveness predictions about specific policies on a community and the real-time monitoring of the population response, supported by powerful real-time data visualizations. |
| EU Smart childhood Obesity CARing solution using IoT potential (OCARIoT) | Brazil, Greece and Spain | European Union’s Horizon 2020 research and innovation program. BigO collects and analyses anonymous data on children’s behavioral patterns and their living environment. By using advanced analytics and sophisticated visualizations, BigO extracts data-driven evidence on which local factors are involved, and how these factors influence childhood obesity in Europe. | 2017-2020 | http://www.ocariot.eu. Provision of an app specifically for children in order to attract them in its use and with a clear focus on treating obesity health problems. - Combination of personalized health interventions with a gamification strategy addressing the specific needs of children with overweight and obesity problems. - Enabling a motivational self-management process adapted to children’s intrinsic and extrinsic motivators. |
| EU: FOOD 2030 Platform (den Boer et al., 2021) | Portugal, Ireland, Germany, France, Bulgaria, UK, Serbia, Denmark, Italy, Netherlands | Nutrition for sustainable and healthy diets is one of four priority areas of the platform, in order to tackle childhood obesity. | 2017-2020 | Lab coordinators operating in different localities, targeting different audiences, and with different intersecting (organizational) needs, norms, and priorities were presented with normative (inclusivity, diversity) and topical (food and R&I system transformation) facilitation content. The project sought to prepare coordinators for (and stimulate learning and exploration around) challenges to inclusion. The specific ways in which coordinators faced and responded to challenges by intervening in group discussions, identifying and inviting stakeholders, or otherwise contribute so that marginalized stakeholders were not only included in formal but also substantive ways, nevertheless varied greatly. |
Table 2.
National – Level Public Health Intervention Programmes in European countries tackling childhood obesity (Data provided: https://extranet.who.int/nutrition/gina/en/policies/summary & https://globalnutritionreport.org/resources/nutrition-profiles/europe/)
| Program | Country/ies involved | Areas of intervention | Year/s of implementation | Progress Outcomes, Results |
|---|---|---|---|---|
| Food Dudes Program (Upton et al., 2015) | West Midlands, United Kingdom, Ireland | The ‘Food Dude Healthy Eating Program’ by the Irish Food Board aims at improving children’s long-term consumption of fruits and vegetables by providing free fruits and vegetables at school for 16 days along with videos and rewards based on the ‘Food Dude’ characters. | 2005-2008 | A significant increase in the consumption of lunchtime fruit and vegetables was found at three months for children in the intervention schools, but only for those eating school-supplied lunches. For children consuming school meals, consumption of high-fat and high-sugar foods for children in the intervention and control schools increased over time. No relationship was found between increases in fruit and vegetable consumption and decrease in consumption of high-fat and high-sugar foods following the Food Dudes intervention. The Food Dudes Program has a limited effect on decreasing consumption of high-fat and high-sugar foods at lunchtime. |
| Albanian Food and Nutrition Action Plan (AFNAP) (Mersini et al., 2017) | Albania | Has been developed in the framework of the Joint Program on Nutrition implemented by the Ministry of Health (MoH) and the Ministry of Agriculture, Food and Consumer Protection (MoAFCP) The Plan has been developed with the inputs of five-line ministries: Ministry of Health, Ministry of Agriculture, Food and Consumer Protection, Ministry of Education and Science, Ministry of Labour, Social Affairs and Equal Opportunities, Ministry of Finance and the respective local and national institutions. | 2013-2020 | The quantitative and qualitative assessment of 2003-2008 Albanian Food and Nutrition Action Plan revealed that the implementation process has faced serious barriers linked to the design of the plan, which did not accurately anticipate a theoretical framework, or structured methods for its implementation. Other impeding factors included the lack of institutional/infrastructure support, lack of intersectoral coordination and motivation, as well as insufficient capacities and know-how. Intersectoral response to the multifaceted nature of double burden of malnutrition is of key importance to improve nutritional wellbeing and health outcomes in Albania. https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/albania/Albania is 'on course' to meet four targets for maternal, infant and young child nutrition (MIYCN) . |
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| National Nutrition Action Plan |
Austria Ministry of Health |
Overweight, obesity and diet-related NCDs, Overweight in children 0-5 yrs, and school children Action areas: Maternal, infant and young child nutrition, Counselling on healthy diets and nutrition during pregnancy, Breastfeeding promotion/counselling, Nutrition in schools (Regulation/guidelines on types of foods and beverages available, Provision of school meals / School feeding program, School fruit and vegetable scheme, School milk scheme). |
2011-2020 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/western-europe/austria/ Policy document adopted. |
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| EU school milk and fruit scheme | 2011 (ongoing) | https://eurohealthobservatory.who.int/countries/austria/ Overweight and obesity rates among 15-year-olds also increased substantially over the past two decades, reaching 21 % in 2018. This was also slightly above the EU average of 19 %. The Milk Scheme is still largely ineffective today. |
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| National Nutrition and Health Pan | Belgium | It emphasizes the need to create an environment stimulating healthy eating habits and physical activity; this is to be achieved by improving education on food and nutrition and involving a number of stakeholders. Working with the private sector, the plan aims at increasing the availability of food for a healthy diet and improving the nutritional composition of food. | 2006 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/western-europe/belgium/ |
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| The school in good condition program |
https://eurohealthobservatory.who.int/countries/belgium/ Over the past two decades, obesity rates among adults in Belgium increased by four percentage points to reach 16 % in 2018, but this remains lower than in most EU countries.2 The rate of overweight and obesity among 15-year-olds has also risen steadily, from 11 % in 2002 to 17 % in 2018 – this is higher than in many other EU countries, but slightly below the EU average (19 %). |
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| National Food and Nutrition Action Plan (NFNAP) | Bulgaria | The strategic goal is to improve the health of the Bulgarian population by improving nutrition and the reducing the risk of foodborne and diet-related chronic diseases. The Action Plan covers the three strategic areas of nutrition, food safety and food security. Efforts to tackle the increasing numbers of overweight and obese children include the Healthy Kids Project, which promotes physical activity and balanced nutrition in primary schools Bulgarian Parliament passed an amendment to the Food Act which prohibits the advertisement and marketing of genetically modified and 'unhealthy' foods to children - including via television, print, and online. The general objective of the scheme for the provision of fruit, vegetables, milk and milk products in kindergartens, schools and special educational support centers is to provide legal and financial conditions for a long-term increase in the share of these products in children’s diets, especially at the age when their nutritional habits are formed. |
2005–2010 | https://eurohealthobservatory.who.int/countries/bulgaria/ |
| National NCD Prevention Program | 2014-2020 |
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| National Strategy for Physical Education and Sports Development | 2012-2022 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/bulgaria/ | ||
| Bulgarian Food Act | 2017 |
