Policy options for responding to the growing challenge from obesity Polish results

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Policy options for responding to the growing
challenge from obesity Polish results

• Lucjan Szponar, Janusz Ciok,
• Agnieszka Dolna, Maciej Oltarzewski
• Consulted by prof. dr hab. n. med. Miroslaw
  Jarosz
• Director of National Food and Nutrition Institute
• National Counterpart for Nutrition within the WHO
  European Region

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Epidemic of Obesity in Poland
3
L. Szponar et al. National Survey on Dietary
Habits and Nutritional Status of Polish
Population in 2000
4
L. Szponar et al. National Survey on Dietary
Habits and Nutritional Status of Polish
Population in 2000
5
Other surveys on children and adolescents

• Oblacinska A. et al. survey carried out in the
  year 1994/95 on children falling into 7-17 age
  group
• Chrzanowska et al. survey carried out in the year
  2000 on children and adolescents falling into
  3-18 age group and the findings of this research
  team of the survey in Cracow performed earlier
  using both own centile grids and measurements of
  the fatty skinfolds in three body areas.
• Mazur et al. survey on children at the school age
  using the IMID centile grids criterion for BMI
  and IOTF criterion for overweight and obesity
• Malecka- Tendera survey on children at the school
  age using centile grid criterion for BMI and IOTF
  criteria
• E. Rychlik survey on children in the 11-15 age
  group dating back to the 1996-2000 period using
  IMID centile grids
• J. Charzewska survey dating back to 1988-1991 and
  1999-2000 on children in the 11-15 age group
• and S. Koziel et al. survey on the conscripts in
  the 18.5-19.5 age group dating back to 1986, 1995
  and 2001

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L. Szponar et al. National Survey on Dietary
Habits and Nutritional Status of Polish
Population in 2000
7
L. Szponar et al. National Survey on Dietary
Habits and Nutritional Status of Polish
Population in 2000
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Comparison with other results in adults

• Overweight, male population
• In the year 2000 in 41.0 of the surveyed (L.
  Szponar et al., as above)
• In the year 2002 in 42.0 of the surveyed
  (Zdrojewski T. et al., as above)
• In the year 2003-2005 in 40.4 of the surveyed
  /U.Biela et al., as above)
• Overweight, female population
• In the year 2000 in 28.7 of the surveyed
  (Szponar L et al., as above)
• In the year 2002 in 29.0 of the surveyed
  (Zdrojewski T. et al., as above)
• In the year 2003-2005 in 27.9 of the surveyed
  (Biela U. et al.)

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• Obesity, male population
• In the year 2000 in 15.4 of the surveyed
  (Szponar L. et al.
• In the year 2002 in 19.0 of the surveyed
  (Zdrojewski T. et al.
• In the years 2003-2005 in 20.6 of the surveyed
  (Biela U. et al.)
• Obesity, female population
• In the year 2000 in 18.9 of the surveyed
  (Szponar L. et al.)
• In the year 2002 in 19.0 of the surveyed
  (Zdrojewski T. et al.)
• In the years 2003-2005 in 20.2 of the surveyed
  (Biela U. et al.)
• Morbid obesity, men
• In the year 2000 in 0.3 of the surveyed (Szponar
  L. et al.)
• In the year 2003-2005 in 0.6 of the surveyed
  (Biela U. et al.)
• Morbid obesity, women
• In the year 2000 in 1.0 of the surveyed (Szponar
  L. et al.)
• In the year 2003-2005 in 2.2 of the surveyed
  (Biela U. et al.)

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Conclusions

• The prevalence of overweight and obesity in the
  group of boys in accordance to IOTF criteria,
  accounts for more than 20.
• The prevalence of overweight and obesity in the
  group of girls in accordance to IOTF criteria,
  accounts for 16.
• In the group of men in accordance to WHO criteria
  from 2002 the prevalence of overweight is about
  40 but the prevalence of obesity exceeds 15.
• In the group of women the frequency of overweight
  is approximately 30 and the frequency of obesity
  achieve the 20.

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• Moreover abdominal fatness is more frequent in
  female than in male population.
• Overweight more frequently occurs in men than in
  women, while women more often suffer from
  obesity, including extreme obesity than men.
• The data sets presented in the Report with regard
  to the occurrence rates of overweight and obesity
  in the populations of children and adolescents,
  and adults show that the problem occurs
  throughout the lifecycle of the individual.
• The growth rate of disadvantageous health changes
  in individual phases of lifecycle of the
  individual seems to vary a great deal and to
  depend not only on the quality of diet and
  nutritional pattern, but also on several other
  lifestyle drivers, including in particular the
  physical activity.

