This document discusses promoting well-being and preventing disease through nutrition and lifestyle changes in Europe. It notes that central Europe and central Asia have seen the slowest life expectancy gains of any world region. The top preventable risk factors for disease burden are smoking, high blood pressure, overweight/obesity, and physical inactivity. It argues for policies like limiting junk food marketing to children, taxing unhealthy foods, and establishing healthy food standards in schools and government institutions to effectively promote public health.

1. A "Whole of Government"
approach to promoting short and
long term well-being in the
European Region
Philip James MD, DSc, FRCP
London School of Hygiene and Tropical
Medicine, International Association for the Study
of Obesity

2. Health's contribution to improved prosperity
in the past 50 years: a missed opportunity in
Central Europe and Central Asia
Health's contribution
to full income growth
% 50
40
30
20
10
Europe+
C. Asia
SEARO WPRO
EMRO
AFRO
Lat Am+
Caribb.
Smith et al
World Bank
June 2013.

3. EU 15
Europe+
Central Asia
South Asia
Latin America+
Caribbean
Middle East +
North Africa
Central Europe and Central Asia (WHO EURO) is the
region with the slowest improvement in life expectancy
since 1960 of all the WHO regions in the world.
Smith et al. Improving health
service outcomes in Europe
and Central Asia.
World Bank June 2013.
80
70
60
50
40
1960 1970 1980 1990 2000 2010

4. -2 0 2 4 6 8 10
Smoking
High blood pressure
Overweight & obesity
High cholesterol
Alcohol use
Physical inactivity
Low fruit & veg. intake
Illicit drug use
Unsafe sex
Iron deficiency anemia
Attributable disease burden (% regional DALYs; total 149 million)
The top risk factors underlying the disease burden
of high income countries (all preventable)
WHO / World Bank.
Global Burden of Disease.
Lopez et al., 2006.
Primary
dietary cause

5. Classic problems of nutritional deficiency
persist: Lancet July 2013
• Anaemia - a neglected issue affecting
Children 11% affluent; 26% Central/Eastern Europe
Women 16% affluent; 22% Central/Eastern Europe
• Exclusive breast feeding limited and needs ignored:major
public health issue in Western & Central Europe: need to replicate
Scandinavia and transform societal approach
• Childhood stunting still affects 20-30% in some rural areas of EURO
• Pregnancy - the forgotten public health issue:
15% small for dates babies in Caucasus/Central Asia+ Asian
immigrants: babies programmed for abdominal obesity + diabetes
Overweight girls/women: gestational diabetes+ big babies: programmed
obesity and diabetes. Optimum birth weight range!

6. Crucial nutritional effects do not just affect the
first 1,000 days of life: sensitive organs mature
at different rates
Muscle, bo
ne &gut
Reproductive
organs
Lymphatic
immune
system
Liver, kidney, hear
t, lung.
Brain: follows internal organ
changes in size but major
structural and functional
changes before full
maturation at age 20+.
Adolescent brain highly
susceptible to emotional
cues
Prentice et al. Critical windows for
nutritional interventions against stunting
Am J Clin. Nut. 2013;97: 911-918
For brain changes see::
Dosenbach et al . Prediction of
individual brain maturity using fMRI.
Science 2010;329: 1358-1361

7. Marked changes in societal practices needed :
eliminate smoking, limit markedly alcohol intake &
transform dietary and inactivity patterns
FIBRE-RICH
Vegetables &
Fruit
Increase fatty
acids from fish
&n-3 vegetable
sources
Exclusive
Breast Feeding
for 6 months
Modest animal
protein intake
Saturated
Fats
TOTAL FAT
Trans fat
Sugars &
Refined
starches
Salt Iodine+

8. Why do we not eat optimally - is it a matter of
education? The current obesity dilemma
Obesity is a normal "passive" biological
response to our changed physical and
food environment
Some children/adults are more
susceptible for genetic, social and
economic reasons
Overwhelming environmental
impact reflects outcome of normal
industrial development
"Obesity reflects failure of the
free market"
UK Government report Oct. 2007
Provided on a non - political basis by the Chief Scientist

9. 25 years
65 years
GeneralPop.
Decrease in obesity rates in 25 and 65 year olds + general population
induced by different government policies. OECD 2010. Note insignificance
of approaches using media on its own
Media
Work-site
Schools Drs + Dietetic
Fiscal
Food
Labelling
Food
Advertising
Regulated
Voluntary

10. The cost-effectiveness of policies: individual education for
behavioural change for a whole population is very expensive and
often ineffective. Legislative/regulatory measures usually much more
effective and less costly.