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| NATIONAL STRATEGY ON THE IMPLEMENTATION OF A KINDERGARTEN AND SCHOOL FRUIT, VEGETABLES, MILK AND MILK PRODUCTS SCHEME | 2017-2022 | |||
| National Action Plan against obesity |
Czech Republic National Council for Obesity |
Established as a permanent advisory body to design and implement a. The national cycling strategy of 2004 is progressively recommended to regional and local governments, businesses and NGOs to be included as a complementary part of their activities, programs and documents. | 2004 | https://eurohealthobservatory.who.int/countries/czechia/ |
| OW&OB levels in Czechia are also rising among adolescents: 20 % of 15-year-olds were overweight or obese in 2018, up from 17.5 % in 2014. This is more prevalent among boys (26 %) than girls (14 %). Obesity is contributing to a growing epidemic of diabetes and other diet-related illnesses in the country. Poor nutrition is the main determinant of obesity. Dietary risks were the most prevalent, contributing to more than one fifth of all deaths (23 %) – well above the EU average (17 %). | ||||
| https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/czechia/ | ||||
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Croatia | Legislation relevant to nutrition, with the following action areas: Promotion of healthy diet and prevention of obesity and diet-related NCDs, Ban or virtual elimination of industrial trans fatty acids. | 2021 | https://eurohealthobservatory.who.int/countries/croatia/ |
| 2015 |
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| 2008-2011 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/croatia/ | |||
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| National Nutrition Action Plan | Cyprus | Areas of intervention: | 2005 | https://eurohealthobservatory.who.int/countries/cyprus/ Obesity rates among children are higher. In 2015-17, 20 % of children aged 6-9 years were obese – the highest rate among EU countries (WHO Regional Office for Europe, 2018). One in seven Cypriot adults (14.6 %) were obese in 2019 – a share similar to the EU average (16.0 %). Low physical activity is an important contributor to overweight and obesity. |
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| National nutrition and exercise guidelines | Ministry of Health, Ministry of Education, consumer and nutrition associations, and non-governmental organizations. | Cyprus has two sets of guidelines, one directed at the general population and another at children aged 6–12 years. | 2007 (ongoing) | |
| National Action Plan against Obesity |
Denmark Danish Ministry of Health |
To reduce social inequalities and the number of overweight children. These guidelines follow on from the National Action Plan against Obesity which included 66 recommendations for the prevention and treatment of obesity. (69) Denmark also has a set of policies to help increase PA across the nation, from the City of Cyclists environmental intervention to Get2sport, an ongoing project promoting participation in sports among children from the most deprived areas. | 2014 | https://eurohealthobservatory.who.int/countries/denmark/ More than 40 % of deaths in Denmark can be linked to behavioral risk factors, including tobacco smoking, unhealthy diets, alcohol consumption and low physical activity – a rate similar to the EU average. Obesity rates among adolescents remain lower than in most other EU countries. |
| https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/denmark/ | ||||
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| The Children’s Obesity Clinic Treatment (TCOCT) |
Denmark by Danish pediatrician Dr Jens Christian Holm. |
A protocol aimed at helping clinically obese children achieve weight loss through personalized behavior change techniques targeted at the child and their family. Children are initially admitted to hospital for 24 hours, having a series of tests and body composition measures. | 2008 | From 2008, over 2,300 children and adolescents were enrolled and results published in 2011 found significant reductions in BMI standard deviation scores after 1.5 years, including reduction of several comorbidities. Adoption of the protocol in another Danish clinic also found a significant reduction in BMI among children aged 5-18 after one year and even greater reduction after two years. Retention rates were acceptable, at 0.57 after two years of treatment. Similar improvements in BMI were found when the TCOCT protocol was transferred to a community healthcare setting, suggesting that the protocol can be feasible and effective when implemented more widely. These results have led to the Danish clinical guidelines, set in 2014, for examining and treating overweight and obese children and adolescents in pediatric settings. |
| Nordic monitoring of diet, physical activity, and overweight (NORMO) (Stockmarr et al., 2016) | Sweden,Denmark, Finland, Iceland | 2011, 2014 | No significant change in mean BMI nor in the crude OWOB and OB prevalence estimates were found in the Nordic countries between 2011 and 2014. For the Nordic Region, a non-significant decrease from 17.3 to 17.1 in mean BMI was even observed in children. OWOB and OB prevalences seem to have plateaued in the Nordic countries. | |
| Childhood obesity: a plan for action (Griffin et al., 2021) |
England Department of Health |
To Significantly reduce England’s rate of childhood obesity within the next 10 years, to review the nutrient profile model, update School Food Standards, provide guidance on reducing sugar content of foods, and set targets for product composition. | 2016, 2018, 2019 | Εmphasis has been placed on collaboration with the private sector. Evaluations have revealed it to have been a failure, focusing on industry-friendly but ineffective measures: Local authorities are encouraged to focus on health inequality, but specific guidance (and support) is unclear. Another gap is related to mandatory action or legislation aimed at the early years, a key life stage for understanding the impacts of the SDH and therefore interventions to reduce health inequalities. The reference to early years consists of voluntary food and physical activity guidelines and suggests research is undertaken exploring curriculum development that supports good physical development in the early years, but with no details on the research or proposed timescales |
| Healthy Weight, Healthy Lives |
England Department of Health |
A Cross Government Strategy program including increased funding for pregnancy and early years, promoting a culture of healthy eating in schools and building more cycle lanes and safe places to play. Fundamentally a prevention strategy, it sets out to change the behaviors and circumstances that lead to weight gain, rather than a weight-loss program for the already obese. | 2007 to ongoing | www.thensmc.com |
| Change4Life (Lamport et al., 2021) |
England Department of Health |
Change4Life is England’s first ever national social marketing campaign to reduce obesity. It is a three-year marketing strategy to drive, coax, encourage and support people through each stage of the behavior change journey. Change4Life focuses on prevention and aims to change the behaviors and circumstances that lead to weight gain, rather than being a weight-loss program for the already obese. In its first year, Change4Life focused on families, particularly those with children under 11. In years two and three, the campaign has expanded to address other at-risk groups. | 2009-2012 | Intervention fidelity was low and the intervention is unlikely to have had a substantial or long-term effect on customers’ consumption of fruit and vegetables. |
| Estonia Action Plan | Estonia | Action areas | 2017-2020 | https://eurohealthobservatory.who.int/countries/estonia/ Overweight and obesity rates in Estonia are particularly worrying because policy action on nutrition and obesity is lagging in Estonia. Overweight and obesity rates are a growing issue in adolescents, as the rates have increased substantially over the last two decades, reaching 19 % in 2018, up from only 7 % in 2002. Nearly half of the adult population report that they do not eat any fruit (49 %) or vegetables (47 %) on a daily basis. The government began working on a green paper on nutrition and physical activity in 2014, but it has not yet been approved. This has delayed policy action that might tackle the rising overweight and obesity rates, although some measures are under development, including a plan for food reformulation and a voluntary code on responsible marketing. |