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Dietary energy, nutrients and food intake
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Low activity for adolescents and adults
L. Szponar et al. National Survey on Dietary
Habits and Nutritional Status of Polish
Population in 2000
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L. Szponar et al. National Survey on Dietary
Habits and Nutritional Status of Polish
Population in 2000
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L. Szponar et al. National Survey on Dietary
Habits and Nutritional Status of Polish
Population in 2000
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Source Szponar L. Sekula W., Rychlik E. et al.
Badania indywidualnego spozycia zywnosci i stanu
odzywienia w gospodarstwach domowych (Household
Food Consumption and Anthropometric Survey),
Prace IZZ 101. Warsaw 2003
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Source Food balance sheets Sekula et al.
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Source Food balance sheets Sekula et al.
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Situation in Poland with regard to physical
activity at ones leisure in the adult population
according to WOBASZ survey results
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Policy Making Institutional Framework
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Under this scheme the prevention and control of
overweight and obesity become the national
scheme. The leading role in the respect of
scientific risk assessment and risk communication
in this area play the National Food and Nutrition
Institute. Risk management in the area of
prevention and overcoming of overweight and
obesity is under responsibility of Minister of
Health. This process can be successful, if it
will be supported by other Ministries. Minister
of Health, as a member of Council of Ministries
have possibilities by law, to ask other
Ministries for support, to diminish the frequency
of overweight and obesity.
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For the first time in Poland a small budget was
allocated to prevent and control overweight and
obesity, starting from 2007, though a number of
specific projects were designed for
implementation already in 2006. Based on the
above Government Document a detailed
implementation schedule for the scheme will be
developed for the nearest five years but with a
10-year-long time horizon.
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Key findings of the Polish PorGrow Study
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Options

• All participants were willing to score all of the
  7 core options.
• Engagement with the discretionary options in
  Poland was variable, but the 3 that focus on
  education (except research) were the most widely
  retained for scoring (6 categories selected
  these) by participants.
• Several discretionary options were not appraised
  by a number of participants 5 of these were
  rejected for scoring by all of participants
• Common Agricultural Policy reform
• Incentives to improve food composition
• Increased use of medication to control body weigh
  
• Increased use of synthetic fats and artificial
  sweeteners
• Create new governmental body to co-ordinate
  policies relevant to obesity

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• Participants introduced 13 additional options for
  scoring
• Promotion of physical activity / Cat. 2
• Setting up a platform for co-operation in the
  area of fighting obesity / Cat. 2
• Making health products more attractive / Cat. 3
• Implementation of a network of user-friendly fast
  food bars serving health meals / Cat. 5
• Involvement of public persons in the campaign
  propagating healthy lifestyle. / Cat. 13
• Making physical education classes more attractive
  at schools / Cat. 13
• Setting up a network of POS offering health
  products / Cat. 15
• Taking measures so that slim figure becomes
  fashionable / Cat. 16
• Preparation of the list of recommended foodstuffs
  / Cat. 16
• Setting up an agency certifying healthy products
  / Cat. 18
• Making healthy lifestyle fashionable / Cat. 18
• Activities aimed at the improvement of
  self-acceptance by people / Cat. 20
• Propagation of family physical activities / Cat.
  21

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Criteria

• In Poland, all participants chose from 5 to 9
  criteria to appraise options.
• All 133 criteria defined by participants were
  grouped into 9 Issue groups
• I. Societal benefits
• II. Additional health benefits
• III. Efficacy in addressing obesity
• IV. Economic impact on public sector
• V. Economic impact on individuals
• VI. Economic impact on commercial sector
• VII. Economic impact unspecified
• VIII. Practical feasibility
• IX. Social acceptance
• Efficacy in reducing obesity was used the most to
  judge the performance of options, followed by
  practical feasibility, and other societal
  benefits.