11. The keys to success in the food business and in
obesity and chronic disease (NCDs) prevention
• Price
• Availability
• Marketing

12. Margaret Chan, DG WHO.
WHO 8th Global Health Promotion Conference
June 10th 2013
• "..it is not just Big Tobacco anymore. Public health
must also contend with Big Food, Big Soda and
Big Alcohol. All of these industries fear
regulation, and protect themselves by using the
same tactics.
• Research has documented these tactics well.
They include front groups, lobbies, promises of
self-regulation, lawsuits, and industry funded
research that confuses the evidence and keeps
the public in doubt.

13. Margaret Chan, DG WHO.
WHO 8th Global Health Promotion Conference
June 10th 2013
• Tactics also include gifts, grants and
contributions to worthy causes that cast
these industries as respectable corporate
citizens in the eyes of politicians and the
public. They include arguments that place the
responsibility for harm to health on
individuals, and portray government actions
as interference in personal liberties and free
choice.

14. PACO III Latin American & Caribbean
Ministerial Conference on childhood obesity 6th
- 8thJune 2013
Ministers of Health's primary role is to act as leaders and ambassadors
for change in other government departments e.g.
a) Education - changing curriculum and total food + drink sources in all
educational facilities
b) Transport: structural changes promoting walking/cycling + public transport
& minimizing car use
c) Finance: Taxation of unsuitable foods/drinks; financial incentives for
behavioural change allowing for regressive effects on disadvantaged;
Planning for progressive help to local farming/food provision + activity
industries
d) Business : promote good food and activity: import /export health criteria +
supermarket changes
e) Agriculture &Food: Link local industries to government supported
catering.

15. Food tax developments
 Trans fats: Denmark bans in 2003 . Now also Austria&Switzerland.
New 2013 analyses: legislation is the most cost effective
intervention not voluntary measures.
 Sugar : Finland introduced taxes on sugared products such as
soft drinks , ice cream and confectionary by EUR 0.75 per kilo
product. Also Denmark.
France introduces a 7 cent/litre tax on all soft drinks
 HFSS: Sept. 1, 2011. Hungary: a 10 forint (€ 0.37) tax on foods with
high fat, sugar and salt content; also increased taxes on soft
drinks and alcohol
 Saturated fat. Denmarkintroduces small selective tax for 15
months: clear reduction in intake - see separate presentation

16. Early success of major French Parliamentary initiatives in
changing school foods, limiting marketing of foods high in
fats, sugar and salt and new taxes on soft drinks; now a new
National Nutrition and Health Programme 2011 - 2015
2005
1. Vending machines banned in schools;
quality of all foods served improved
2. All national advertising of foods and
drinks must carry a health
message, with the penalty of being
subject to an earmarked tax
December 2011
3. Tax of 7 cents/ litre on all soft drinks
4. Food quality in schools controlled by
law
Repeated national surveys:
Overweight &obesity rates in
7-9 year old children
(IOTF criteria)
Fall of ≈ 15% from 1998-2007
Government initiatives Results
1 Actual price increase =7cents/l
2. Sales fall by 4%
3. Population accepts especially if
some tax transferred for health care
4.Tax income 280 M€ in 2012

17. Profitable government opportunities for adults and children based on
evidence from Chile, Denmark, France, Finland, Netherlands & Sweden
relating to cardiovascular disease, diabetes and obesity prevention.
1. Control foods+ drinks available in schools, hospitals, all government supported
institutions - thisinduces major driver in the free market food chain
2. Develop local farming consortia to provide school meals etc. as educational +
financially rewarding strategy (a major opportunity for Europe)
3. Promote inclusion of vegetables/salad bar in main mealat no extra cost
4. Ban trans fat productionin country
5. Define progressively lower food salt content ; no salt on tables as a default measure
6. Regulate lower cost for half and skimmed milk, butter and margarine sales
7. Tax price sensitive items: sugar, - fat (especially saturated fats) on a commodity not a
retail basis
8. Ban all marketing of food and drink to all children including adolescents
9. Control fast food outlet density as well as alcohol and tobacco sales in city centres

18. Conclusions
• The burden of diseases from inappropriate diets and physical inactivity in
the WHO EURO region is exceptionally high
• Slow progress in reducing the premature mortality and disease burden in
many countries in the region.
• Anaemia and poor pre-pregnancy and maternal nutrition are neglected
issues; low birth weight and stunting persists: EURO is also the region
with the lowest natural dietary iodine supply.
• High priorities in nutrition: Reduce substantially intakes of total fat, trans
fat, saturated fat, sugar, salt. Iodize salt and ensure folate + iron for
anaemia. All are explicit, newly reinforced, WHO recommendations.
• Legislation, regulatory, fiscal policies are far more effective than media
campaigns; establishing a healthy foods exclusive policy in all
government supported institutions transforms the food chain and health.