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https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/estonia/ | |||
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| National Program to tackle obesity | Finland | Including information and communication campaigns to improve nutrition and physical activity and greater collaboration between national, regional and local actors. | 2012-2018 | https://eurohealthobservatory.who.int/countries/finland/ Obesity is an important public health issue in Finland, since Overweight, obesity and diabetes are on the rise.: Among 15-year-olds, nearly one in five (19 %) were overweight or obese in 2018 – a rate equal to the EU average, based on the HBSC survey. National register-based sources reported high and increasing OW&OB rates between 2014 and 2019. In 2019, 24 % of boys aged 2-6 were overweight or obese, while the share was 15 % among girls in the same age group. Boys were also more overweight or obese than girls in the age groups 7-12 years and 13-16 years (Finnish Institute for Health and Welfare, 2020). National Program’s to tackle obesity results have not yet been evaluated (Finnish Institute for Health and Welfare, 2019). |
| https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/finland/ | ||||
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France | A community-based prevention program, continuation of the previous EPODE obesity prevention scheme. Aims: promoting healthier lifestyles, improving eating and physical activity habits amongst children and their families, involving municipal services in charge of child education and care to mobilize a wide diversity of local stakeholders, especially in schools, pre-schools, extracurricular organizations and any social network of associations. A nutritional logo to improve nutrition and tackle rising rates of obesity which provides easy-to-understand information on the overall nutritional quality of food products to promote more healthy nutrition habits. |
2008-2015 | The results of the 7-year VIF Programme community-based intervention are promising for addressing obesity and related issues in French youngsters, regardless of sex or socio-economic environment. Thus, the VIF Program may potentially play a role in the prevention of childhood overweight and obesity. https://eurohealthobservatory.who.int/countries/france/ |
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| 2017 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/western-europe/france/ | |||
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| Intersectoral National Initiative to Promote Healthy Diets and Physical Activity, (IN FORM) |
Germany Federal Ministry ofFood and Agriculture and Federal Ministry of Health |
To achieve sustainable improvements in healthy diets and PA by 2020.No explicit focus on weight, but rather on PA and nutrition | 2008 | Focuses on PA and nutrition rather than weight. This focus on individual behaviors is favored by the food industry, neglecting evidence on the importance of tackling the upstream social, commercial, and political determinants, most notably the role of the food and agriculture industries. Obesity is still an underestimated public health problem in Germany; the policy response has so far been insufficient and obesity levels continue to increase dramatically. However, Germany is one of the countries that has an explicit state-level obesity policy, aiming to encourage healthy diets and physical activity. https://eurohealthobservatory.who.int/countries/germany/ Unhealthy diets are also a significant driver of mortality in Germany, and are linked to 14 % of deaths. More than one in five 15-year-olds were overweight or obese in 2018, with a higher share of boys reporting being overweight or obese. Overall, obesity rates – particularly among adolescents – are higher than in manyother EU countries. They have also increased over the last decade, although national data indicate that the rate for children has stabilized somewhat since 2015. These trends are driven in part by dietary habits: Among adolescents, only 30 % consume fruit and 25 % eat vegetables daily, while only 10 % of 15-years-olds reported doing at least moderate physical activity every day in 2018 |
| https://globalnutritionreport.org/resources/nutrition-profiles/europe/western-europe/germany/ | ||||
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| Nutrition circular on Kindergartens |
Greece Ministry of Health |
Evidence of Nutritional or Health Strategy/ Guidelines/Policy/Action plan for children | 2021 (ongoing) | https://data.worldobesity.org/country/greece-80/#data_policies https://eurohealthobservatory.who.int/countries/greece/ OW&OB among adolescents are a particular public health concern in Greece. More than one in five 15-year-olds were overweight or obese in Greece in 2018, which is a higher proportion than in most other EU countries, and a significant rise since 2001-02. Boys are more likely to be overweight or obese than girls. In Greece, as in other countries, poor nutrition is the main factor contributing to being overweight or obese. Fewer than one in three 15-year-olds reported eating vegetables daily and only about one in four 15-year- olds reported eating fruit daily in 2018. Low PA also contributes to obesity: only one in eight 15-year-olds reported doing moderate to vigorous PA each day in 2018. A dedicated national strategy is now in place to address the previously neglected areas of prevention and health promotion. |
| National Action Plan on Food Reformulation | Greek Ministry of Health General Directorate of Public Health and Quality of Life Directorate of Public Health Department on NCDs and Nutrition | Primary concern of the Action Plan is to reduce the following nutrients of foods: salt, industrially produced trans fatty acids, added sugars. | 2017 | |
| Legislation on food offered in School Canteens (www.moh.gov.gr) | Greek Ministry of Health | Evidence of Nutritional or Health Strategy/ Guidelines/Policy/Action plan | 2013 (ongoing) | https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/greece/ |
| Action plan for implementation of the national nutrition policy | Ministry of Health and Social Welfare | Taxation/Subsidies on Food or Beverages or law relating to public health for children | 2006 |
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| Public Health Product Tax | Hungary | A public health product tax on non-staple, pre-packaged foods with high levels of sugar, salt and other ingredients with proven health risks. This included confectionary, salty snacks, fruit jams, soft drinks and energy drinks. | 2011 | https://eurohealthobservatory.who.int/countries/hungary/ |
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| https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/hungary/ | ||||
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Iceland | Health sector policy, strategy or plan with nutrition components Settings for health: At least 95% of schoolchildren should receive systematic education and training in health promotion. Highlights the healthier alternatives within a product group. Products with the Keyhole comply with one or more of these requirements: more whole grain, less saturated fat, less salt and less sugar. |
2016 | https://eurohealthobservatory.who.int/countries/iceland/ |
| 2004-2010 |
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| 2013 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/iceland/ | |||
| 2006 |
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| Nutrition Standards for School Meals Standard |
Ireland Department of Health |
Action areas: Nutrition in schools including: a) school-based health and nutrition programs b) regulation/guidelines on types of foods and beverages available c) provision of school meals / School feeding program, d) school meal standard |
2018 | https://eurohealthobservatory.who.int/countries/ireland/ People in Ireland lead longer and healthier lives than most other Europeans, although behavioral risk factors, including smoking and obesity, remain important public health concerns. Among adolescents, 14 % of 15-year-olds were overweight or obese in 2018 – a share lower than in most EU countries. |
| https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/ireland/ | ||||
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| “Gaining Health” |
Italy National Centre for Disease Prevention and Control |