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• Public interest NGOs Perspective appears to give
  more emphasis to the affairs related to cost to
  state budget, practical feasibility of options
  and their efficacy in reducing obesity.
• Representatives of Food chain, large industrial
  and commercial organisations selected criteria
  quite evenly and all fields met with their
  similar interest.
• Small food and fitness commercial organisations
  Perspective was mostly interested in issue of
  practical feasibility of options and their
  efficacy. Representatives revealed rather little
  interest to question of additional health
  benefits and economic impact on all sectors.
• Large non-food industrial and commercial
  organizations Perspective emphasised positive
  health benefits and efficacy of options in
  reducing obesity. Practical feasibility of
  options, costs and additional health benefits
  were less important for representatives of this
  perspective.
• Policy-makers attached importance to practical
  feasibility of options, economic impact on public
  sector and social acceptance. They did not chose
  any criteria related to additional health
  benefits and cost to entrepreneurs.
• Public providers selected mostly efficacy in
  reducing obesity, positive societal benefits and
  economic impact on public sector. Less important
  issue for this group was practical feasibility of
  options.
• Public health specialists Perspective were
  concerned about the practical feasibility of
  options, economic impact on public sector and
  individuals. Representatives revealed little
  interest to question of positive societal
  benefits and (unexpectedly) additional health
  benefits.

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• Efficacy, feasibility, and societal benefits were
  the 3 groups of criteria given the most
  importance by stakeholders when assessing policy
  options.

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Performance of options under different criteria

• The educational cluster of options (except
  research) and exercise and physical
  activity-oriented cluster, controlling marketing
  terms and mandatory nutrition labelling are
  widely seen as having positive social benefits.
• Improving communal sports facilities, providing
  healthier menus and Including food and health in
  the school curriculum are widely seen as
  affording additional health benefits.
• Educational cluster of options (except research),
  controls on food composition, controlling
  marketing terms, mandatory nutrition labelling
  and improve communal sports facilities are seen
  as practically feasible.
• Taxes and increase obesity research are seen as
  the least feasible options by almost all
  perspectives.
• Cluster of options Exercise and physical
  activity-oriented, Information-related
  initiatives, Educational and research initiatives
  are seen as the most effective options in
  reducing obesity.
• Control sales of foods in public institutions are
  seen as costly to industry.

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Average ranks for all participants showing ranks
by favoured order under optimistic conditions
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Public Interest Perspective (A) gave the most
favourable scores to the education cluster of
options, i.e. general health education, food and
health education in schools, and training for
health professionals. The lowest ranks were
assigned to the following options the controls
on food in public institutions and taxation of
unhealthy food.
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The Food Chain Perspective (B) gave favourable
scores to improving sports facilities and the
education cluster of initiatives (apart from the
option involving changes in town planning and
urban transport). They gave lowest scores to
taxation and subsidising to some food products.
Additionally low rank was also assigned the
option of improvement of controls on food
advertising.
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Small food and fitness commercial organisations
Perspective (C) gave favourable scores to three
options improved availability of physical
activity facilities and equipment, mandatory food
labelling and subsidising healthy food. The
lowest ranks were assigned to the idea of higher
taxes on unhealthy food and controls on food
sales in public institutions
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The Non-food Commercial Perspective (D) gave most
favourable scores to educational options. Low
ranks were assigned to the controls on food sales
in public institutions, controls on food
advertising and fiscal options subsidising and
taxation system applied to some food categories.
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The Policy Makers Perspective (E) gave high
scores for improvement of availability of
physical activity facilities and equipment,
mandatory food labelling and controls on light,
lite marketing terms. Low scores were given to
subsidising some food categories and
implementation of varied food taxation system.
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The Public Providers Perspective (F) gave
particularly favourable scores to food and health
education in schools and in all the population.
The lowest scores were given to options for
subsidising some food categories and varied
taxation on food.
46
Public Health Specialists (G) mostly favoured
improving health education in schools, and for
the general public and health professionalists.
Three lowest pessimistic ranks included controls
on food sales in public institutions, higher
taxes on some foodstuffs and improved catering
menus.
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Examples of rankings given by all participants
for several options
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Examples of rankings given by all participants
for several options
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Overall Performance of options

• The highest ranking options overall were those in
  the cluster of educational and research
  initiatives which were all discretionary
  options these were seen by stakeholders as
  relatively low cost, socially beneficial,
  feasible, and effective in changing behaviour.
  There is strongest support for improved health
  education of school-aged children in relation to
  eating well and physical activity. Other health
  education and training options are also well
  regarded. Many interviewees also argued that it
  would be important to improve the training
  provided to health professionals, to enable them
  more effectively to identify and respond to
  examples of overweight and obesity with which
  they come into contact.