To prevent and change unhealthy behaviors that promote increases in degenerative and chronic diseases. | 2006 | “Gaining Health” is an important milestone in the recent history of Italian public health. Concrete projects have been undertaken towards health prevention in many areas relevant to obesity including: environment and climate, chronic diseases, promotion of healthy lifestyles, support for vulnerable people, and information flows. However, several weaknesses need to be addressed, including the persistence of strong regional disparities in health status and in the quality of public health services. |
| https://eurohealthobservatory.who.int/countries/italy/ | ||||
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| https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/italy/ | ||||
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| National Prevention Plan | Italy | Obesity-related goals included | 2014-2018 | The existence of a National Prevention Plan was a major development in this area, as were Regional Prevention Plans, which increasingly concentrate on the prevention of NCDs and the promotion of healthy lifestyles. However, this progress threatens to be undermined by recent budget cuts to prevention, which have left fewer resources that can be allocated to tackling obesity. There are also few efforts to make the required structural and systematic changes to urban environments to encourage people to increase their PA. |
|
Latvia Concept of the Cabinet of Ministers |
Action areas: Infant and young child feeding Breastfeeding Overweight, obesity and diet-related NCDs Overweight in school children Dietary practice |
2003–2013 | https://eurohealthobservatory.who.int/countries/latvia/The obesity rate in Latvia is well above the EU average. Adolescent Latvians fare better, with below-average obesity rates and higher levels of PA. |
| The State program for improvement of nutrition of schoolchildren, Prohibition of sales of sweets containing sweeteners, colors and drinks containing sweeteners, colors, caffeine in pre-schools and schools. Recommendations for using of fruits and vegetables, Implementation of Baby-Friendly Hospital Initiative. | 2007 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/latvia/ | ||
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| State Food and Nutrition Strategy and Action Plan | Lithuania | Action areas: | 2020 | https://eurohealthobservatory.who.int/countries/lithuania/ OW&OB rates are a growing issue among adolescents in Lithuania: the rates have tripled over the last two decades, reaching 15 % in 2018, although this remains below most EU countries. |
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https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/lithuania/ | |||
| It sets out guidance for the planning and evaluation of these activities for municipal public health bureaus, and mainly relies on tackling population health literacy, improving the nutritional value of school meals and other foods, and creating an environment that enables a healthy lifestyle. |
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| National program to promote healthy nutrition and physical activity. | Luxembourg | Following the first National Health Conference in November 2005, an initiative was taken to elaborate an interdisciplinary coordination to implement the policy, to evaluate the initiatives realized, to identify further needs and regularly to adapt the program on nutrition and PA. | 2005 | https://eurohealthobservatory.who.int/countries/luxembourg/ |
| Poor nutrition and low PA contribute to rising obesity among adolescents in Luxembourg. More than one in five 15-year-olds were overweight or obese in Luxembourg in 2018 – a higher proportion than in most EU countries, and a significant rise since 2006. Boys are more likely to be overweight or obese than girls. In Luxembourg, as in other countries, poor nutrition is the main factor contributing to being overweight or obese. | ||||
| https://globalnutritionreport.org/resources/nutrition-profiles/europe/western-europe/luxembourg/ | ||||
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| “The Healthy Lifestyle Promotion and Care of Non-Communicable Diseases Act” | Malta | To establish and ensure an inter-ministerial life-course approach favoring PA and healthy balanced diets to achieve healthy lifestyles and reduce NCDs in all age groups. Maltese government issued subsidiary legislation to regulate the food being sold and provided by schools, implement programs for healthy eating, ban advertising or sponsorship of unhealthy foods, and ensure provision of drinking water in schools. |
2016 | https://eurohealthobservatory.who.int/countries/malta/ |
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| A legislative tool for schools. | 2018 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/malta/ | ||
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| National Food and Nutrition Program (NFNP) and its Action Plan |
Moldova Ministry of Health |
Aim: Zero increase in obesity prevalence among children and adults. The NFNP and its Action Plan provide for multisectoral actions regarding health promotion and obesity prevention via taxes, mandatory nutritional labelling, restrictions on advertising and banning the involvement of children in food advertising, elimination of trans-fats, reformulation of food to reduce the content of sugar, fat and salt, health education and establishing a national obesity surveillance system. | 2014-2020 |
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| Law on Public Health | Moldova | Established methods to control obesity. | 2009 | The Food Law was amended and preparation, selling and distribution of unhealthy food on school premises and within 100 meters of schools was banned. |
| https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/republic-moldova/ | ||||
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| National Prevention Plan (NPP) |
The Netherlands Ministry of Health, Welfare and Sport |
The NPP covers five domains: school, work, living environment, healthcare, and health protection. It encompasses a wide range of activities in these domains, from promoting health and preventing illness at home, school and work, and making prevention more prominent in health care, to maintaining the current, high level of health protection. Overweight is one of the strategic areas of action of the Plan. | 2014-2020 | https://eurohealthobservatory.who.int/countries/netherlands/ |
| The overweight and obesity rate among Dutch teenagers is lower than in most EU countries. | ||||
| https://eurohealthnet-magazine.eu/monitoring-the-dutch-national-prevention-program/ | ||||
| The process indicators on the health programs showed that many of the health programs have reached their goals, with notable progress in schools. The indicators showed for instance, that at the end of 2016, 1065 schools have become a ‘Healthy School’ overreaching the target of 850, and 70 ‘Healthy School Squares’ have been developed. Progress has also been made in other settings. Nearly 1,000 sports clubs are currently working on a ‘Healthy Sport Canteen’, exceeding the target of 600. By the end of 2016, 116 municipalities were affiliated with Youth at a Healthy Weight (JOGG), a program to prevent obesity among young people. This means that potentially, around 832,000 children could be reached. | ||||
| Young People at a Healthy Weight (JOGG) | The Netherlands | A program coordinated at national level targeting maintenance of healthy weight for children and adolescents aged 0-19. JOGG encourages healthy eating and exercise within cities, town and neighborhoods. The local approach targets health professionals, shopkeepers, schools, companies and local authorities to help children and families attain and maintain a healthy weight. Over 84 municipalities in the Netherlands are now using JOGG. The program is based on the French EPODE program, with five main pillars which each town and city plans activities around: |
2010-2014 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/western-europe/netherlands/ |
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| Amsterdam Healthy Weight Program (AAGG) | The Netherlands:Amsterdam | Established by the Amsterdam Municipality. The objective of AAGG to “give every child a healthy childhood and future, regardless of their start in life”. The Rainbow Model on Childhood Obesity program outlines the numerous factors influential to children’s health and development, and thus the need to engage all sectors to achieve healthy weight children. |
2013 | Between 2012 and 2015, the program reported a decrease in obesity from 8% to 6% among all children 0-18 years, with an 11% decline among low and 9% very low socioeconomic groups. The combined prevalence of overweight and obesity fell from 21% to 18.5%. Alongside Dutch children, there were significant reductions in obesity among children from other ethnic groups, including Turkish and Moroccan. Of the 11 heaviest neighborhoods, 9 are now lighter. Sugar sweetened beverage consumption among children decreased and the proportion of children exercising increased. Exclusive breastfeeding rates also increased by 4% at 3 months and 5% at 6 months. Though there have been improvements amongst most age groups, there have been mixed results in younger children 2-4 years, with no clear reason as to why. Much can be learnt from this multi-level intervention, in particular as regards the focus and impact on lower socioeconomic groups. |
| The Amsterdam Rainbow Model on Childhood Obesity | 2015-2018 | |||
| Norwegian National Action Plan for a Healthier Diet | Norway | Aims & intervention areas: Promotion of healthy diet and prevention of obesity and diet-related NCDs | 2017-2021 | https://eurohealthobservatory.who.int/countries/norway/ Obesity levels are lower than the EU average |
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https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/norway/ | |||
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| National Health Program | Poland | Obesity-related goals included in strategic health policy documents The 2015 Act on Public Health shifted the strategic focus of the National Health Program from the treatment of common diseases to the promotion of healthier lifestyles and the reduction of important risk factors. The new edition of the Program for 2021–25 includes operational goals on prevention of overweight and obesity, healthy ageing, mental health promotion, addiction prevention and reduction of health risks arising from environmental factors and infectious diseases. |
Four editions of the Program have been adopted 1995 – 2005 2007 – 2015 2016-2020 2021-2025 |
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| https://eurohealthobservatory.who.int/countries/poland/ | ||||
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| https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/poland/ | ||||
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Portugal |
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| https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/portugal/ | ||||
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| National Plan of Food for Nutrition | Romania | Action areas: Overweight, obesity and diet-related NCDs, Overweight in children 0-5 yrs. | 2009-2010 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/romania/ |
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| Priority Project ''Development of Healthy Lifestyle'' | Russian Federation | Action areas: Nutrition in schools, School-based health and nutrition programs, Promotion of healthy diet and prevention of obesity and diet-related NCDs | 2017-2025 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/russian-federation/ |
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| National Program on Nutrition Improvement | Slovakia | All thee (3) national programs include educational activities focused on reducing the consumption of foods high in fat, sugar or salt (HFSS) by adults, adolescents and children. | 2006-2010 | https://eurohealthobservatory.who.int/countries/slovakia/ |
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| National Obesity Prevention Program | -2008 | https://www.euro.who.int/__data/assets/pdf_file/0018/243324/Slovakia-WHO-Country-Profile.pdf | ||
| No prevalence figures are available for overweight and obesity in schoolchildren based on measured intercountry comparable data. Slovakia is not yet participating in the WHO European Childhood Obesity Surveillance Initiative (COSI) | ||||
| National Program on Care for Children and Adolescents | 2008 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/slovakia/ | ||
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| National program on Nutrition and Physical Activity and HEPA |
Slovenia Ministry of Health |
The program aims to address the physical activity habits of the Slovenian population from the early years of life to old age, as well as promoting daily physical activity. | 2015–2025 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/slovenia/ |
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| Strategy for Nutrition, Physical Activity and prevention of Obesity (NAOS) (Neira and de Onis, 2006) |
Spain Spanish Ministry of Health & Consumer Affairs Coordinated by the Spanish Food Safety Agency and the General Directorate of Public Health |
To improve the diet and encourage the regular practice of physical activity by all citizens, with special emphasis on children. the Strategy includes recommendations for action in 4 main sectors: 1) Family and community, 2) At School, 3) In business, 4) The Health System. Surveillance and monitoring the dietary intake and nutritional status of population, to correct micronutrient deficiencies and prevent their occurrence, dissemination of nutrition information, nutrition education in school and at national levels to provide information concerning the nutritional value, information on proper food preparation, information about risk factors that affect nutritional status. |
2005 | https://eurohealthobservatory.who.int/countries/spain/ With the aim of improving the health of consumers and reducing overweight and obesity levels, in 2019 the government and the food industry reached an agreement to cut the content of sugar, salt and fat in more than 3 500 food and drink products over the next three years, with the voluntary commitment of nearly 400 companies. These ingredients are expected to be cut by around 10 %, on average. |
| Estrategia de Seguridad Alimentaria (Food safety and Nutrition Strategy) | 2008-2012 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/southern-europe/spain/ | ||
| Nutritional labelling system Nutri-score | 2021 |
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| A Healthy School Start Plus (Elinder et al., 2018) | Sweden | Aims to prevent childhood obesity and overweight in disadvantaged areas in a 6-month program using education directed at parents, motivational interviewing of parents, school-based activities for children and online self-test Aims to reduce the proportion of overweight and obesity in adults, children and pregnancy by 2020. |
2018 (ongoing) | In Sweden, the responsibility for performing surveys lies with the Public Health Agency. Trends in dietary habits and levels of physical activity in the population have been monitored by the agency and reported in public health reports. Nationally representative data on obesity among children in Sweden are not available, but some regions have been monitoring long-term trends based on data from routine school health examinations. Small-scale projects designed to reduce childhood obesity are evaluated through maternal and child health services, but no national database exists. |
| National guidelines for prevention and treatment in case of unhealthy lifestyles | 2018 (ongoing) | https://globalnutritionreport.org/resources/nutrition-profiles/europe/northern-europe/sweden/ | ||
| Action plan for overweight and obesity - Stockholm | 2016-2020 |
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Switzerland Federal Council Federal Office of Public Health FO PH, the Federal Office of Sport FOS PO, Health Promotion Switzerland and the cantons). |
To reduce the prevalence of nutrition-related diseases, ensure the supply of safe and high-quality food and contribute to the sustainable and environmentally friendly production and distribution of food. The Network Health enhancing Physical Activity Switzerland was created to promote PA among the population. The NPDPA has five goals, which are implemented by its four partners |
2013-2016 2004 |
https://globalnutritionreport.org/resources/nutrition-profiles/europe/western-europe/switzerland/ |
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| Organization of a food in establishments of education and children's establishments | Ukraine | Action areas Nutrition in schools: - School meal standard - Home grown school feeding |
2021 | https://globalnutritionreport.org/resources/nutrition-profiles/europe/eastern-europe/ukraine/ |
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Table 3.