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• Information-related initiatives had a mixed
  reception. Calls for mandatory nutrition
  labelling met with an unenthusiastic response, as
  there was wide shared doubt about whether
  consumers read labels, and even if they do
  whether they have an influence on behaviour.
  There were reservations about the over simplicity
  of the proposed traffic light labelling system by
  many stakeholders, especially representatives of
  food chain. Controlling marketing terms such as
  lite and diet was also well received, even
  though it was not widely scored it was the most
  favoured of the information-related initiatives
  proposed.

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• There was wide support for providing improved
  facilities for physical activity and recreation.
  There was less enthusiasm for changes to
  transport and planning policies, which were seen
  as costly and complex, and would be unacceptable
  to some citizens.
• Economic instruments, such as taxes on obesogenic
  foods and/or subsidies on relatively healthy
  foods met almost unanimous objection subsidies
  were slightly less unacceptable, but were not a
  part of the solution. Policies that modify
  supply and demand on a local or smaller scale
  were more acceptable, and incentives to provide
  healthier catering menus was widely favoured, if
  it focussed on settings where people ate on a
  regular basis, such as schools and workplaces,
  rather than commercial restaurant settings, where
  it was seen to have a negative impact on business
  and would be socially unacceptable, as citizens
  eat out for pleasure, rather than for health.

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• There was a broad agreement that several of the
  options were unlikely to be valuable for
  countering the obesity epidemic, specifically the
  options concerning
• physical activity monitoring devices,
• medication for controlling weight, and
• the use of synthetic food ingredients.
• Most participants did not deem these options
  worthy of scoring and others gave them low scores.

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• There are some relatively sharp disagreements,
  but these are between representatives of
  particular contrasting interest groups rather
  than between the broader Perspective groupings.
• One pattern that can clearly be identified from
  the data is that no single option emerges as
  universally or generally most favoured. No
  participant argued that any single option on its
  own would be sufficient to address the problem of
  obesity.
• On the other hand, there is almost universal
  consensus that at least some options are required
  in each of the 4 groups of options, namely those
  concerned with
• A)    levels of physical activity
• B)     the supply of, and demand for, foodstuffs
• C)    improved information and
• D)    education and research.

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Options considered as having chance of successful
implementation. 

• Increase opportunities and incentives for
  physical activity improving communal sports
  facilities was preferred out of the exercise and
  physical activity cluster of options.
• Modify patterns of demand and supply for food
  stuffs and beverages Controlling sales of food
  in public institutions was the preferred core
  option in the modifying supply and demand
  cluster, and controlling food composition was the
  most favoured discretionary option in this
  cluster.
• Augment the quantity and quality of information
  available to citizens concerning food, diet,
  physical activity and health controlling food
  and drink advertising was the preferred core
  option in the information-related initiatives
  cluster and controlling marketing terms was the
  most favoured discretionary option in this
  cluster.
• Improve levels of knowledge and understanding
  about food, diet, health and physical activity
  Food and health education in school was the most
  favoured in the Education and research
  initiatives cluster.

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Rank means for Countries - Polish results
Rank Means for Countries
Rank Means for Countries
Option 2
Option 1
Cyprus
Cyprus
Finland
Finland
France
France
Greece
Greece
Hungary
Hungary
Italy
Italy
Poland
Poland
Spain
Spain
UK
UK
0
20
40
60
80
100
0
20
40
60
80
100
Rank Means for Countries
Rank Means for Countries
Option 3
Option 4
Cyprus
Cyprus
Finland
Finland
France
France
Greece
Greece
Hungary
Hungary
Italy
Italy
Poland
Poland
Spain
Spain
UK
UK
0
20
40
60
80
100
0
20
40
60
80
100
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Rank Means for Countries
Rank Means for Countries
Option 6
Option 5
Cyprus
Cyprus
Finland
Finland
France
France
Greece
Greece
Hungary
Hungary
Italy
Italy
Poland
Poland
Spain
Spain
UK
UK
0
20
40
60
80
100
0
20
40
60
80
100
Rank Means for Countries
Option 7
Cyprus
Finland
France
Greece
Hungary
Italy
Poland
Spain
UK
0
20
40
60
80
100
57
Rank Means for Countries
Rank Means for Countries
Option 8
Option 10
Cyprus
Cyprus
Finland
Finland
France
France
Greece
Greece
Hungary
Hungary
Italy
Italy
Poland
Poland
Spain
Spain
UK
UK
0
20
40
60
80
100
0
20
40
60
80
100
Rank Means for Countries
Option 15
Cyprus
Finland
France
Greece
Hungary
Italy
Poland
Spain
UK
0
20
40
60
80
100