WHO Regional Office for Europe data sources for monitoring and surveillance of childhood obesity
| Data Source | Year | Aims & description |
|---|---|---|
| European Charter on Counteracting Obesity | 2006 | To address the growing challenge posed by the epidemic of obesity to health, economies and development |
| The EU Platform for Action on Diet, Physical Activity and Health (Tselengidis and Östergren, 2019) | 2005 | www.eu-pledge.eu. An action-oriented cooperative process to help stem the obesity trend, aimed at addressing the dynamic marketing and media environment in the EU. While it provides a common framework, member companies can make commitments that go beyond it, and several do. Since its launch, most of the member companies have stepped up their corporate commitments, tightening the way they define advertising to children, broadening the scope of their actions and strengthening nutrition criteria. |
| Nutrition, Obesity and Physical Activity (NOPA) database (Swinburn et al., 2013) | 2008 | NOPA Europe database was developed to compile information for 53 Member States to help policymakers identify gaps and needs in data collection and policy development, and monitor progress in addressing obesity. The NOPA database examines progress made by countries based on their Second European Action Plan for Food and Nutrition Policy, which provides an integrated approach to nutrition, food safety and food security from 2007 to 2012. |
| e-Library of Evidence for Nutrition Action (eLena) | 2011 | https://www.who.int/elena/en/ Supported by The WHO's Department of Nutrition for Health and Development, eLena is an online library of evidence-informed guidelines for an expanding list of nutrition interventions. It is a single point of reference for the latest nutrition guidelines, recommendations and related information such as: available scientific evidence supporting the guidelines; biological, behavioral and contextual rationale statements; and commentaries from invited experts. eLENA aims to help countries successfully implement and scale-up nutrition interventions by informing as well as guiding policy development and program design. |
| Global database on the Implementation of Nutrition Action (GINA) | 2012 | Contains information from various sources, including a questionnaire to Member States, analyzed in the context of the Global Nutrition Policy review, and direct submissions collected through a wiki platform. GINA will address issues such as child growth and breastfeeding, and will be based on countries' implementation experiences. |
| Smart childhood Obesity CARing solution using IoT potential (OCARIoT) | 2017-2020 | The main goal of OCARIoT, implemented from 2017-2020 in Spain and Greece, was to promote the improvement of eating and physical disorders and also the prevention of the obesity onset for 9-12 years old children. For doing so, OCARIoT developed an IoT-based customized, personalized obesity coaching plan guiding children to implement healthy eating and PA behavior, and an IoT network observing child activity patterns of daily living, health evolution, physiological & behavioral parameters and environmental data. The proposed solution aimed to empower children, educational staff and families to take control of their health by collecting real-time information about nutrition and PA, and interconnecting doctors and children (including parents and tutors) to adapt the individual obesity coaching plan. |
The demanding puzzle of handling childhood obesity pandemic still remains miscompleted, since better understanding this problem requires a critical reframing from a broader perspective considering childhood obesity as a systemic problem - action needed dipole symptom (Swinburn et al., 2019) in order to reach the following addressed roots of the problem and filling the following childhood obesity prevention, monitoring and implementation policy gaps. The main question concerning the pragmatic efficacy of all aforementioned adopted European -wider or at national level- policies for the prevention, treatment, and cure of childhood obesity remains a hot discussion debate.
3.2. Slow and inconsistent implementation of effective obesity-prevention policies by European countries.
It has been estimated that one in five children will be affected by overweight and obesity (OW &OB) by 2025 in Europe, representing more than 16 million children and if cutting-edge trends maintain, the global incidence of early-life obesity is projected to reach 254 million with the aid of 2030, an boom of a hundred million over the following decade (Breda et al., 2020). Childhood obesity prevalence is increasing; however, effective obesity prevention interventions are slow and inconsistently implemented (Roberto et al., 2015).
Evidences concerning formative years overweight & obesity problems control (Frank, 2022, Mahase, 2022) acknowledge in dark colors that while European countries may have elevated focus and lots of have launched techniques and movement plans to curb and reverse early life obesity rates in recent years, its effective control has not been accomplished by any country so far; As highlighted in the World Obesity Federation's 2019 Global Atlas of Childhood Obesity (Federation, 2019), is expected to successfully fulfill by 2025 the WHO childhood obesity targets.
A rational for this fact is that inconsistent and fluctuating progress (Roberto et al., 2015), a “hodgepodge” rather than a symphony (Lloyd-Williams et al., 2014) has been achieved covering and practicing existing nutrition policies due to “policy inertia,” a descriptive term for the inadequate impact of political management in adopting meaningful and measurable policies to address the obesity epidemic due to a wide range of robust barriers to these policies from synergistic factors and parameters.
It is a common secret that countries are developing approaches to “fuel” healthy diets that are adapted to local and cultural contexts and that ultimately involve multi-sector and multi-stakeholder priority setting and decision-making (Kickbusch et al., 2016). (World Health Organization, 2013, World Health Organization, 2018a, Van Dam et al., 2022, Pereira and Oliveira, 2021).
According to the World Health Organization Regional Office for Europe, which has mapped the health system response to childhood obesity, participating nations have encountered and reported comparable challenges and barriers (Weghuber et al., 2019), which seem to stand up from numerous factors of governance; the shortage of included prevention and care in countrywide early life obesity techniques, loss of clear care pathways and suggestions, early life obesity management structural and organizational troubles, vulnerable vertical and horizontal integration of companies, and feeble collaboration.
Aside from sociocultural barriers in the populations most in need of treatment for childhood obesity, the lack of enough funding and personnel, along with the lack of adequate training for medical and allied health professionals (such as psychologists, dietitians, physiotherapists, etc) working with overweight or obese children, are also seen as major challenges and significant obstacles addressing childhood obesity (Weghuber et al., 2019).
3.3. Acknowledged gaps in surveillance and monitoring policy implementation for better food and nutrition for children under 5 years.
Monitoring and evaluating progress toward goals related to malnutrition (including childhood obesity), poverty, and disease in children under five years of age is recognized as both a vicious cycle and a central task (Organization, 2021a). According to the WHO (2018) progress report on monitoring the implementation of healthier diets interventions in the European Region (Organization, 2018a), the current status of surveillance and monitoring of children under 5 in Europe is discouraging, as both methods and data collection are highly inconsistent. The irregularity of health and nutrition surveys across many nations makes it difficult to track changes in the prevalence of childhood overweight.
In particular, there is an acknowledged problematic dearth of current primary research data on measured anthropometry of children beyond the age of 5 (Brinsden and Neveux, 2021, de Onis and Blössner, 2003, Williams and Suchdev, 2017) concerning data collection, assessment, and analysis for stunting and overweight in this age-group children; for the European region WHO, availability for these indicators, concerning the age scale from 0 to 59 months exists for only 27 of the 53 countries in the region. The main source of anthropometric data for children under 5 years of age is home-based surveys; countries in the European region rely mostly on kindergarten/preschool data collection for this age-group. As a result, several of the available datasets cover only a small part of the total age range of the indicators and therefore most of them have not been included in the global JME study, although they are nationally representative and there are no major concerns about data quality (United Nations International Children’s Emergency Fund (UNICEF), 2019).
Given the increasing concern and current data gaps regarding childhood obesity in European region, surveillance of population minor 5 years of age should be strengthened to warrant timely, regular, and qualitative data for the development of obesity prevention strategies and interventions (Brinsden and Neveux, 2021). The European region WHO has strengthened surveillance and monitoring of obesity in children aged 6 to 9 years with the implementation of the WHO European Childhood Obesity Surveillance Initiative (COSI) since its launch in 2007 (Spinelli et al., 2021). Thus, expanding the initiative to include data on obesity in children younger than 5 years is of critical importance.
3.4. Examples of progress and gaps in the current European Union school food policy landscape
Public health policies targeting children's food choices and consumption, excluding their dietary choices within school attending hours, have the double aim either to limit the sale of alcoholic beverages and processed foods or to determine the nutritional content of food (nutrient-based guidelines are mostly used to limit foods high in energy, fat, sugar, or sodium) by setting relevant standards (Tatlow-Golden et al., 2021).
As reported by the 2nd Global Nutrition Policy Review, globally, 77 of 160 nations (global rate 48,1%) have in their agenda some sort of regulation in place for the types of food and drink that can be sold in places like schools, cafeterias, supermarkets, convenience stores, and vending machines; In the European context this specific rate comes to 28,6% (22 European countries out of 77 countries). Moreover, eighty-nine percent of the 160 countries surveyed reported having school health and nutrition programs, with most emphasizing the consumption of fruits, vegetables, water, and whole grain cereals and limiting savory snacks, cakes and pastries, fried foods, salt and high sodium condiments, carbonated and noncarbonated soft drinks (Organization, 2018b).
Moreover, optimal national public authorities’ involvement in the educational sector, exerting considerable influence, namely in setting food standards and in food procurement. All EU Member States have exhibited praiseworthy progress in this area, introducing voluntary or mandatory school food policies (SFPs) in the 28 EU countries. However, translating these policies into healthy food realities still remains a challenge.
A review of current European school feeding policies (Storcksdieck Genannt Bonsmann, 2014) indicated that all 28 EU countries currently have national school feeding policies, with half setting mandatory standards and the other half providing voluntary guidelines. The methods by which school policy requirements or recommendations are developed are remarkably varied, ranging from straightforward lists of nutrients that are permitted (or not) to be vented within schools (e. g., in Cyprus and Greece), to extensive collections of instructions on how to handle different aspects of nutrition policy, like purchasing, catering services, and kitchen and dining facilities (e. g. in France and Spain). Three major policy objectives were to improve child nutrition (at a rate of 97 %), encourage kids to adopt healthy eating habits and lifestyles (at a rate of 94 %), and to lessen or prevent childhood obesity (at a rate of 88 %).
In nearly 90 % of all interventions, lunch and snacks were the most frequently discussed meals. In 68 % of the nations surveyed, nutrition education was a required component of national curricula, and in the remaining nations, the importance of the subject was either acknowledged, or it was strongly advised that it should be included. Finally, 65 % of SFPs stipulated certain training requirements for food service staff.
It is encouraging to diagnose that the majority of EU nations are putting policies into place that aim to increase the consumption of wholesome school lunches and decrease the consumption of junk food and sugary drinks. Leading the pack are Finland, Iceland, Denmark, Hungary, and Portugal (Lloyd-Williams et al., 2014). Other encouraging examples of good practice and policy opportunities in Europe to improve the nutrition environment in kindergartens and schools (Kovacs et al., 2020) were identified, including: the Bulgaria’s National Program for Prevention of Non-Communicable Diseases 2013–2020; the Greek School Canteen Policy; the Public Catering Decree and the Legislation on Daily Physical Education classes in Hungary; the coordinated policies to restrict unhealthy foods in kindergartens and schools in Latvia, and the National Health Promotion Program (NPPZ), and the National Action Plan for the Prevention of Obesity in Slovakia. All policies met the nine good practice core criteria, with the exception of the final two. The criteria for monitoring and evaluating the two Slovene policy initiatives were absent. However, they were included to broaden the portfolio. The National Program from Bulgaria and the two policies from Slovakia targeted the general population, while the other four policies targeted children attending daycare or educational institutions (Kovacs et al., 2020).
According to the most recent confirmed data on published EU country measures from the European Observatory on Health Systems and Policies 2022 (Scott L. Greer, 2022), the WHO Europe Countries Nutrition Profile 2022 Report (WHO, 2022), and the WHO Global database on the Implementation of Nutrition Action (GINA) (descriptive Table 2), child obesity is on the rise in European countries, but all EU countries are 'on track' to meet maternal, infant and young child nutrition (MIYCN) targets, with little or no progress toward the exclusive breastfeeding, stunting and emaciation target. All countries are 'on track' to prevent the prevalence of overweight children under 5 years of age from increasing and show limited progress in achieving the targets for diet-related non-communicable diseases (NCDs) (Bellew et al., 2019).
It is not a matter of debate that all EU nations still need to win the bet of implementing – in a truly meaningful and effective way- fiscal, as well as regulatory measures in the field of dietary policies to target childhood obesity. The school foodservice milieu remains a much-underutilized stage for promoting healthy nutrition among children, particularly as it addresses in parallel malnutrition and overweight and obesity issues (World Health Organization, 2018, Carducci et al., 2020). With the aim to make the wholesome choice the simpler choice, endorsing a healthy nutritional head-start ethos, particularly in preschool and school units, posing marketing and advertising limitations to children, are remaining fields in urgent need of deeper consideration.
4. Results
The recent World Health Organization, 2018, World Health Organization, 2018a progress report (Organization, 2018a) and relevant studies (Breda et al., 2020), provide evidence of significant improvement in enactment of key policies addressing childhood obesity in recent years; According to European Observatory on Health Systems and Policies (Eurohealth) 2019 report (Hernández-Quevedo et al., 2019), the most advancement has been accomplished on topics such as providing nutritional guidance, school food, food product reformulation, banning vending machines, encouraging PA in schools, fiscal policies and surveillance of childhood obesity.
Poor performance areas include pre-packaged customer registration and the introduction of strict advertising restrictions with appropriate criteria: Food labeling complies with mandatory regulations regarding packaged food. However, although many countries have indicated that pre-labeling is voluntary, few have specific guidelines or regulations and use pre-package labeling for interpretation, particularly for groups with low economic, educational and social background. Relevantly, EU member states still anticipate the revision of the audio-visual media services directive (AMSD), which also regulates -due to its harmful effect in children- the advertising on TV, tablets and mobile phones. Moreover, sustenance for breastfeeding and appropriate complementary feeding remain other areas which should be “reinvigorated” or extended, for Member States to attain the set goals.
Furthermore, reformulation is illustrative of the considerable discrepancy between the type and scope of policies undertaken by Member States in terms of a mixture of single-issue policy responses and more coherent measures (Wickramasinghe et al., 2021). Publicly funded obesity education programs for children and young people are one area that may need more attention. However, in certain countries, there is a shortage of funding to conduct such programs. Another persistent difficulty is finding effective ways to interact with the food business in areas such as regulation, taxation, and market processes. Paradoxically, despite the undisputable rise of the burden of childhood obesity epidemic, there are still European countries, where this does not represent a topic of public health debate (Hernández-Quevedo et al., 2019).
5. Directions for further actions
Further actions needed for reversing the burden of childhood obesity prevalence, thus filling the gap of relevant public health interventions, are highlighted by the WHO itself, even from 2007, until recently (World Health Organization, 2021b, Branca et al., 2007), regarding the following pivotal childhood obesity prevention areas: 1) Develop and improve national food-based dietary guidelines; 2) Implement measures to regulate prices to support socially disadvantaged groups in accessing healthy foods; 3) Work together with the media and Internet service providers to regulate advertising aimed at children. Included in this effort is the dissemination of nutrition education, the improvement of food labeling, the promotion of breastfeeding, the enhancement of food nutrition profiles, the encouragement of the cultivation and marketing of fruits and vegetables, and the provision of healthy food in educational institutions. 4) Measures taken to encourage people to get more active, such as making PA more accessible and less expensive, encouraging safe PA transportation, especially for school commutes, bolstering PA at schools, promoting PA in the recreation and counseling sectors, and so on.
6. Conclusions
Europe faces a new and unprecedented public health threat from obesity, which has been underappreciated, underassessed, and not fully recognized as a strategic government problem with significant economic repercussions. Policies in Europe aimed at reversing the rise in childhood obesity are complicated, dynamic, and fast evolving. According to data from the 2021 Global Nutrition Report (Report, 2021) we are not on track to reach five out of six global maternal, infant, and young children nutrition (MIYCN) targets, including those for reducing stunting, wasting, low birth weight, anemia, and childhood overweight, salt consumption, hypertension, obesity, and diabetes are all noncommunicable diseases (NCDs) for which dietary goals have not been met yet.
Information on the prevalence of OW&OB among children is crucial for informing the creation and dissemination of effective public health policies and programs, which are seen as the only realistic alternative for reducing the epidemic of childhood obesity. Although European nations have made significant strides toward slowing the rise of obesity, the prevalence of overweight people is still cause for concern, especially among the young populace.
The current narrative review critically addressing European community interventions, monitoring and surveillance targeting childhood obesity, highlighted that implementation of key policies may have been significantly improved in recent years, with advancement being achieved in areas such as school food, food product reformulation, fiscal approaches and surveillance of childhood obesity.
Areas, however, in which implementation is lagging and therefore necessitate more reinvigorated or extended attention and effort embrace: i) front-of-package labelling and comprehensive marketing restrictions, ii) support of breastfeeding, as exclusive breastfeeding rates in most countries of the European region tend to considerably decline after four months, being very low in infants under six months of age due to widespread inappropriate complementary feeding practices, iii) reformulation, monitoring policy implementation for better food and nutrition children under 5 years. If we are to attain the Sustainable Development Goals and associated targets, which governments across the European Region have agreed upon, more formidable approaches to food and nutrition policy may be needed in the coming years.
Funding
The authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors for the research, authorship, and/or publication of this article.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
CRediT author statement: D.P. designed the protocol and determined the scope of the review, appraised the quality of evidence, supervised the review process and revised the manuscript, and is the guarantor of the review. M.C. developed the search strategy, conducted the search and screening, extracted the data, appraised the quality of evidence, performed the data analysis, and drafted and revised the manuscript. Both authors have critically reviewed the manuscript content and approved the final version submitted for publication.
Data availability
Data will be made available on request.
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Associated Data
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Data Availability Statement
Data will be made available on request.